Nursing Diagnosis Essay

CHAPTER 2 CLIENT’S PRESENTATION This is a case of a nuclear family that has a matriarchal type of authority. Family R is currently residing at La Paz, Makati City. They are consisting of eight members namely: Mr. MR, 38 years old, works as one of the utility that helps clean the barangay hall. On the other hand Mrs. RR, 31 years old is a housewife but she is a part of a community organization known as MADAC. The two are not married and are cohabitated.

They have 6 children namely: Mr. R1, 17 years old, Mr. R2, 15 years old, Ms. R3, 14 years old, Mr. R4, 13 years old, little Ms. R5, 4 years old and the youngest little Mr.

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R6, 3 years old. Currently the family is not complete because their eldest son R1 is in prison for 8 years already. According to Duvall’s family stages they are under the Family with School Age, Adolescents and Launching Center. Mr. R3 is also in the Child bearing stage. The researchers had their first interaction with the clients during their home visit last September 4, 2009 at exactly 9:00 am.

On the way to the Family P’s house, the researchers noticed that the environment is congested. The stairs and the hallway leading to the family’s door was narrow wherein one or two persons can pass at a time.

As the researchers passed by they notice that there were presence of insects, and rodents such as flies, cockroaches and rats. The stairs leading to the houses in the building also has poor lighting facility making it dark to pass through. Stagnant water was also present. The house is concrete and made up of wood. There was also trash scattered on the way and it has a peculiar smell and smoke. Upon entry to the family’s residence, the researchers introduced themselves and were welcomed inside. Then the mother greeted, “Pasensiya na maliit at magulo ang bahay. The house was divided into first, second floor and has 2 windows. Measurement is approximately 160 square centimeters and 18 inches high. There were 2 doors which were the main door and a door which was cut to become a window near the canal. The living room also serves as a multi purpose room for everyone –the living room, kitchen, and bedroom. The size of their living room is not enough for the family. Their appliances were also observed to be dusty. There was 1 electric fan, 1 TV and 1 DVD. There were some bulky cabinets as well as other storage compartments which were disorganized.

The kitchen wares were also scattered on the floor and uncovered. The family has a single burner stove as their cooking facility beside the comfort room. Their water supply is from NAWASA which they pay their neighbor for the gallons and pails they consumed for P1. 00 each. Their water is being stored in big bottles of Wilkins which are not sure if it can be reused. They get their water using a hose passing it through downstairs up to their comfort room. They also use it for drinking. The comfort room’s toilet facility is a “buhos” type or pail system.

It was noticed crowded with pails and with no tiles. It is divided by a shower curtain to the living room. They do their laundry outside and hang it outside. The garbage is placed outside in a half part of a 1 gallon container and their father collects it and throws outside the vicinity. They don’t segregate and it is mixed with different types of garbage. There is a canal at the back side of the house which they intend to make as an extension but due to lack of money it was still open. The canal also has garbage scattered and mostly are plastics and it has a peculiar bad smell that came from dead rats.

From these cues, Poor Environmental Sanitation specifically breeding sites for vectors of disease, inadequate living space, unsanitary waste disposal, poor lighting and ventilation, and air pollution was identified as Health Threat. The researchers also saw that there are 2 windows that divide the house and the canal; one is found in the comfort room. It was considered dangerous because the children climb from the canal going up the windows to pass the hose inside the house. As one of the researchers went up to the 2nd floor she found out that the entrance to it is through a ladder and a small hole enough for a single person to fit.

She noted that it was dangerous and with no handrails. It has a very low ceiling- even standing up is impossible to the level of the ceiling. Researcher also noticed a rusty protruding roof. Thus, Accident Hazards specifically Fall hazard as Health Threat was identified. Inside the room it has a big dirty mattress without a cover, a small storage compartment full of big bags, boxes and other things, a dusty electric fan, clothes hanged near the entrance and pillows and mattresses that are placed in the 1st floor for sleeping. Researchers interviewed the family with regards their home environment.

