Anda di halaman 1dari 13

PRACTICAL – 1

I. IDENTIFICATION OF THE FAMILY:

Name of head of the family: Mrs. Sarojamma

Address : House No.12, Sanyasi Hut – II


Gavipuram, Guttahalli,
Bangalore.

Nature of the family : Joint Family

Religion : Hindu

Caste : Gowda

Date : 25/01/06

II. FAMILY CHARACTERISTICS:


A. FAMILY COMPOSITION:

Sl. Name of Age Sex Relationshi Literacy Occupatio


No. the family p with head qualificatio n
member of the family n

1) Sarojamma 55 Yrs. F Head of the Nil Nil


family

2) Selva raj 33 Yrs. M Son 10th Clerk

3) Saraswathi 30 Yrs. F Daughter in 10th Nil


law

4) Ambinanda 4 Yrs. M Grand son LKG -


n

B. ECONOMIC STATUS:
House : Rented
Land : Nil
Main Occupation : Son is working as a clerk
Income of the family: Rs. 2,500/- month
C. RELATIONSHIP OF MEMBERS:
Family Members : There is healthy family relationship between family
members

Neighbours : There is good relationship with neighbour.

Health Personnel : They are cooperative with health personnel

Others : There is not much political involvement and they are


cooperative with the social organizations, working
there.

D. DECISION MAKING:
Whole family member together and taking decision for all the family
matters.

E. NUTRITION PATTERN:
Food is being prepared by Mrs. Saraswathi separate diabetic food for Mrs.
Sarojamma. They are cooking 3 times a day. There is no separate kitchen.
They are taking both vegetarian and non – vegetarian foods. Monthly three or
four times they are taking non – vegetarian food. There is no separate kitchen
garden. They are cooking the food very hygienically. The nutritional status of
the mother and child is moderate. Mrs. Sarojamma having some beliefs
regarding food habits.

F. TRANSPORT AND COMMUNICATION:


There is in front of their house. They are using public conveyance for
their transportation. There is no communication facilities in their house. There is
no specific leisure time activities.

III. ENVIRONMENTAL FACTORS:

A. HOUSING:
 Katcha house
 Roof - cement sheet
 Wall - Bricks
 Floor - Mud
 No. of rooms - 1
 There is no separate kitchen
 They are not having any domestic animals
Accidental Hazards:
There is a very big open drainage system in front of their house.

B. SANITATION:
1) There is no adequate light or ventilation in their house. There is electricity
in their house. They are disposing the waste in waste box, they are using
common latrine.

Water supply:
They are getting water from public tap.

Presence of insects:
There are mosquitoes, flies, and stray dogs.
PHYSICAL EXAMINATION
General Examination:
Name : Mrs. Saraswathi
Age : 30 years
General Appearance : Dull, moderately nourished
Body built : moderately built
Activity : Active

Posture:
Body curve : No lymphosis, lordosis, scoliosis
Movements : All range of motion is possible

Skin condition:
Colour : Dark in complexion
Texture : Firm
Lesions : No lesions seen
Temperature : Warm

Vital Signs:
Temperature : Normal
Pulse : 80 / mt
Respiration : 22 / mt
B.P : 130 / 80 mm Hg

Head and Face:


Scalp : Clean, healthy hair, no infections, no dandruff,
no pediculosis

Face : Not pale, no puffiness, no enlargement of


parotid gland
Eyes:

Eye brows : Normal


Eye lashes : No infection
Eye lids : No edema, no lesions, no ectropion, or
entropion
Eye ball : Not sunken
Conjuctiva : Normal
Pupil : Little opaque
Eye muscles : No squint
Vision : Cataract

Ears:
External ears : No discharge
Hearing : Normal

Nose:
External hares : No cuts or discharge
Nostrils : No inflammation of mucous membrane

Mouth and Pharynx:


Lips : No crusts or cyanosis
Odour of mouth : No foul smelling odour
Teeth : No discoloration or dental carries
Mucous membrane and gums : No bleeding or ulceration
Tongue : No lesion, tongue tie
Throat and pharynx : No enlarged tonsils

Neck:
Lymph nodes : Not enlarged or palpable
Thyroid gland : normal
Range of motion : All range of motion is possible
Chest:
Thorax : Symmetrical movement
Breath sound : Normal, bilateral air entry
Heart sound : Normal

Breast:
 No lumps felt on palpation

Abdomen:
 No scar, or ascites
 No enlargement of liver or spleen

Back:
Spine and curvature : No abnormalities noted
: No lumps or lesions
Symmetry : No abnormalities
Movement : All movements are possible
Tenderness : No tenderness detected

Genitalia:
 Normal female genitalia
 No abnormal discharge

Upper Extremities:
 No deformities noted, no swelling edema
 No muscle waisting
 No lymph nodes enlargement
 Normal range of motion possible

Blood Vessels:
 All peripheral pulse are felt
Fingers:
 No abnormalities, grip strength is good

Nails:
 No cyanosis
 No dryness or lesion

Lower Extremities:
 Both lower extremities
 No deformities
 No edema
 No muscle waisting
 Lymph nodes not palpable
 All range of motion possible

Nervous System:
Higher function : Conscious, coherent, answer to all questions
relevantly

Speech : Fluent speech, comprehension good


Cranial nerves : No abnormalities noted
Sensory function : Good
Reflexes : Normal in both, lower & upper extremities
ANTE – NATAL ASSESSMENT OF SARASWATHI:
1) Personal History:
Name of the mother : Mrs. Saraswathi
Age : 30 years
Marital status : Married
Address : Sanyasi Hut II, Gavipuram, Guttahalli,
Bangalore
Gravida : 2 para 1, Living – 1

2) Socio Economic History:


