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BULACAN STATE UNIVERSITYCOLLEGE OF NURSING

City of Malolos, Bulacan

Family Service and Progress Record

Name of Family: ___________________________________

Address: _________________________________________

I. Summary/ Significant Findings of ADBA. Demographic/ Socio-economic, Cultural, and Environmental Characteristics

Family Structure, Characteristics and Dynamics/

Relational PatternSocial/ Cultural Characteristics Home and Environmental

Members of HouseholdLiving with Family

Members not CurrentlyLiving with the Family


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B. Health Status

History of Present/

Current or Significant

Past Illness

Nutritional AssessmentDevelopmental

AssessmentRisk Factor Assessment Physical Assessment

Result of Responses,

Laboratory/ Diagnostic

and other Screening

Procedure


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C. Values, Habits, Practices on Health Promotion, Maintenance and Disease Prevention

Belief Practices Immunization StatusAntenatal Registration/

Family PlanningLifestyle Practices

Awareness of Community/

DOH Health Programs


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II. Health Condition and Problem SheetHealth Conditions and

ProblemsFamily Nursing Problems Supporting Data/ Cues

Date Action/s taken, Responses

and Evaluation of OutcomesIdentified Resolved


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III. Family Nursing Care Plan

Health ConditionFamily Nursing

Problem

Objectives of Nursing

CarePlan of Intervention

Evaluation Plan

Evaluation

Criteria/

Indicators,

Standards

Methods Goals


6/20



Teaching Plan1st 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


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Community Accomplishment Report1st Semester, S.Y. 2011-2012

Brgy. Bagumbayan, Bulakan, Bulacan

Name of Student:__________________________


Target Dates Activities Facilitating Factors Inhibiting Factors Actual Output Evaluation Documents


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Instructional Plan1st Semester, S.Y. 2011-2012

Brgy: ________________________ Purok: ___________

Name of Student:__________________________


Date/VenueLearning

Objectives

Target

PopulationActual Activities

Alternative

ActivitiesResource Person Resources Evaluation


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Family Nursing Care Plan

Name of Family: ___________________________________

Address: _________________________________________

Health ConditionFamily Nursing

Problem

Objectives of Nursing

CarePlan of Intervention

Evaluation Plan

Evaluation

Criteria/

Indicators,

Standards

Methods Goals


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Physical Assessment

Name: Mrs.LBG

BODY PARTS ASSESSED TECHNIQUES NORMAL FINDINGS ACTUAL FINDINGS REMARKS

A. GENERAL SURVEY1. Body Built Inspection Proportionate, varies with lifestyle Proportionate Normal

2. Posture InspectionRelaxed, erect posture;

coordinated movementSlightly slouched

Normal, because the

client is exhausted

because of labor and

delivery.

3. Gait Inspection Coordinated Coordinated Normal

4. Overall hygiene and

groomingInspection Clean and neat Sweaty

Deviation from normal

due to elevated

temperature of the room

5. Body and breath odor Inspection

No body odor or minor body odor

relative to work or exercise; no

breath odor.

Normal

6. Sign of distress in

posture and facial

expression

Inspection No distress noted Facial grimaceDeviation from normal

due to delivery


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7. Obvious sign of health

or illnessInspection Healthy appearance Healthy appearance Normal

8. Vital Signs

a. Temperature

b.

Pulse Rates

c. Respiratory Rates

d. Blood Pressure

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

B. MENTAL STATUS1. Clients affect/mood;

appropriateness of the

clients responses.

Inspection

Understandable, moderate pace;

exhibits thought association.Responses are appropriate to

the situationNormal

2. Orientation Inspection Oriented Oriented Normal

3. Emotional Status Inspection Cooperative Cooperative Normal

4. Language and

Communication

Inspection Voice at normal pace Voice at normal pace Normal

C. SKIN

1. Color Inspection

Varies from light to deep brown;

from ruddy pink to light pink; from

yellow overtones to olive;

generally uniform. Linea nigra,

Client has a skin color of light

brown. Linea nigra is present

midline in her abdomen. Striae

Gravidarum is present in both

Normal. Increase

pigmentation in

pregnancy due to

increase level of


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Chloasma and Striae Gravidarum

may be present.

sides of her abdomen. Chloasma

is also evident on her face and

neck

melanocytes.

2. Temperature Palpation Within normal rangeTemperature within normal

range

Normal

3. Moisture PalpationMoisture in skin folds and axillae There is moisture in skin folds

and the axillae of the client.Normal

4. Edema Palpation

Edema may be present in

pregnant woman in her feet. Also

present in the perineum because

of the excessive pressure in the

perineum while giving birth.