Family R rents their home which they pay for 430. 00 monthly but their last payment was way back 1991 and now does not pay for the rent. Their house is made up of both concrete and wood. The family’s lighting facility is electricity from a submitter connected to their neighbor’s meter. They just pay them every month approximately 1000 pesos as reported by the client for what they had consumed. The family’s type of neighborhood is congested. The barangay hall and health center are just two blocks from the client’s area which is very accessible.

Researchers then inquired about Ms. R3. Ms. R3 is a 14 year old, born on September 24, 1995. She is 5 months pregnant and is now in her 2nd trimester of pregnancy. History showed that she had her menarche at the age of 13 years old, has regular menses that lasted for three days with moderate flow. Mr. PA is her boyfriend, During the course interaction, the researchers found out that Ms. R3’s obstetric history revealed that she is G2P0 TPAL (OO10). She had her first pregnancy but it was accidentally aborted because she fell. Nung nasa Cr ako may lumabas na parang dugo na mabilog na sobrang liit, akala ko wala lang kaya itinapon ko” as verbalized by the client when asked about what happened. “Pero ayun sabi ni ma pumunta ako canter, eh takot ako kaya dito lang ako nagpahilot sa matanda, May buobuo pa kaya daw masakit sa loob” as verbalized by client when asked regarding what did she did after. Therefore, Pregnancy as a Foreseeable threat was identified. She stated that her last menstrual period was last April 15, 209. Her Age of Gestation (AOG) revealed that she is already 21 weeks.

The Expected Date of Confinement (EDC) will be on January 22, 2010. She does not drink alcohol but she admitted that she smokes a lot since she was 13 years old. She just keeps it a secret and she admitted that she was really interested on it to try. She indicated that her peers thought her about it. “Nagyoyosi ako hanggang ngayon, dati 2 kaha pero ngayon isa na lang siguro kada araw. ” As verbalized by the client. Thus Unhealthful lifestyle and personal habits/practices specifically cigarette smoking as Health Threat was identified.

When the researchers ask if she intend to stop smoking because she is pregnant she verbalized that “di rin mapigilan eh, madalang na nga ngayon. ”. – She is not picky when it comes to food. She usually eats rice, vegetables and meat but is also fond of eating junkfoods- “Pagkain, madalas kanin at ulam. ” “Madami, baboy, adobo, sinigang, hotdog” “pero mas mahilig ako sa sitsirya” as verbalized by the client. . Since client’s pre-natal check up she had stopped eating bitter foods and softdrinks. Thus, Potential for enhanced Capability for Healthy Lifestyle (Nutrition) was identified.

As the researchers interviewed the client about her sleeping pattern, she informed that she sleeps around 11pm at night in her boyfriend’s house and wakes up at 3-5am then sleeps again when she gets home to her parent’s house. The client also has a slight trouble in going to sleep. She is able to sleep at about an hour from the time she lies down on the bed. To help her sleep, she text her friends and watch television until she feels sleepy. Therefore, Unhealthful lifestyle and personal habits/practices specifically inadequate rest or sleep as Health Threat was identified. Ms. R3’s vital signs was taken and as follows: 36. C taken axillary (Normal Value 36. 5-37. 5 C); Pulse rate is 69 beats per minute (Normal Values: 60-100 beats per minute); Respiratory rate of 16 breaths per minute (Normal Values: 12-20 breaths per minute); and Blood pressure of 110/70 mmHg (Normal Values: 90/60-120/80 mmHg). There were no obvious physical deformities observed She has a full range of motions and has difficulty in sleeping. No apparent sign of acute distress noted. Her Fundic height revealed that a palpable uterus was located just above the symphysis pubis, however her fetal heart tone was not appreciated using a stethoscope. MR. PC was not around during the interaction Ms.

R3 verbalized, “ Nasa trabaho kasi siya. ” Then the researchers asked for the availability time of Mr. PC then Ms. R3 verbalized “Kakausapin ko muna siya tapos tignan ko na lang. ” After the interaction the researchers then asked consent for another home visit the next day upon which Mrs. RR granted. Second home visit was conducted the next day, September 5,2009. As the researchers passed by the hallway, they still noticed the presence of insects and rodents such as flies, roaches and dead rats. And the stairs were wet. Then the researchers were again welcomed inside. The researchers indicated what they saw outside and MRs.

