ST.

PAUL UNIVERSITY PHILIPPINES

TUGUEGARAO CITY 3500

SCHOOL OF HEALTH AND SCIENCES

A DOCUMENTATION OF THE ACTIVITIES

ON PRIMARY HEALTH CARE 101
(RLE)

1ST SEMESTER S.Y. 2009-2010

SUBMITTED BY:
ZAREX JOHN B. BACCAY
BSN 2-E

SUBMITTED TO:
MS. SARAVON LEGASPI RN
MS. OLIVE BECKER RN
PHC INSTRUCTORS

Table of Contents

I. Care of Individual Client

A. Client Profile

B. Client History

C. Physical Assessment

D. Nursing Care Plan

 II. Care of Family Client

A. Client profile

B. Client History

C. Family Nursing Care Plan

III. Learning feed back diary

IV. Appendix

A. Assessment tool

B. Photo Documentation of other activities

Client Profile

Name: M.C.G.
Address: (confidential)
Age: 16
Gender: Male
Contact Number: 09052640601
Birthday: November 28, 1992
Marital: Single
Religion: Roman Catholic
Health Care Financing:
Visual Source of Medication: Family Income
Nationality: Filipino
Occupation: Student
Client history
Client M.C.G experienced having measles during his childhood years. He receives
vaccinations like BCG vaccine, OPV, and Hepa-B vaccine, where it was the last vaccine that was
administered to him during his second year college. Client M.C.G doesn’t have any allergies.
Client M.C.G encountered motor was bump by a fast approaching car. He was treated by
bringing him to an “albularyo/manghihilot”. According to him there were no complications
regarding the treatment. He also verbalized that he was not confined to hospital.

Client M.C.G verbalized that he rarely feels difficulty in breathing whenever he

performed vigorous activities. There place is well ventilated because of the many trees and open
space. The client usually drinks coffee, water and concentrated juices. He takes 3 cups of coffee,
4-5 glasses of water and 1 glass of concentrated juice per day. The client gets their water supply
in a pump well. In every 5-6 times the client urinate; he does not feel any difficulty. The usual
characteristics of his urine are transparent yellow with not much odorous smell and an amount of
130mm.

Client M.C.G eats 3 times a day with a usual time of 7:00 am for breakfast, 12:00 noon
for lunch and 7:00 pm for dinner. The usual amount of his meal is 1 slice of meat, 1 cup of rice
and a bowl of vegetables. For client M.C.G, stress is the very primary factor that affect his
appetite where in he always encounter every time he got home after school. Client M.C.G does
not take any food supplements or vitamins. The client only defecates every morning before he
takes a bath. The usual characteristics of his feces are yellow/brown, with a not much foul odor
in small amount. He rarely feels difficulty in defecating every time he skips his bowel.

The client regularly has 4-5 hours of sleep and do not take naps. Client M.C.G has
difficulty in sleeping due to being a heavy coffee drinker, stress and environmental factors. He
improve his sleeping habit by reading a book before sleeping and having a room with complete
darkness

The usual activity he does is going to school. “I cannot find time to do exercise due to my
hectic schedule”, client verbalized. The client was circumcised when he was Grade 5 in summer
time.

For Client M.C.G., the physician is his source of medical care where in he verbalized,
They are very much available, accessible and effective for my medical care.”

Client M.C.G. verbalized that he has knowledge on self defense but not that much. They do
not have any first aid tools that are readily available. Client M.C.G. stated that he does not much
visit his physician for health check-up. He is now living with his parents and he stated that he is
very much safe with his family. The reason is that, they provide his needs and they show care on
him. Likewise, with his friends where in he feels relaxed if he is with them because for him, they
make him smile. Client M.C.G expressed that he feels safe in their community due to “baranggay
tanod” to maintain peacefulness. The clients owns the house where there are living now, wherein
the nearest establishment are the bank, school and cinema theater. According to him there are no
factories or dumpsites near their house.

