APPENDIX E1

FAMILY SERVICE AND PROGRESS RECORD

HEAD OF THE FAMILY: Genita M.Ramos FAMILY NUMBER: 09292668335
ADDRESS: Blk 77 Lot 7 Commando St. Barangay. Rizal Makati City
1. Assessment of the Family, Home and Environmental Conditions:
A. Members of the Household

FAMILY MEMBER RELATION TO SEX BIRTHDAY MARITAL HIGHEST EDUC. OCCUPATION REMARKS/DATE
HEAD STATUS COMPLETED ENTERED
No. Name Month Year Type of Place
Work
1 Genita Ramos Mother F March 1964 Separated College Degree House Makati 10/07/2020
wife city
2 JennyLou Ramos-Marbones Daughter F April 1994 Married College Degree Call Makati 10/07/2020
center city
3 Rodel Marbones Son in Law M Octob 1988 Married College Degree Call Makati 10/07/2020
er center city
4 Franco Marbones Grandson M Dece 2015 Single none none Makati 10/07/2020
mebr city
5 Sophia Ysabel Ramos Daughter F June 2007 Single Highschool Student Makati 10/07/2020
city
6 Louwella Ramos Daughter F Octob 2000 Single College Degree Student Makati 10/07/2020
er city
B. B. Home and Environment
Date Assessed: 10/07/2020
1. Home
a. Ownership: ( ) owned () rented ( ) rent-free
b. Construction materials used: ( ) Light ( ) Mixed ( ) Strong
c. Number of rooms used for sleeping: 2
d. Lighting facilities: () Electricity ( ) Kerosene ( ) Others: Specify:
e. General sanitary condition: Clean

Source: Nursing Practice in the Community by Araceli S. Maglaya

2. Drinking Water Supply
Source: ( ) private ( ) public Potability:
Distance from house: near
Storage: (  ) none (direct from faucet or pipe) ( ) large uncovered container without faucet
( ) large covered container with faucet ( ) others: specify
3. Kitchen
Cooking facility: ( ) electric stove (  ) gas stove ( ) firewood/charcoal
Sanitary condition: Clean
Drainage facility: ( ) open drainage (  ) blind drainage ( ) none
4. Waste Disposal
a. Refuse and garbage
Container: (  ) covered ( ) open ( ) none
Method of disposal:
( ) hog feeding ( ) open burning ( ) open dumping (  ) garbage collection
( ) burial in pit ( ) compositing ( ) others, specify:
b. Toilet
Type: ( ) none ( ) pail system ( ) overhung latrine ( ) Antipolo
( ) open pit privy ( ) water-sealed larine ( ) closed pit privy (  ) flush type
( ) bored-hole latrine ( ) others, specify:

Distance from the house: Near

Sanitary condition: Clean
5. Domestic Animals:
Kind Number Where kept

N/A N/A N/A

Source: Nursing Practice in the Community by Araceli S. Maglaya

6. The Community in General:
a. General sanitary condition: Clean
b. Housing congestion: (  ) Yes ( ) No
c. Presence of Breeding Sites of Vectors and Diseases:
(  ) Yes; Specify: Sewage system
( ) None
d. Recreational facilities: Yes

e. Availability of health care services (describe briefly): Yes, we have primary health care baranggay and the secondary health care
services is the ospital ng Makati (OSMAK) that will really help for the community specially for the family.

f. Distance of house from nearest health care facility: Near and it can walk or ride a tricycle

II. Health Condition and Problem Sheet

HEALTH CONDITION AND NURSING PROBLEMS SUPPORTING DATA / CUES D A T E

PROBLEMS IDENTIFIED RESOLVED
Scoliosis Disturbed Body Image  Negative feelings about body
 Verbal response to actual change
in structure of spine
 Inability to participate in some
activities.
Diabetes Mellitus Risk for Unstable Blood Glucose  Stress
 Inadequate blood glucose
monitoring
 Lack of adherence to diabetes
management
 Lack of acceptance of diagnosis
 Deficient knowledge of diabetes
management.
 Medication management

Source: Nursing Practice in the Community by Araceli S. Maglaya

 Hypertension Risk for Decreased Cardiac Output  Increased vascular resistance,
vasoconstriction
 Myocardial ischemia
 Ventricular hypertrophy/rigidity