RR verbalized “ Oo, dami nga pati dito sa may canal. ” The researchers then encourage the family to cover the window with the canal to prevent the smell and the garbage to go in the house. “ Diyan kasi sila dumadaan pag mag aakyat ng tubig kaya hindi muna. ” As verbalized by Mrs. RR. The researchers inquired for the availability of Mr. PC but Ms. R3 verbalized, “Wala pa siya, kaalis lang sa work pa. ” then the researchers asked for the possible day he is at home and was confirmed Saturday. The researchers then did the assessment for family. They finished getting the nursing history of Ms. R3.

She usually manages her problems with herself but sometimes she consults her family when she cannot stand it. Her significant other (boyfriend) already known her condition and was said to become thrill and was anxious regarding their baby. It was their second baby with the same man. The family had fully accepted her pregnancy and would not talk too much regarding it especially the father Mr. MR. “Sa pamilya at sa tropa ko” as verbalized by the client when asked about whom she can easily share her problems “Okay naman, masaya rin kahit ganito” as verbalized by client when asked her satisfaction in life.

She plans to study after giving birth and also when she reaches 18 she would marry her boyfriend. She is a Catholic but she indicated that she don’t go to church anymore nor try to pray. “Isang beses lang ata kami nagsimba, matagal na yun, nung bata pa” as verbalized by the client when asked about the family. She indicated that she attends “simbang gabi” with her peers. After getting the nursing History of Ms. R3, the researchers gather the nursing history of Mr. MR and Mrs. RR. Mrs RR, a 35 year old born on the 27th of May, 1971, female and is cohabitated with her partner.

They are residing at La Paz, Makati City. She is a housewife but she is a part of a community organization known as MADAC that helps her start a small business. She sells silver products, tocino and hotdogs. Researchers then inquired about Mrs. RR’s health condition. “Wala naman masakit o sakit. ” As verbalized by the client. She indicated that she maintains her health through taking a bath, eating regular meal pattern and drinking her medicines if she feels sick but incase it gets worse she immediately goes to the health center for consultation. She does not drink alcohol or smoke.

She has history of asthma attacks since childhood and the attacks are not that complicated anymore. Her doctor prescribed her to take Salbutamol as her medication but she indicated that it was not effective for her and it cost much so she takes Prednisone 5mg tablet 1 dose every night which is over the counter if she feels difficulty in breathing. She has no allergies. Mrs. RR doesn’t experience constipation and has reported that she has normal elimination. Mrs. RR usually wakes up in the morning, watch TV and do household chores such as the laundry and cooking. She also goes to the market to buy for food.

Sometimes she is the one who brings the young ones to the daycare and fetches them. She not active in exercise but she indicated that her routine everyday is already a exercise for her. She has history of asthma that is being controlled with medications when it occurs She can feed, bathe, go to the toilet, groom herself and move normally. She is able to maintain her home clean when she has visitors. The client has no trouble in going to sleep but sometimes she feels difficulty whenever she hears the clashing sound of pans and pots. History of present illness is unremarkable except for having asthma since childhood.

Past History noted that she already had mumps at the age of 7 with the treatment of dye with vinegar. She also had chickenpox at age 8 with the treatment of drinking egg yolk. She was hospitalized due to her asthma that she stayed for 2 days for nebulization. She already completed her Hepa b, rabies and tetanus toxoid immunization. Her current medication is Salbutamol 1 dose and she takes it if she feels difficulty in breathing. She has no allergies. Her menarche was when she was 12 years old. She menses monthly with 7 days duration and heavy in amount. Her last menstrual period was April 5, 2005.

Her Obstetric Score is G7P0 TPAL (0016). Family history revealed that her son has asthma and his father died of liver cancer. She indicated that she had increased weight. Review of systems is unremarkable except for lice in head and wheezes in pulmonary tract upon auscultation. The researchers checked Mrs. RR’s vital signs and reveled the following: 36. 7 C taken axillary (Normal Value 36. 5-37. 5 C); Pulse rate is 64 beats per minute (Normal Values: 60-100 beats per minute); Respiratory rate of 14 breaths per minute (Normal Values: 12-20 breaths per minute); and Blood pressure of 100/70 mmHg (Normal Values: 90/60-120/80 mmHg).