Client M.C.G has a happy and close tied family. He get along with them through doing
household chores, watching TV and going to mass together. His family shows their support to
him through giving what he needs. In return, he shows love to his family by making them proud
of him and respecting them. His family is very important, because they are the reason why he
continuous to live. Client M.C.G verbalized that he prefers to be with his friends. He knows very
well his friend that makes him very much close with them. The client often goes out with his
friends when he is having free time and the usually activities they do chatting and eating
together. For the client, his friends show him how life lives to the fullest. The client is very
active in joining school organizations through the motivation of his friends and his talents that he
has. According to the client the usual problem he encounter to other people are insecurities and
misunderstanding. Client maintains his relationship with other people by respecting them and
time management. Client stated that he is accepted by other people by who he is. In return, he is
giving his service to others in his own capabilities.

Client described himself as a simple and a down to earth person. He verbalized that he is
contented for whom he is and what he had but do not close his self to any development.
According to him, he is more on a leader rather than a follower, because for him being a good
leader is a good follower. The client gain respect from others by respecting them also. To
finished studies and become a professional, and give a better future for his self, for his family,
and for his future family, is the clients goal and ambition. He also stated that in any
circumstances he can face everything with enough strength because he knows that his family, his
friends and BRO is there for him.

For client M.C.G, he is proud and very happy for every accomplishment he done.
According to him, being a student there are many things to accomplish and to achieve. The client
values much every past actions and decisions he make, because for him all those things
contributes for who he is now. He also forgive those people sinned against him through
accepting them again for who they are. According to the client, there are no things he hardly
accepted. He also verbalized that he does not yet gained the real wisdom. He values his wisdom
by sharing them to others like sharing his talent because he knows that is also GOD who gives it.
Client M.C.G view death as another step for a new life with GOD but now he is still not ready to
accept death because there are still things to accomplish here on earth.
 PHYSICAL ASSESSMENT

AREA METHOD/TECHNIQUE USED NORMAL FINDINGS ACTUAL FINDINGS

HEAD AND NECK

EARS

Symmetry Inspection Symmetrical Symmetrical

Color Inspection Color same as face Color same as face

Elasticity Palpation Pinna recoils after it is folded Pinna recoils after it is folded

NOSE

Symmetry Inspection Symmetrical Symmetrical

Color Inspection Light to deep brown Light to deep brown
Mucosa color Inspection Reddish to pinkish Pinkish
Nares Inspection Oval, symmetrical Oval, symmetrical
Sinuses Palpation Non-tender Non-tender
MOUTH

Lips
Color Inspection Pinkish Pinkish
Symmetry Inspection Symmetrical Symmetrical
Texture Palpation Soft, moist, smooth Soft, moist, smooth
Gums
Color Inspection Pinkish Pinkish
Teeth
Color Inspection Ivory/yellowish Yellowish
Tongue
Color Inspection Pinkish Pinkish
Symmetry Inspection Symmetrical Symmetrical
Mobility Inspection Moves freely Moves freely
NECK

Position Inspection Head-centered Head-centered

Movement Inspection Moves freely Moves freely
Range of motion Inspection Full range Full range
Thyroid glands
Consistency Inspection Moves upward when swallowing Moves upward when swallowing
Nodules and masses Palpation Absence of nodules and masses Absence of nodules and masses
CHEST AND THORAX

AREA METHOD/TECHNIQUE USED NORMAL FINDINGS ACTUAL FINDINGS

Posterior thorax

Symmetry Inspection Symmetrical Symmetrical

Spinal alignment Inspection Spine vertically aligned Spine vertically aligned

Skin integrity Palpation Skin intact Skin intact

Temperature Palpation Warm to touch Warm to touch

Nodules/Lesions Palpation Absence of nodules/lesions Absence of nodules/lesions

Chest expansion Palpation Full and symmetric Full and symmetric

Tactile fremitus Palpation Bilateral, symmetrical Bilateral, symmetrical

Anterior Thorax

Breathing pattern Inspection Breathing is automatic and effortless Breathing is automatic and effortless