No edema Normal

5. Texture Palpation Smooth Smooth Normal

6. TurgorInspection and

palpation

Springs back immediately Skin springs back when pinched

(less than a second)Normal

7. LesionsInspection and

palpation

Freckles, some birthmarks, some

flat and raised nevi; no abrasions

or other lesions

No lesions; with Striae

gravidarum on her waist; with

linea nigra in the midline of her

abdomen

Normal, increase

pigmentation in the skin

of a pregnant woman is

normal due to increase

melanocytes

8. Hair Distribution Inspection Evenly distributed Evenly distributed Normal


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D. NAILS1. Nail plate and shape Inspection

No clubbing ; convex curvature;

160 nail plate angle

No clubbing ; convex curvature;

160 nail plate angleNormal

2. Nail condition/texture Inspection Smooth Smooth Normal

3. Nail bed color Inspection

Highly vascular and pink in light-

skinned clients; dark-skinned

clients may have brown or black

pigmentation in longitudinal

streaks

Fingernail and toenail bed color

is pink.Normal

4. Tissues surrounding

nailsInspection Intact epidermis Intact epidermis Normal

5.

Capillary refill

Inspection and

palpation

Prompt return of pink or usual

color (generally less than 4 sec)

Prompt capillary refill within

3sec.Normal

E. HEAD AND FACE

1. SkullInspection and

palpation

Normocephalic, symmetrical,

smooth skull contour, absence of

nodules or masses

Client has a smooth, rounded

and symmetrical skull.Normal

2. ScalpInspection and

palpation

White, no dandruff, no nodules,

no tenderness

White, no dandruff, no nodules,

no tendernessNormal

3. Hair conditionInspection an palpation

Fine, black, thick, evenly

distributed, no infestations

Fine, black, thin, evenly

distributed, no infestationsNormal


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4. Face

a. Symmetry

b. Facial Movement

Inspection

Inspection

Symmetrical

No involuntary facial movement

Symmetrical

No involuntary facial movement

Normal

Normal

F. EYES1. Eye condition Inspection Straight normal, non protruding Straight normal, non protruding Normal

2. Eyebrows Inspection

Skin intact, hair evenly

distributed, symmetrically aligned,

equal movement

Skin intact, hair evenly

distributed, symmetrically

aligned, equal movement

Normal

3. Eyelids and Eyelashes Inspection

Skin intact, no discharge, lids close

symmetrically, no visible sclera

above corneas and upper and

lower borders of corneas are

slightly covered

Skin intact, no discharge, lids

close symmetrically, no visible

sclera above corneas and upper

and lower borders of corneas

are slightly covered

Normal

4. Blink Response InspectionApproximately involuntary blink

per minute

Approximately involuntary blink

per minute (17 blinks/minute)Normal

5. Bulbar Conjunctiva Inspection

Transparent, capillaries

sometimes evident, sclera appears

white

Transparent, capillaries evident,

sclera appears whiteNormal

6.

Lacrimal gland Palpation No edema or tenderness No edema or tenderness Normal

7. Lacrimal duct and Inspection and No edema or tearing No edema or tearing Normal


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nasolacrimal duct palpation

8. Cornea InspectionTransparent, shiny and smooth;

iris are visible

Transparent, shiny and smooth;

iris are visibleNormal

9.

Pupils

a. Reaction to light

b. Visual Acuity

c. Visual Fields

Inspection

Pupils equally round react to light

and accommodation

Able to read news paper

When looking straight ahead,

client can see objects in the

periphery

Round and equal pupils

Able to read newspaper

Client can see objects when

looking straight ahead

Normal

Normal

Normal

10.Extra ocular muscle

testsInspection

Both eyes coordinated, move in

unison, with parallel alignment

Both eyes coordinated, move in

unison, with parallel alignmentNormal

G. EARS1. Auricles

a. Color

b. Symmetry and

Position

c.

Texture and

Elasticity

Inspection

Same in facial skin

Symmetrical, auricle aligned with

outer canthus of eye. About10

from vertical

Mobile, firm, and not tender;

pinna; recoils after it folded

Same in facial skin

Symmetrical, auricle aligned

with outer canthus of eye.

About10 from vertical

Mobile, firm, and not tender;

pinna; recoils after it folded

Normal

Normal

Normal


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2. External ear canal and

tympanic membrane Inspection

Dry cerumen, grayish- tan color,

sticky wet cerumen, tympanic

membrane is pearly gray,

semitransparent

Dry cerumen, grayish- tan color,

sticky wet cerumen, tympanic

membrane is pearly gray,

semitransparent

Normal,

3. Gross hearing acuity

testsInspection

Normal voice tones audibleNormal voice tones audible Normal

H. NOSE1. External Inspection

Symmetrical and straight, no

discharge, no flaring

Symmetrical and straight, no

discharge, no flaringNormal

2. Nasal septum Inspection Intact and in midline Intact and in midline Normal

3.