Religion : Hindu
Educational status : 10th Standard
Occupation : House wife
Income : Nil

3) Dietary History:
Non vegetarian

4) Family History:
type of Family : Nuclear family
disease : No illness

5) Previous Medical and Surgical History:


No chronic diseases

6) Obstetrics History:
LMP : 06/06/05
EUD : 13/03/06

7) Menstrual History:
age of puberty : 13 years
Menstruation : Regular
Flow : Normal / 3 days
8) History of previous pregnancies:
Number of pregnancy : 2
Date of delivery : 02/02/02
Full term : Yes
Weight at birth : 28 kgs
Condition during pregnancy: Normal
Condition during labour : Normal
Nature of labour : Normal
Nature of pure : Normal

9) Investigations:
Urine : Albumin / Sugar – Normal
Blood : Hb 12 gms
Weight : 55 kgs
BP : 120/80 mm of Hg
Height : 150 cms

10) Physical Examination:


Heart : Normal
Lungs : Normal
Breast and Nipples : Normal
General condition : Satisfactory
Skin : Normal
Vagina : No discharge
Oedema : No edema in the leg and no varicosities

11) Abdominal Examination:


Inspection : Head to toes – normal
Palpation : Height of the fundus – 32 weeks
Position : L.O.A.
Presentation : VX
Auscultation : 140 / min.
Risk factory any : No abnormalities

12) Antenatal Advice:


1) Explains about regular ante – natal check up
2) Explains about growth and development of the foetus
3) Explains about ante – natal diet
4) Explains about personal hygiene specially oral hygiene
5) Explains about ante – natal exercise
6) Explains about permanent family planning
7) Method or small family norm
8) Explains about taking care of the baby
9) Explains about safe delivery

Medication:
 Tab. Calcium T od 15 days
 Tab Iron and folic acid T od x 15 days

Action:
For the growth and development of the foetus for the formation of bones,
teeth and hair for increase RBC in the blood and prevention of anemia.

Nursing Diagnosis:
1) Explains the mother the importance of personal hygiene and taking rest
2) Altered nutritional status to increase body requirement and growth and
developments of the foetus
3) Explains the mother the importance of regular check up
4) Explains the mother about taking care of the baby
5) Explains the mother about small family norm
APPLICATION OF SISTER CALLISTA ROY’S ADAPTATION
THEORY:

Sister Callista Roy began her model and expanded from 1970 to the
present. She focused individual as a bio psychosocial adaptive system and
describe nursing as a humanistic discipline that places emphasis on the persons
own coping abilities. The model contain five essential elements:

1) Patency (patient / person receiving nursing care)

2) Goal of nursing (adapting to change) health environment and (direction of


nursing activities) (facilitating adaptation). Fill these elements are inter
related.

The individual is in constant interaction with the changing environment,


and the person has to adapt that the major concepts are,

Systems:
A system is a set of units related or connected as to form a unity or whole
and characterized by input, output, control and feed back processes.

Input is defined as stimuli which can come from the environment or from
with in a person.

Stimuli are:
1) Focal – immediately confronting the person
2) Contextual – all other stimuli that are present
3) Residual – non specific such as cultural beliefs or attitude about illness

Adaptation level:
Range of stimuli to which a person can adapt easily, each person’s
adaptation level is unique and constantly changing.

Coping Mechanisms:
These are processes or behaviour patterns that a person uses for self-
control. These are of two types.

1) Regular: It include input stimuli can come from the external environment
or from with in the person. Internal process includes chemical, endocrine
stimuli.

2) Cognator: It regulates self – concept role function and interdependence.


Adaptive models: Can be used to determine the person’s adaptation level.
a) Physiological Functions: It involves the body’s basic needs and
ways to adapt. Person’s pattern or oxygenation, nutrition,
elimination, activity and rest, skin integrity, senses, fluids and
electrolytes and endocrine functions.

b) Self – concept: It refers to beliefs and feelings about oneself.


Comprises of sensation, body image personal self, moral and
ethical self.

c) Role Function: It based on the persons position in the society is


dependent on how a person is interacts with others in a given
situation.

d) Interdependence mode: Involves person’s relationship with


significant others and support system.

Balance between dependent and independent behaviour. Meet the


person’s need for love, nurturing and affection.

Assessment of Mrs. Saraswathi with Roy’s Adaptation Model:


Physiological Adaptive Mode:

Oxygenation : Chest size and shape normal. Chest expansion


equal
on both sides and respirations are normal. Palpation
revealed no swelling or palpable lymph node.
Auscultation revealed no consolidations, rhales or
wheeze. Cardiac boarders well with in normal limits.
S1S2 heard. No problem identified in oxygenation.

Nutrition : Has no problem with appetite, digestion she has no


nausea and vomiting.

Elimination : She has no problems with elimination pattern bladder


and bowel are functioning normal.

Activity and rest : Because she is 8-month aminorrhoea she needs


more rest and antenatal exercise. Specially need
evening walk.

Protection : Due to pregnancy she should protected by infection


for her health as well as the growth of the foetus.

Fluid & electrolytes: The skin is moist and warm to touch.


Neurological function: Conscious, oriented speech is fluent.

Assessment of stimuli:
Focal - Pain in the back and the leg due to pregnancy
Residual - Anxious due to pregnancy

Interdependence Adaptive Mode:


Significant other: She is dependent on her husband
Support + system: Family members are cooperative and supportive

Assessment of stimuli: She is adapting to the new situation and coping up


with problem

Self – concept mode: She understands that she has to be adequate


nutrition, rest and need to take exercise, medication
and follow up etc.

Role Function Adaptive Mode:


She is anxious due to pregnancy. She is worried about her delivery and
the home maintenance.