Skin integrity Palpation Skin intact Skin intact

Temperature Palpation Warm to touch Warm to touch

Nodules/Lesions Palpation Absence of nodules/lesions Absence of nodules/lesions

NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTION RATIONALE

Subjective:  Encourage slower/deeper  To assist client in “taking control”
“Minsan nahihirapan Ineffective breathing pattern At the end of 1 hour, the client respiration, used ofpursed-lip of the situation.
din ako huminga” as related to respiratory muscle will enumerate 5-10 ways on technique, and so on.  Result in an effective breathing
verbalized by the client. fatigue as manifested by how he can improve his  Assist client in the use of pattern.
usage of accessory musles breathing pattern. relaxation techniques.  To know the significance of
Objective: when breathing and a  Teach conscious control of knowing the respiratory rate of
-respiratory rate: 14 respiratory rate of 14 respiratory rate. such.
cycle/min. cycle/min.  Encourage adequate rest periods  To limit fatigue.
- use of accessory between activities.
muscles to breathe
.
Subjective:
“Tuwing gabi Insomnia related to intake of At the end of 45 minutes the  Observe and/or obtain feedbacks  To determine usual sleep pattern
nahihirapan na akong stimulant such as coffee, client will be able to fromclient regarding his sleep and provide comparative baseline.
matulog” as verbalized by stress and environmental enumerate 7-10 ways to problems, usual bedtime, number  To enhance client’s ability to fall
the client. factors. improve his sleeping pattern. of hours of sleep, time of arising, asleep.
and environmental needs.  Worrying about not sleeping can
Objective:  Discuss /implement effective age- perpetuate the problem.
- Observed lack of appropriate bedtime rituals.  To aid in stress control/release of
energy.  Assure client that occasional energy.
- Visible dark sleeplessness should not threaten  Napping, especially in the
eyebags. health. afternoon, can disrupt normal
 Encourage participation in regular sleeping pattern.
exercise program during day.
 Recommend midmorning nap.
Subjective: Constipation related to At the end of 1 hour, the client  Instruct in/encourage a diet of  To improve consistency of stool
“Minsan nahihirapan irregular defecating habit will be able to enumerate balanced fiber and bulk. and facilitate passageway through
akong dumumi.” the client and habitual denial/ignoring ways on how he can improve  Promote adequate fluid intake, colon.
had verbalized. the urge to defecate as his bowel habit. including high-fiber juices.  To promote passage of soft stool.
manifested by straining with  Encourage activity/exercise within  To stimulate contractions of the
Objective: defecation. limits of individual ability. intestines.
- Hard formed stool.  Provide a routinely schedule time  So that client can respond to urge.
- Straining with for defecating.
defecation.
 Family Assessment
A. Family Structure, Characteristics and Dynamics

HOUSEHOLD AGE SEX CIVIL POSITION IN

MEMBERS STATUS THE FAMILY
Zaldy C. Baccay Sr. 46 Male Married Father
Carmelita B. Baccay 45 Female Married Mother
Zharmaine B. Baccay 20 Female Single Daughter
Zarex John B. Baccay 18 Male Single Son
Zaldy B. Baccay Jr. 7 Male Single Son
Corazon N. Briones Female Widow Grandmother
(Mother side)
Adelyn B. Cudal 19 Female Single Cousin

1. Place of Residence:

Living with the Family___ Elsewhere (Specify) ___

2. Type of Family:
 Nuclear___ Extended___

3. Who often decides regarding Family matters? Especially on health?

-Mother

4. Is communication Constant in your Family?

-Yes

5. How do you interact in your Family? Do you do same things together?

-Yes, like doing household chores, watching T.V and going to mass together.

