BULACAN STATE UNIVERSITY

COLLEGE OF NURSING
City of Malolos, Bulacan

Family Service and Progress Record

Name of Family: ___________________________________ Address: _________________________________________ I. Summary/ Significant Findings of ADB A. Demographic/ Socio-economic, Cultural, and Environmental Characteristics

Family Structure, Characteristics and Dynamics/ Relational Pattern Members of Household Members not Currently Living with Family Living with the Family

Social/ Cultural Characteristics

Home and Environmental

B. Health Status History of Present/ Current or Significant Past Illness Result of Responses, Laboratory/ Diagnostic and other Screening Procedure

Nutritional Assessment

Developmental Assessment

Risk Factor Assessment

Physical Assessment

C. Values, Habits, Practices on Health Promotion, Maintenance and Disease Prevention Belief Practices Immunization Status Antenatal Registration/ Family Planning Lifestyle Practices Awareness of Community/ DOH Health Programs

II.

Health Condition and Problem Sheet Health Conditions and Problems Family Nursing Problems Supporting Data/ Cues Date Identified Resolved Action/s taken, Responses and Evaluation of Outcomes

III.

Family Nursing Care Plan Evaluation Plan Health Condition Family Nursing Problem Objectives of Nursing Care Plan of Intervention Evaluation Criteria/ Indicators, Standards Methods Goals

BULACAN STATE UNIVERSITY

COLLEGE OF NURSING
City of Malolos, Bulacan

Teaching Plan
1 Semester, S.Y. 2011-2012 Brgy: ________________________ Purok: ___________ Name of Student: __________________________ Course/Year/Section: BSN-3C Group 2 Learning Objectives Learning Content Strategies Time Allotment Resources Evaluation
st

BULACAN STATE UNIVERSITY

COLLEGE OF NURSING
City of Malolos, Bulacan

Community Accomplishment Report

1st Semester, S.Y. 2011-2012 Brgy. Bagumbayan, Bulakan, Bulacan

Name of Student: __________________________ Course/Year/Section: BSN-3C Group 2 Target Dates Activities Facilitating Factors Inhibiting Factors Actual Output Evaluation Documents

BULACAN STATE UNIVERSITY

COLLEGE OF NURSING
City of Malolos, Bulacan

Instructional Plan
1st Semester, S.Y. 2011-2012 Brgy: ________________________ Purok: ___________ Name of Student: __________________________ Course/Year/Section: BSN-3C Group 2 Date/Venue Learning Objectives Target Population Actual Activities Alternative Activities Resource Person Resources Evaluation

BULACAN STATE UNIVERSITY

COLLEGE OF NURSING
City of Malolos, Bulacan

Family Nursing Care Plan

Name of Family: ___________________________________ Address: _________________________________________ Evaluation Plan Health Condition Family Nursing Problem Objectives of Nursing Care Plan of Intervention Evaluation Criteria/ Indicators, Standards Methods Goals

 Physical Assessment Name: Mrs. LBG

BODY PARTS ASSESSED A. GENERAL SURVEY 1. Body Built

TECHNIQUES

NORMAL FINDINGS

ACTUAL FINDINGS

REMARKS

Inspection

Proportionate, varies with lifestyle Proportionate

Normal Normal, because is the

2. Posture

Inspection

Relaxed,

erect

posture;

coordinated movement

Slightly slouched

client

exhausted

because of labor and delivery.

3. Gait 4. Overall grooming hygiene and

Inspection

Coordinated

Coordinated

Normal Deviation from normal

Inspection

Clean and neat

Sweaty

due

to

elevated

temperature of the room No body odor or minor body odor

5. Body and breath odor

Inspection

relative to work or exercise; no breath odor.

Normal

6. Sign

of

distress and

in Inspection No distress noted Facial grimace

posture expression

facial

Deviation from normal due to delivery

7. Obvious sign of health or illness 8. Vital Signs a. Temperature b. Pulse Rates c. Respiratory Rates d. Blood Pressure B. MENTAL STATUS 1. Clients affect/mood;

Inspection

Healthy appearance

Healthy appearance

Normal

Inspection Palpation Auscultation Palpation

36.5C- 37.5C 60-100 beats/min 12-20 breaths/min 120/80 mmHg

37C 74 beats/min 21 breaths/min 120/90mmHg

Normal Normal Normal Normal

Understandable, moderate pace; Inspection exhibits thought association.

appropriateness of the clients responses. 2. Orientation 3. Emotional Status

Responses are appropriate to the situation Oriented Cooperative

Normal

Inspection Inspection

Oriented Cooperative

Normal Normal

4. Language Communication C. SKIN

and

Inspection

Voice at normal pace

Voice at normal pace

Normal

Varies from light to deep brown; Client has a skin color of light Normal. 1. Color Inspection from ruddy pink to light pink; from brown. Linea nigra is present pigmentation yellow overtones to olive; midline in her abdomen. Striae pregnancy