Patency of nasal cavity Inspection

Air moves freely as the client

breath through the nares

Air moves freely as the client

breath through the naresNormal

4. Nasal cavities Inspection Mucosa pink with discharge Mucosa pink with discharge Normal

5. Sinuses Palpation Not tender Not tender Normal

I. MOUTH

1. Lips Inspection

Pink in color, soft and moist,

smooth texture, symmetrical, no

tenderness and no lesions

Pink in color, soft and moist,

smooth texture, symmetrical, no

tenderness and no lesions

Normal

2. Mucosa InspectionPink, no inflammation, no lesions Buccal mucosa is moist, smooth

and pink in color. There were noNormal


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lesions noted.

3. Teeth InspectionWhite or yellowish teeth, smooth

and shiny, 32 adult teethYellowish teeth Normal

4. Gums InspectionPink gums; moist, firm texture of

gums; no retractions of gums

Pink gums, smooth, no lesions,

no discharge, moist

Normal

5. Tongue

a. Surface of the

tongue

b. Base of the tongue

c. Floor of the mouth

Inspection

Inspection

Inspection

Place at the midline, pink color,

moves freely

Smooth tongue base with

prominent veins

No lesions

Place at the midline, pink color,

moves freely

Smooth tongue base with

prominent veins

No lesions

Normal

Normal

Normal

Normal

6. Salivary glands InspectionSame as color of buccal mucosa

and floor of the mouth

Same as color of buccal mucosa

and floor of the mouthNormal

7. Palates Inspection

Light pink, smooth, soft palate.

Lighter pink hard palate, more

irregular texture

Light pink, smooth, soft palate.

Lighter pink hard palate, more

irregular texture

Normal

8. Uvula InspectionPosition in midline of the soft

palate

Position in midline of the soft

palateNormal


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J. PHARYNX1. Mucosa Inspection

Uniform pink color; moist, smooth

texture and glisteningNo lesions Normal

2. Tonsils Inspection Pink and smooth. No discharges Pink and smooth. No discharges Normal

K. NECK1. Neck Muscles Inspection

Muscle equal in size; head

centered. Coordinated, smooth

movements with no discomfort

Muscle equal in size; head

centered. Coordinated, smooth

movements with no discomfort

Normal

2. Test for Muscle Strength Inspection100% of equal strength on both

sides of the body

100% of equal strength on both

sides of the bodyNormal

3. Lymph Nodes Palpation Not palpable Not palpable Normal

4. TracheaInspection and

palpation

Central placement in midline of

neck; spaces are equal in both

sides

Central placement in midline of

neck; spaces are equal in both

sides

Normal

5. Thyroid Gland Palpation Lobes not palpable Lobes not palpable Normal

L. THORAX AND LUNGSPosterior Thorax

1. Chest/Lung expansion Inspection

Anteroposterior to transverse

diameter in ratio of 1:2, chest

symmetric. Skin intact. Uniform

temperature. Chest wall intact; no

Anteroposterior to transverse

diameter in ratio of 1:2, chest

symmetric. Skin intact. Uniform

temperature. Chest wall intact;

Normal


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tenderness; no masses no tenderness; no masses

2. Respiratory excursion Inspection Full symmetry chest expansion Full symmetry chest expansion Normal

Anterior Thorax

1. Breathing Pattern InspectionQuiet, rhythmic and effortless

respirations.

Client has quiet, rhythmic and

efforless breathing.

Normal

2. Respiratory excursion InspectionFull and symmetric chest

expansion.

Full and symmetric chest

expansion.Normal

M.ABDOMEN

1. Skin Integrity Inspection

Unblemished skin, uniform color.

No evidence of enlargement of

liver or spleen

Unblemished skin, uniform

color. No evidence of

enlargement of liver or spleen

Normal

2. Contour and Symmetry Inspection Symmetric contour Symmetric contour Normal

3. Abdominal Movement

a. Respiration

b. Peristalsis

c. Pulsations

Inspection

Inspection

Palpation and inspection

Symmetric movement

Peristalsis in not visible

Aortic pulsation in thin person in

epigastric area

Symmetric movement

Peristalsis in not visible

Aortic pulsation in thin person in

epigastric area

Normal

Normal

Normal

4. Vascular pattern Inspection No visible vascular pattern No visible vascular pattern Normal


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5. Auscultation of the

abdomen

a. Bowel sounds

b. Vascular sounds

c.

Peritoneal FrictionRub

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-SKELATALSYSTEM

1.

Muscle size Inspection

Equal site on both side of the

body

Equal site on both side of the

body Normal

2. Muscle tone Inspection

No contractures, no tremors.

Normally firm, smooth coordinate

movement

No contractures, no tremors.

Normally firm, smooth

coordinate movement

Normal

3. Muscle strength Inspection Equal strength on each body siteShe has equal strength on each

side of her body.Normal

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