B. Socio-economic and Cultural Characteristics.

NAME HOUSEHOLD Highest educational Occupation Place of Religious

MEMBERS attainment work affiliations
Zaldy C. Baccay Sr. High School Soldier North Roman Catholic
Graduate Cotabato
Carmelita B. Baccay College Graduate House wife Roman Catholic
Zharmaine B. Baccay College Student Roman Catholic
Zarex John B. Baccay College Student Roman Catholic
Zaldy B. Baccay Jr. Grade School Student Roman Catholic
Corazon N. Briones Roman Catholic
Adelyn B. Cudal High School Roman Catholic
Graduate

1. Individual income/ monthly(Please Check)

__P1000 below
__P1000-P2000
__P3000-P4000
__P5000-P6000
__P7000-P9000
__P1000-above
2. Adequacy to meet Basic necessities(Please Check)
__food
__water
__clothing
__shelter
__electricity
3. Indicate the decision Maker of the Family in terms of money matters.

-Mother
4. Significant others

Name of S.O. Relationship to the Family Role To the life Of the

Family
Siony M. Baccay Relative Adviser
Marible B. Tuliao Relative Adviser
Rommel N. Briones Relative Adviser
Gerry B. Gonzales Relative Adviser
Rogelio D. Bacccay Relative Adviser

5. Relationship of the Family in the larger Community

Member in the Community Organizations

HH Member Name of Type of Position Date of

Organizations Organization Membership
Zaldy C.
Baccay Sr.
 Carmelita B.
Baccay
Zharmaine B.
Baccay
Zarex John B.
Baccay
Zaldy B.
Baccay Jr.
Corazon N.
Briones
Adelyn B.
Cudal

C. Home Environment

1. House

 Adequacy of living space

__Spacious
__Crowded

 Sleeping Arrangement
__Sleep Together
__Sleep In Separate Room
C. Presence of accident hazards
 __River
__Field
__Highway
__Factory
d. Food Storage and Cooking Facilities
1. Food Storage
__Refrigerator
__Plastic Containers

2. Cooking Facilities
__Gas stove
__”Kalan”

e. Water Supply
1. Source:
__Open Wall
__Pump well
__River
__piped Water
__Spring
 __Refilling Station

2. Ownership:
__Personal Property
__Public Property
3. Is it safe to drink? Why?
__Yes
__No
If No: ________________________________________
f. Toilet Facility
1. Type:

__Flush Type
__Water Sealed
__If none of this,

Specify: ______________________________________

2. Ownership:
 __Private Property
__Public Property

3. Sanitary Condition:
__Clean and Safe
__Dirty and Not Conductive to Health
g. Garbage Disposal:
__Communal Pit
__Individual Pit
__Burning Pit
__Open Dumping
__”Wrap and throw”
h. Drainage System:

__Open
__Blind
__None

a. Sanitary Condition:
__Well Sealed
 __Clogged Drainage
__Sometimes Overflows
2. Kinds of Neighborhood

__Congested
__Not congested

3. Social and health Facilities

Facility used Location Service offered CHAR. Of used

4. Communication and Transportation facilities

a. Communication:

__News paper
 __TV
__telephone service
__Radio
__Word of mouth
__Cell phone
__Others, specify

b. Transportation
__Car
__Tricycle
__Pedicab
__Bus
__Kalesa
__Use of domestic animals

D. Health Status of each family Member

1.

Family Member Past significant illness Current Significant illness

Zaldy C. Baccay Sr. Mild Tuberculosis
 Carmelita B. Baccay
Zharmaine B. Baccay Mild Tuberculosis
Zarex John B. Baccay Dextroscoliosis
Zaldy B. Baccay Jr.
Corazon N. Briones
Adelyn B. Cudal Asthma Asthma

A. What are your beliefs and practices and that are conductive in terms of or illness?
-Cure the Family Members as soon as possible.

2.