After getting the Nursing History of Mrs. RR, the researchers gather the Nursing History of Mr. MR . Mr. MR is a 31 year old, cohabitated and male. History of present illness is unremarkable except for having elevated blood pressure sometimes. His blood pressure elevates because of emotion (anger) and fatigue from work. He treats it with rest and there are no associated symptoms. Past history of illness was noted and the client already had rubella at the age of 6 and chicken pox at the age of 11. Both had unrecalled treatment given. He also had mumps at the age of 9 and it was treated with dye with vinegar.

He was already hospitalized because of a motorcycle accident and stayed in the hospital for 5 days. He indicated that he doesn’t have allergies. Family History was also noted that his father died of hypertension. His relative also died of stroke due to 2nd attack of hypertension. His food preferences are baboy and sinigang. He eats a regular meal pattern. He also indicated that he had increased weight. Review of system is unremarkable except for having lice and nits in his hair. The researchers checked Mr. MR’s vital signs and revealed the following: 37. 1 C taken axillary (Normal Value 36. 5-37. C); Pulse rate is 69 beats per minute (Normal Values: 60-100 beats per minute); Respiratory rate of 18 breaths per minute (Normal Values: 12-20 breaths per minute); and Blood pressure of 120/70 mmHg (Normal Values: 90/60-120/80 mmHg). The researchers opted to schedule another home visit the following day. The third Home visit was done last September 10, 2009. The researchers noticed that the hallway is still the same and when they reached the house, they were still eating their breakfast and began to clean their house. ” OO maaga nga pala kayo, nakalimutan ko, sige pasok na” as verbalized by Mrs. RR.

The researchers noticed that the clothes at the top of the cabinet was gone and was placed inside the washing machine. The plates are still inside one of the pails inside the comfort room. The researchers then reminded Mrs. RR that the plates would attract vectors and insects so they have to wash it right away. The researchers checked the availability of MS. R3’s significant other but he was at work so the researchers started to gather the nursing history of Mr. R2 and Mr. R4. Mr. R2 is a 15 year old and male. History of present illness was indicated to have productive cough and colds that started a day before.

It was describe with white secretions. The aggravating factor was the weather. He relieved it with rest and took Soxatrisil the night before. Past History revealed that he had mumps at the age of 7 and was treated with dye and vinegar. He also had chickenpox at the age of 5 which was relieved by putting powder. He has also completed his anti hepatitis and anti rabies immunizations. He indicated that he had increased weight. Review of systems is unremarkable except for lice and nits in his hair and has productive cough and colds. “Wala pa naman akong sakit sa ngayon. ” As verbalized by Mr.

R2. He maintains his health through taking hygiene and eating a regular meal pattern. He also includes brushing his teeth. He does smoke and drink alcohol but he indicated that he only drink during occasions. He started to smoke when he was 12 years old, it was out of curiosity and peer pressure. “Nagustuhan ko kasi. ” As verbalizes by Mr. R2. The client generally does undernourished. He weighs 35 kg and is 170 cm tall. His BMI is 12. 11 which is thin. He eats a regular eating pattern. He prefer eating rice, vegetables,ans sometimes fruits if available. He drinks water 7-8 glasses a day.

He doesn’t have difficulty in elimination twice a day. He does not feel difficulty in sleeping but he sleeps late. He also plays basketball with his peers as a way of exercising. He eats a regular meal pattern. The researchers checked Mr. R2’s vital signs and revealed the following: 36. 8 C taken axillary (Normal Value 36. 5-37. 5 C); Pulse rate is 71 beats per minute (Normal Values: 60-100 beats per minute); Respiratory rate of 19 breaths per minute (Normal Values: 12-20 breaths per minute); and Blood pressure of 120/60 mmHg (Normal Values: 90/60-120/80 mmHg). After taking the nursing history of Mr.