III. Nursing Care Plan

HEALTH CONDITION/S OR
PROBLEM/S AND FAMILY OBJECTIVES OF NURSING PLAN OF INTERVENTION EVALUATION PLAN
NURSING PROBLEMS CARE OUTCOME METHOD/TOOLS
CRITERIA/INDICATORS
Scoliosis  Client will experience  Assess the client feelings on  The patient is  Monitoring
improved body image wearing brace, long-term more confident of spine
 Client will have optimal treatments, restricted of body image angle
physical mobility movements, and inability to  The patient is
 Client will have minimal keep up with peers and having optimum  Tape
pain participate in activities. physical measure
 Client will have an  Encourage verbalization of mobility
adequate breathing feelings and concerns and  The patient no  Notebook
pattern support client’s longer feels or pen
communications with minimal pain
significant others and peers.  The patient is
 Assist child to adjust to self- having normal
perception of short leg, use breathing
of appliance and effect on pattern.
appearance.
 Maintain positive
environment and encourage
activities appropriate to the
client.
 Reassure the client that
most activities are permitted
with use of
appliance.
 Assist the client find ways to

Source: Nursing Practice in the Community by Araceli S. Maglaya

 inform others about wearing
appliance.
 Assist the client to the type
of clothing to cover
appliance that is stylish and
has peer acceptance.
 Educate client about activity
restrictions that include
progression from quiet
activities to involvement in
those to avoid: contact
sports, bike riding, driving,
skating, or those that may
result in a fall if surgery has
been done.
Diabetes Mellitus  Patient has a blood  Assist the patient in  Patient blood  Monitoring
glucose reading of less identifying eating patterns sugar is within blood sugar
than 180 mg/dL; fasting that need to be modified. acceptable level
blood glucose levels of  Administer basal and  Capillary
less than <140 mg/dL; prandial insulin. blood strip
and hemoglobin A1C  Refer to a registered
level <7%. dietitian for individualized
diet instruction.
 Administer insulin
medications as directed.
 Report BP of more than 160
mm Hg (systolic). Administer
hypertensive as prescribed.
 Provide food or other
sources of glucose as
directed for hypoglycemia.
 Educate the patient about
the importance of following a
prescribed meal plan.
 Educate the patient about
the proper ways of taking

Source: Nursing Practice in the Community by Araceli S. Maglaya

 prescribed medications
 Review the progress toward
goals during each patient
visit.
 Instruct the patient
experiencing hypoglycemia
about appropriate actions to
raise blood glucose.
 Discuss the importance of
balance exercise with food
intake.
 Teach the patient on
measuring capillary blood
glucose.
 Instruct patient to carry
medical alert information.
 Refer the patient to an
exercise physiologist,
physical therapist, or cardiac
rehabilitation nurse for
specific exercise
instructions.
Hypertension  Patient will participate in  Assess the family level of  Patient will  Monitoring
activities that reduce understanding regarding the participate in blood
BP/cardiac workload. health problem activities that pressure
 Patient will maintain BP  Discuss with the family reduce
within individually nature signs and symptoms BP/cardiac  Device of
acceptable range. and complication that might workload. BP
 Patient will demonstrate arise due to hypertension  Patient will monitoring
stable cardiac rhythm  Discuss with the family/client maintain BP is manual
and rate within patient’s the risk factors of within or digital
normal range. hypertension such as family individually
 Patient will participate in history, lifestyle and diet. acceptable
activities that will prevent range.
stress (stress  Patient will
management, balanced demonstrate

Source: Nursing Practice in the Community by Araceli S. Maglaya

 activities and rest plan). stable cardiac
rhythm and rate
within patient’s
normal range.
Patient will
participate in
activities that
will prevent
stress (stress
management,
balanced
activities and
rest plan).

Source: Nursing Practice in the Community by Araceli S. Maglaya

IV. Service and Progress Notes
DATE HEALTH CONDITIONS / NURSING OBSERVATIONS, ACTION/S TAKEN, SIGNATURE
NURSING PROBLEMS RESPONSES and EVALUATION
OF PROGRESS / OUTCOMES
Scoliosis

Diabetes Mellitus

Hypertension

Source: Nursing Practice in the Community by Araceli S. Maglaya