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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
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BULACAN STATE UNIVERSITYCOLLEGE OF NURSING
City of Malolos, Bulacan
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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BULACAN STATE UNIVERSITYCOLLEGE OF NURSING
City of Malolos, Bulacan
Community Accomplishment Report1st Semester, S.Y. 2011-2012
Brgy. Bagumbayan, Bulakan, Bulacan
Name of Student:__________________________
Course/Year/Section: BSN-3C Group 2
Target Dates Activities Facilitating Factors Inhibiting Factors Actual Output Evaluation Documents
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BULACAN STATE UNIVERSITYCOLLEGE OF NURSING
City of Malolos, Bulacan
Instructional Plan1st Semester, S.Y. 2011-2012
Brgy: ________________________ Purok: ___________
Name of Student:__________________________
Course/Year/Section: BSN-3C Group 2
Date/VenueLearning
Objectives
Target
PopulationActual Activities
Alternative
ActivitiesResource Person Resources Evaluation
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BULACAN STATE UNIVERSITYCOLLEGE OF NURSING
City of Malolos, Bulacan
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