R2, the researchers gather the nursing history of Mr. R4. Mr R4 is 12 years old, single and male. History of present illness is unremarkable and experiences no pain. Past History noted that he already had mumps at the age of 7 with the treatment of dye with vinegar. He also had chickenpox at age of 7 with the treatment of rest and an antibiotic (unrecalled). He already completed her Hepatitis B immunization. Family history revealed that her brother and mother have asthma and his grand father died of liver cancer and hypertension. He indicated that he had increased weight. Review of systems is unremarkable except for lice in head. Bibong bibo. ” As verbalized by the client when asked to described health. He indicated that he maintains his health through eating nutritious foods, taking a bath, and exercise. “Bago kumain umiinom muna ako ng tubig para di magkaappendicitis kapag kanin masisira para di makasama. ” As verbalized by Mr. R4. He does not smoke and drink alcohol but he indicated that he tried drinking once. He drank alcohol because of his peers during a birthday party last 2008. He indicated that he goes to their clinic at school whenever he feels sick. ” May dentista, doctor at nurse sa clinic sa school. ” As verbalized by Mr.

R4. The client generally does look undernourished. He weighs 20 kg and is 126 cm tall. His BMI is 15. 87 which is thin. He eats a regular eating pattern. He prefer eating rice, vegetables,ans sometimes fruits if available. HE is also fun of eating sweets such as yema. He drinks water 7-8 glasses a day. Mr. R4 doesn’t experience constipation and has reported that he has normal elimination for a day. He has an exercise routine every morning such as doing push up, squatting and jumping jacks. He also play basketball with his peers at around 3 in the afternoon everyday unless it’s not raining.

He goes to school every afternoon so he has time to prepare every morning. As the researchers interviewed the client about his sleeping pattern, He indicated that he does not feel any difficulty sleeping at night and is able to sleep without disturbance. The researchers checked Mr. R2’s vital signs and revealed the following: 37. 2 C taken axillary (Normal Value 36. 5-37. 5 C); Pulse rate is 70 beats per minute (Normal Values: 60-100 beats per minute); Respiratory rate of 13 breaths per minute (Normal Values: 12-20 breaths per minute); and Blood pressure of 110/70 mmHg (Normal Values: 90/60-120/80 mmHg).

After the visit, the researchers scheduled another home visit for the next day. “Sige balik lang kayo. ” As verbalized by Ms. R3. Fourth home visit was done the following day September 11, 2009. The researchers noticed that the hallway is still the same but when they arrived at the house, the house was already clean and they are already awake. The children were waiting for the researchers outside the house. Researchers noted that the living room was finally organized and dusted as soon as they were welcomed inside.

Then the researchers checked the availability of the significant other and Ms R3 indicated that he has his day off tomorrow so the researchers scheduled the time. Physical Assessment was done to Mr. MR, Mrs. RR and Ms. R3. MR. MR’s physical examination revealed that upon taking the Vital Signs the temperature was taken 35. 8 C, pulse rate 68bpm, respiratory rate 16cpm and blood pressure of 110/80 mmHg. His weight is 50 kg and his height is 183 cm. His Body structure is short but he has asymmetrical scoliosis and his posture is slumped. The skin is smooth and dry, color is good and with no lesions and rashes.

There were no obvious physical deformities observed. He was overnourished, no apparent signs of distressnoted and has full range of motion. Assessment shows that both Mr. MR’s anterior and posterior’ lungs and thorax were symmetrical, has full expansion, was resonant when percussed and has normal breath sounds. Mrs. RR ‘s physical examination revealed that upon taking the vital signs the temperature was 37 C, pulse rate of 68 beats per minute, respiratory rate of 19 cycles per minute and blood pressure of 100/70 mmHg. She weighs 35 kg and is 143 cm tall. Her body structure is short but she stands erect and symmetrical.

There were no obvious physical deformities observed. She was undernourished, no apparent signs of distress noted and has full range of motion. Her Hair was observed dry, evenly distributed and the hair color is black with few brown highlights under. The Scalp was examined and it was normocephalic with no tenderness and no lesions but it was seen with lice and nits. Her teeth are yellowish and have missing cavities and dentures The breath sounds that can be heard is vesicular and wheezes was also noted. Ms. R3 physical examination revealed that Upon taking the Vital Signs, the temperature was 36. C, pulse rate of 64 bpm, respiratory rate of 14cpm and has a blood pressure of 90/70 mmHg. Her teeth are yellowish and have missing cavities and dentures The abdomen has a rounded contour which is common to pregnant women. . There was also Uterus-Hegar’s sign found. Upon measurement of the fundic height, it was 20 cm which is 21 weeks (AOG). Her motor function has full resistance and all her reflexes are normal. Examination of the breast was done and it was symmetrical, the areola is brownish, and the nipples were round with no masses and are soft in consistency.