Family Member Weight Height BMI

Zaldy C. Baccay Sr. 5’6
Carmelita B. Baccay 5’5
Zharmaine B. Baccay 5’5
Zarex John B. Baccay 5’7
Zaldy B. Baccay Jr.
Corazon N. Briones
Adelyn B. Cudal

A. How many times does your family eat per day?

 Family Member How many times
Zaldy C. Baccay Sr. 3
Carmelita B. Baccay 3
Zharmaine B. Baccay 3
Zarex John B. Baccay 3
Zaldy B. Baccay Jr. 3
Corazon N. Briones 3
Adelyn B. Cudal 3

B. What food does your family usually eat?

Food Amount
__vegetable

__Meats

__Fruits

__Fish

__Canned goods

__Noodles

__Other please
specify
C. Do you eat on time?
- Sometimes no because of busy schedule

4. Physical Assessment

Family Member Abnormalities Location

(If Present)
Present Absent
Zaldy C. Baccay Sr.
Carmelita B. Baccay
Zharmaine B. Baccay
Zarex John B. Baccay
Zaldy B. Baccay Jr.
Corazon N. Briones
Adelyn B. Cudal

5. Did any of the family members undergo laboratory examinations or diagnostic procedure? (If yes, answer the table below)

Family Member Laboratory Examination Results

Zaldy C. Baccay Sr.
Carmelita B. Baccay
Zharmaine B. Baccay
Zarex John B. Baccay
 Zaldy B. Baccay Jr.
Corazon N. Briones
Adelyn B. Cudal

E. Values and Practices on Health Promotion/ Maintenance? Disease Prevention

1. What are the vaccinations you’ve already taken?
- BCG vaccine and Hepa-B vaccine
2. Where do you seek medical assistance for simple illness?
__Private hospital/Clinic
__District Hospital
__Rural Health Care
__CHN worker
3. Reason for choosing the place of consultation
__Accessible
__ Accessible
__Effective /dependable
__Others, specify
5. Where do you usually medical assistance for complicated illness?
__Private hospital/Clinic
__District Hospital
__Rural Health Care
 __CHN worker
__Self-medication
__Others, specify
6. Reason for choosing the place of consultation
__ Accessible
__Effective /dependable
__Charges reasonable rate
__Others, specify

7. How often do you take a nap?

-Sometimes if tired.

8. How many hours do you sleep?

- 5-6 hours

9. What are the factors that help you attain a good sleep?
-read books before sleeping and a completely dark room.

10. Do you exercise daily?

-no
10. What are your exercise activities?
- doing household chores

11. Do you exercise with your family?

- yes

12. What are your relaxation activities?

-Watching television and sleeping

13. How often can you find time to relax?

- Few

14. Can you relax better with your family around?

-yes

15. What are the existing recreational activities in your community which your family participates in?
-None

16. How do you manage your stress?

 -I just take a long sleep

17. How do your stress management activities affect your family life?
- Easily become hot tempered if I’m in stress condition
Fncp
LFD
PHYSIOLOGIC NEEDS:

 Oxygenation:
1. How’s your breathing?

• How often do you feel this?

• What activities trigger this feeling?

 2. Is your place well ventilated?

• What provides ventilation to your place?

• Are there trees/other plants present in your community?

 Fluids:
1. Describe your fluid intake.

• What do you drink?

• How often do you drink this fluid?

• How much of this fluid do you drink?

2. Where do you get your water supply?

3. How often do you urinate?

4. Do you feel any discomforts in urinating?

• How often do you feel these discomforts?

5. What are the usual characteristics of your urine?

Color:
Odor:
 Amount:
Others:
(Blood stained, etch.)

 Food:

1. How many times do you eat in day (including snacks)?

• When is the usual time of your meal/snacks?

2. Description of meals: (usual)

- Components:

- Amount:

3. What factors affect your appetite?

• How often do you encounter these factors?

4. What are your food allergies?

5. What vitamins/food supplements do you take?

• How often?

6. How many times do you move your bowel?

 • Every what time do you defecate?

7. What are the usual characteristics of your feces?

Color:
Odor:
Amount:
Others:
(Blood stained,
etch.)

8. Do you have any difficulty in defecating?

• How often do you feel this difficulty?

• When do you usually experience this difficulty?