Increase in due level to of

generally uniform. Linea nigra, Gravidarum is present in both increase

Chloasma and Striae Gravidarum sides of her abdomen. Chloasma melanocytes. may be present. is also evident on her face and neck 2. Temperature Palpation Within normal range Moisture in skin folds and axillae Temperature range There is moisture in skin folds and the axillae of the client. Edema may be present in within normal Normal

3. Moisture

Palpation

Normal

pregnant woman in her feet. Also 4. Edema Palpation present in the perineum because No edema of the excessive pressure in the perineum while giving birth. 5. Texture 6. Turgor Palpation Inspection palpation Smooth and Springs back immediately Smooth Skin springs back when pinched (less than a second) No lesions; with Striae Normal Normal Normal, increase Normal

7. Lesions

Inspection palpation

and

Freckles, some birthmarks, some flat and raised nevi; no abrasions or other lesions

gravidarum on her waist; with linea nigra in the midline of her abdomen Evenly distributed

pigmentation in the skin of a pregnant woman is normal due to increase melanocytes Normal

8. Hair Distribution

Inspection

Evenly distributed

D. NAILS 1. Nail plate and shape 2. Nail condition/texture Inspection Inspection No clubbing ; convex curvature; No clubbing ; convex curvature; 160 nail plate angle Smooth Highly vascular and pink in lightskinned 3. Nail bed color Inspection clients; dark-skinned Fingernail and toenail bed color is pink. 160 nail plate angle Smooth Normal Normal

clients may have brown or black pigmentation streaks in longitudinal

Normal

4. Tissues nails

surrounding

Inspection Inspection palpation

Intact epidermis

Intact epidermis

Normal

5. Capillary refill E. HEAD AND FACE

and Prompt return of pink or usual Prompt capillary refill within color (generally less than 4 sec) 3sec.

Normal

1. Skull

Inspection palpation Inspection palpation

and

Normocephalic,

symmetrical,

smooth skull contour, absence of nodules or masses

Client has a smooth, rounded and symmetrical skull.

Normal

2. Scalp

and White, no dandruff, no nodules, White, no dandruff, no nodules, no tenderness Fine, black, thick, no tenderness evenly Fine, black, thin, evenly

Normal

3. Hair condition

Inspection an palpation

distributed, no infestations

distributed, no infestations

Normal

4. Face a. Symmetry b. Facial Movement F. EYES 1. Eye condition Inspection Straight normal, non protruding Skin 2. Eyebrows Inspection intact, hair Straight normal, non protruding intact, hair evenly Normal Inspection Inspection Symmetrical No involuntary facial movement Symmetrical No involuntary facial movement Normal Normal

evenly Skin

distributed, symmetrically aligned, distributed, equal movement

symmetrically Normal

aligned, equal movement

Skin intact, no discharge, lids close Skin intact, no discharge, lids symmetrically, no visible sclera close symmetrically, no visible 3. Eyelids and Eyelashes Inspection above corneas and upper and sclera above corneas and upper Normal lower borders of corneas are and lower borders of corneas slightly covered 4. Blink Response Inspection are slightly covered Normal

Approximately involuntary blink Approximately involuntary blink per minute Transparent, capillaries per minute (17 blinks/minute) Transparent, capillaries evident, sclera appears white No edema or tenderness No edema or tearing

5. Bulbar Conjunctiva

Inspection

sometimes evident, sclera appears white

Normal

6. Lacrimal gland 7. Lacrimal duct and

Palpation Inspection

No edema or tenderness and No edema or tearing

Normal Normal

nasolacrimal duct 8. Cornea

palpation Inspection Transparent, shiny and smooth; Transparent, shiny and smooth; iris are visible iris are visible Normal

9. Pupils a. Reaction to light Inspection b. Visual Acuity c. Visual Fields

Pupils equally round react to light Round and equal pupils and accommodation Able to read news paper Able to read newspaper Normal

When looking straight ahead, Client can see objects when Normal client can see objects in the looking straight ahead periphery Normal

10. Extra tests G. EARS 1. Auricles

ocular

muscle

Inspection

Both eyes coordinated, move in Both eyes coordinated, move in unison, with parallel alignment unison, with parallel alignment

Normal

a. Color b. Symmetry Position and Inspection

Same in facial skin

Same in facial skin auricle

Normal aligned Normal

Symmetrical, auricle aligned with Symmetrical,

outer canthus of eye. About10 with outer canthus of eye. from vertical About10 from vertical

Mobile, firm, and not tender; Mobile, firm, and not tender; c. Texture Elasticity and pinna; recoils after it folded pinna; recoils after it folded Normal

2. External ear canal and tympanic membrane Inspection

Dry cerumen, grayish- tan color, Dry cerumen, grayish- tan color, sticky wet cerumen, tympanic sticky wet cerumen, tympanic membrane is pearly gray, membrane is pearly gray, Normal,

semitransparent 3. Gross tests H. NOSE 1. External 2. Nasal septum 3. Patency of nasal cavity 4. Nasal cavities 5. Sinuses I. MOUTH Inspection Inspection Inspection Inspection Palpation Symmetrical and straight, hearing acuity Normal voice tones audible

semitransparent

Inspection

Normal voice tones audible

Normal

no Symmetrical and straight, no discharge, no flaring Intact and in midline

discharge, no flaring Intact and in midline

Normal Normal Normal Normal Normal

Air moves freely as the client Air moves freely as the client breath through the nares Mucosa pink with discharge Not tender breath through the nares Mucosa pink with discharge Not tender