Leopolds Maneuver procedure was done and it was identified that that presentation is Cephalic and the head is still floating over the inlet of the pelvis. The fetal heart tone is not highly appreciated using the stethoscope. After taking the physical examination of Mr. MR, Ms. RR and Ms. R3. Follow up questions regarding the interview was done. After the interaction, the researchers then asked consent for another home visit the next day upon which Mrs. RR granted. Fifth Home visit was conducted the next day September 12,2009. The researchers noticed that the house was still the same as the day before.

Researchers were welcomed inside and continued their observation, the living room was organized exept for the second floor which was disorganized. There were clothes hanging outside so the researchers presume that they woke up early. Two Water bottles has no caps. Purpose was restated by the researchers which was to finish the physical examination of the remaining members of the family. Mr. R2’s physical examination revealed that upon checking his Vital Signs and physical examination, the temperature was 36. 3 C, has a pulse rate: 89 beats per minute, respiration of 17 breaths per minute and a blood pressure of 100/80 mmHg.

He is short, standing 170cm and 35 kgs in weight. He stands erect and has symmetrical body structure. He is undernourished, 12. 11 BMI and with no apparent signs of distress. Body odor is also present. His teeth are yellowish and have Teeth are yellowish, with 3 cavities and 1 missing tooth. There were no obvious physical deformities observed. He was undernourished, no apparent signs of distress noted and has full range of motion. Assessment shows that both Mr. R2’s anterior and posterior’ lungs and thorax were symmetrical, has full expansion, was resonant when percussed and has normal breath sounds.

Mr. R4’s physical examination revealed that upon taking the Vital Signs, the temperature is 37 C, pulse rate of 82 beats per minute, respiratory rate of 16 breaths per minute and has a blood pressure of 90/60 mmHg. He is short, standing 49inches and 20 kgs in weight. He is undernourished with a BMI of 15. 87. He looks younger than his stated age. His Hair is Smooth, black, evenly distributed and has lice Her teeth are yellowish and have missing 2 cavities and 6 missing teeth. He was undernourished, no apparent signs of distress noted and has full range of motion.

Assessment shows that both Mr. R4’s anterior and posterior’ lungs and thorax were symmetrical, has full expansion, was resonant when percussed and has normal breath sounds. Ms. R5 physical examination revealed that upon Upon taking the vital signs, the temperature was 36. 5 C, has a pulse rate of 90 beats per minute and respiration of 20 cycles per minute. She is short, standing 37 inches and 12 kgs in weight. He stands erect and has symmetrical body structure. She is undernourished, 13. 58 BMI and with no apparent signs of distress. Her teeth are yellowish and have missing 6cavities.

Assessment shows that both Ms. R5’s anterior and posterior’ lungs and thorax were symmetrical, has full expansion, was resonant when percussed and has normal breath sounds. Mr. R6 physical examination revealed that upon taking his Vital Signs, the temperature was 36. 7 C, has a pulse rate of 92 beats per minute and has a respiration of 22 cycles per minute, He is short, standing 35. 43 inches and 10 kgs in weight. He stands erect and has symmetrical body structure. He is undernourished, 12. 34 BMI and with no apparent signs of distress. The lips are symmetrical and color is good.

His teeth are yellowish and have missing 5 cavities. Assessment shows that both Mr. R6’s anterior and posterior’ lungs and thorax were symmetrical, has full expansion, was resonant when percussed and wheezes. After the assessment of the family, the researchers thanked the family for the participation during the assessment and scheduled their home visit on Saturday. September 19,2009 for health teaching. They also informed the family about the next researchers that are going to continue the health teachings. “Sige salamat din. ” As verbalized by the MS. R3.

Cite this Nursing Diagnosis Essay

Nursing Diagnosis Essay. (2018, Feb 27). Retrieved from https://graduateway.com/nursing-diagnosis/

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