 Sleep:

1. How many hours of sleep do you regularly have?

• Do you take naps?

 • How long is it?

2. Do you have any difficulty in sleeping?

• What are those?

• What are the factors that affect your sleeping?

• What are your ways to improve your sleep?

3. Do you experience difficulties in performing those activities?

• What are those?

 Procreation:

 Male

1. When was your circumcision?

• Where did the circumcision happen?

 Female

1. What age did you have your first menarche/menstruation?

2. Do you regularly have monthly period?

• What is the usual duration of your menstruation?

 3. What difficulties do you experience when you have your menstruation?

(Optional questions for female clients)

1. How old are you when you had your first pregnancy?

2. Did you have difficulties in delivery? What are those?

 Either male or female:

1. When did you have your first coitus?

2. How many children do you have?

• What are their age gaps?’

3. Do you have any idea in family Planning?

4. What are your sources of knowledge about Family Planning?

5. What method do you Patronized?(Natural or Artificial)

• In artificial, Please specify:

 Source of medical care:

 1. Who is the source of your medical care?

2. How available/accessible is your source of medical care?

3. How effective is your medical source?

SAFETY AND SECURITY NEEDS

 To yourself:

1. Do you have any knowledge on self-defense?

• How well do you know it?

2. Do you have first aid tools which are readily available?

3. How often do you visit your physician for your health check up?

4. How stable is your job?

 To your family:

1. Are you living with your parents?

• If not, why? Who then do you turn to in tomes of needs?

2. Do you feel safe when you are with your friends?

• What made you say so?

  To your friends:

1. Do you feel safe when you are with your friends?

• What made you say so?

 To your community:

1. Do you feel safe in your community?

• What made you say so?

2. Is your working place safe?

• What made you say so?

3. When do you feel safe?

 To your house or property:

1. Do you have your own house?

2. What are the nearest establishments in your place?

• Do you live near factories or dumpsites?

LOVE AND BELONGINGNESS

 Family:

1. What kind of family do you have?

 2. Do you get along with your family?

• If yes, what activities do you usually do together?

• If no, what are the reasons why?

3. How does your family show their support to you?

4. In what ways do you love your family in return?

5. How important is your family in building your personality?

 Friends:

1. Which would prefer; to be alone or to be with your friends?

2. How close are you with your friends?

• How well do you know them?

3. How close are you with your friends?

• What activities do you usually do?

4. How does your circle of friends help in developing yourself?

 Society:

1. Do you associate yourself with the people in your society?

 2. What organizations/clubs are you into?

• How active are you?

• What motivated you?

3. What problems do you usually encounter when dealing with others?

4. How do you maintain your relationship with others?

5. In what way are you accepted by other people?

6. In what way you can show your love to others?

7. What services can you provide for the society?

SELF ESTEEM

1. How do you describe yourself?

2. If there is one thing you want to change or develop what would that be?

3. Are you a leader or a follower?

• How do you say so?

4. How do you gain respect to others?

 5. What are you goals, ambitions, and aspirations?

6. Do you have enough strength in facing all the challenges in life?

• In what circumstances?

7. Are you free of doing whatever you want?

• To what extent?

8. What is the worst problem encountered so far?

SELF ACTUALIZATION
1. What have you achieve so far?

2. How do you fell about your accomplishment?

3. What are those things that you still want to accomplish?

4. How do you show your contentment toward your goals/ achievements?

5. How do you value your past actions?

• Do you regret some of your past decisions?

• What do you think are the reasons why?

6. Have you forgiven those people who sinned against you? How?

7. What are the things hardly accept?

• What are the reasons why?

8. In your own perception, have you gained the real wisdom?

9. Where do you think is the source of your wisdom?

10. Haw do you value your wisdom?

 11. How do you view deaths?

12. At this point of life are you ready to accept death?

Vital signs:

Temperature:
Pulse Rate:
Respiratory Rate:
Blood Pressure:
Pain (depends on the client):
Remarks: