INTRODUCTION Definition and Concepts of Family Family Family is the basic unit of society.

. It is a primary entity of health care or institution responsible for the physical, emotional and social support of its institution. Marriage is the foundation of family. There are two types of family, the family of orientation and the family of procreation. The Family Care Plan Formulation of the care plan is the next step in the nursing process after assessment. When health and family nursing problems have been clearly defined. A family nursing care plan is the blue print of the care that the nurse designs to systematically minimize or eliminate the identified health and family nursing problems through explicity formulated outcomes of care (goals and objectives) and deliberately chosen set of interventions, resources and evaluation criteria, standards, methods and tools. (Arceli S. Maglaya pg.83)

Centro Escolar University College of nursing Makati Priority Setting (Case illustration or Priority setting) Name of Family: The Nicol Family Date: July 15, 2011 Completed by: Alban, James Vincent Magtibay, John Emmanuel Tan, Kevin Ranyll

Health Problems: Accident Hazard: Fall Hazard Criteria Computation Actual Score 1. Nature of the Problem 2/3 x1 0.66

Justification Immediate intervention is needed. It is a health threat.

INDIVIDUAL HEALTH CARE PROCESS (INITIAL DATABASE) Name of Students: Alban, James Vincent Magtibay, John Emmanuel Tan, Kevin Ranyll Year/Section/Group: BSN 2A/2A2 and 2A4 Family Name : The Nicol Family A. Biographical Information Name: Joan T. Nicol Address: Road3,Blk 9, Brgy, North Daang Hari Birthday: Sex: Female Race: Filipino Martial Status: Single Occupation: None Birthplace: Bicol Usual Source of Health Centers, Hospitals Date of Interview: July 14,2011

B. Chief Complaint There were no complaints from the client during the interview C. Present Illness/Present Health Status There were no illness mentioned by client. She was in good condition at that time. D. Past History The client experienced common childhood illness such as ferers, coughs and colds. She receive complete immunizations in the nearby Health Center in Brgy. North Duang Hari. She didnt experience accidents/injuries that triggered hospitalizations. She smokes and drinks alcohol only on occasions. E. Family History The client has no history of hereditary diseases in their family. F. Physical System 1. General Appearance The client has medium framed body with an upright posture. She walks in a smooth rhythmic walking gait. She is a appropriately dressed and is well groomed. She has no breath odor or body odor. There are no signs of any physical deformities. She is 410 in height and her weight is 42 kg. Hervital signs are as follows: Temp 37.0 C, BP 110/70 mmhg, PR=67 bpm , RR = 18cpm 2. Skin The clients skin is of normal racial tone which is brown, it is warm to touch, dry and smooth to touch. It has good elastic skin turgor and no presence of lesions. 3. Hair Hair is evenly distributed, shiny and thick. There are no presence of infestations Hair is black in color. 4. Nails Nails are convex 160,smooth, and it has pinkish nail bed color. Capillary refills within 3 seconds. 5. Head and face Head is proportionate to the body size with smooth contour. Scalp is white and free of infestations. Facial movements are symmetrical with easy movement. 6. Eyes Eyes are in straight normal condition, with effective closure of eyelids. Bilateral blink response are frequent. Eyeballs are symmetric with clear bulbar and pinkish palpebral conjunctiva. Pupils are equal in size, 2cm, with moist lacrimal apparatus. 7. Ears

Ears are light brown in color , symmetrical and elastic. Pinna recoils when folded and some cerumen are found in the external canal. The client responds to normal voice. 8. Nose and Sinuses Nose is for normal racial tone, located at the center of the face. Septum is at midline and muscosa are pink. Borth nasal pathways are patent with moist nasal cavity. Sinuses are non tender. 9. Mouth and Throath The client has pink symmetrical lips with pink oral mucosa. Tongue is located at the midline with rough texture , pink color and is movable. Teeth are complete and gums are pink in color. Gag reflex is present. Tonsils are not inflamed and uvula is located at the midline. 10. Breast Breast are symmetrical with round slightly flat contour. Smooth appearance and it has averted nipples. Lymph nodes are not palpable. 11. Chest and Lungs Has an AP to lateral ration 1:2 with symmetrical anterior & posterior chest expansion. Fremitus is symmetrical. Bronchial, vesicular and brochiovesicular sounds are heard. G. Sociological System Joan lives with her family in their house in Brgy. North Daang Hari in Taguig. She stopped finishing Highschool due to financial constraints. She often goes with her friends playing basketball and sometimes drink alcohol with them H. Phychological System The client is well adjusted to their way of lie. She doesnt complain of the things that happened in their lives. She is open to new teachings for her health. I. Nutritional Data 1. Dietary survey The client usually eats twice a day and her diet consist of rice vegetables but these days she has been eating soy sauce with rice because they couldnt buy foods that would provide their nutritional requirements 2. Clinical Appraisal She seeks medical attention in the nearby health center in their baranggay.

Centro Escolar University College of Nursing Makati Individual Health Care Process (Initial Database) Name of Students: Alban, James Vincent Magtibay, John Emmanuel Tan, Kevin Renyll Year/Section/Group: BSN 2-A / 2A2 & 2A4 Family Name : The Nicol Family A. Biographical Information Name: Julie Ann T. Nicol Address: Road 3, Blk 9,Brgy North Daang Hari, Taguig City Birthday: November 16,1995 Sex: Female Race: Filipino Religion: Roman Catholic Birthplace: Taguig City Source of reliability of information: Vicenta T. Nicol (Mother) Date of interview: July 15, 2011 B. Chief Complaint

 Masakit kapag umihi ako. , as verbalized by the client. Dalawang buwan na. C. Present Illness / Present Health Status The clients mother stated that she has no known sicknesses at the moment but she had a history of UTI. She also stated that she noticed her daughter experiences pain everytime she voids urine and it has been going on for two months.