Pink in color, soft and moist, Pink in color, soft and moist, 1. Lips Inspection smooth texture, symmetrical, no smooth texture, symmetrical, no Normal tenderness and no lesions 2. Mucosa Inspection Pink, no inflammation, no lesions tenderness and no lesions Buccal mucosa is moist, smooth and pink in color. There were no Normal

lesions noted. 3. Teeth Inspection White or yellowish teeth, smooth and shiny, 32 adult teeth Yellowish teeth Normal

4. Gums

Inspection

Pink gums; moist, firm texture of Pink gums, smooth, no lesions, gums; no retractions of gums no discharge, moist

Normal

5. Tongue a. Surface tongue Inspection b. Base of the tongue of the Inspection Place at the midline, pink color, moves freely Smooth tongue base with Place at the midline, pink color, Normal moves freely Smooth tongue base with Normal

prominent veins

prominent veins Normal

c. Floor of the mouth

Inspection

No lesions

No lesions

Normal

6. Salivary glands

Inspection

Same as color of buccal mucosa Same as color of buccal mucosa and floor of the mouth Light pink, smooth, soft palate. and floor of the mouth Light pink, smooth, soft palate.

Normal

7. Palates

Inspection

Lighter pink hard palate, more Lighter pink hard palate, more Normal irregular texture irregular texture Normal

8. Uvula

Inspection

Position in midline of the soft Position in midline of the soft palate palate

J. PHARYNX 1. Mucosa 2. Tonsils K. NECK Muscle 1. Neck Muscles Inspection equal in size; head Muscle equal in size; head Inspection Inspection Uniform pink color; moist, smooth texture and glistening Pink and smooth. No discharges No lesions Pink and smooth. No discharges Normal Normal

centered. Coordinated, smooth centered. Coordinated, smooth Normal movements with no discomfort movements with no discomfort Normal Normal

2. Test for Muscle Strength 3. Lymph Nodes

Inspection Palpation Inspection palpation Palpation and

100% of equal strength on both 100% of equal strength on both sides of the body Not palpable sides of the body Not palpable

Central placement in midline of Central placement in midline of neck; spaces are equal in both neck; spaces are equal in both Normal sides Lobes not palpable sides Lobes not palpable Normal

4. Trachea

5. Thyroid Gland L. THORAX AND LUNGS Posterior Thorax

Anteroposterior 1. Chest/Lung expansion Inspection

to

transverse Anteroposterior to transverse Normal

diameter in ratio of 1:2, chest diameter in ratio of 1:2, chest symmetric. Skin intact. Uniform symmetric. Skin intact. Uniform temperature. Chest wall intact; no temperature. Chest wall intact;

tenderness; no masses 2. Respiratory excursion Anterior Thorax 1. Breathing Pattern Inspection Inspection Full symmetry chest expansion

no tenderness; no masses Full symmetry chest expansion Normal

Quiet, rhythmic and effortless Client has quiet, rhythmic and respirations. efforless breathing. Full and symmetric chest

Normal

2. Respiratory excursion

Inspection

Full

and

symmetric

chest expansion.

expansion.

Normal

M. ABDOMEN Unblemished skin, uniform color. Unblemished 1. Skin Integrity Inspection No evidence of enlargement of color. liver or spleen 2. Contour and Symmetry Inspection Symmetric contour No skin, uniform of Normal

evidence

enlargement of liver or spleen Symmetric contour Normal

3. Abdominal Movement a. Respiration b. Peristalsis c. Pulsations Inspection Inspection Symmetric movement Peristalsis in not visible Symmetric movement Peristalsis in not visible Normal Normal

Palpation and inspection Aortic pulsation in thin person in Aortic pulsation in thin person in Normal epigastric area epigastric area No visible vascular pattern Normal

4. Vascular pattern

Inspection

No visible vascular pattern

5. Auscultation abdomen

of

the

a. Bowel sounds b. Vascular sounds c. Peritoneal Rub Friction

Auscultation Auscultation Inspection

Audible vowel sound Absence of arterial bruits Absence of friction rub

Audible vowel sound Absence of arterial bruits Absence of friction rub

Normal Normal Normal

6. Areas of tenderness

Palpation

No tenderness; relaxed abdomen

No tenderness

Normal

N. MUSCULO-SKELATAL SYSTEM 1. Muscle size Inspection Equal site on both side of the Equal site on both side of the body body Normal

No contractures, no tremors. No contractures, no tremors. 2. Muscle tone Inspection Normally firm, smooth coordinate Normally movement 3. Muscle strength Inspection Equal strength on each body site firm, smooth Normal

coordinate movement She has equal strength on each side of her body. Normal