FAMILY CARE STUDY
General Information about the family
Date of Registration - 26.11.2019
Head of the family - Albert Oraon
House No - 52
House - Own quarter availed by Tea
Estate
Address - Girja lane, Pahargoomiah
T.Estate
Type of House - Semi Pucca, Kitchen is made out
of mud but the living and bed room made of cement.
Religion - Christian
No of Rooms - 2 Two (cemented) and 1 (Mud)
Caste - Schedule Tribe
Ventilation - Ill ventilated, no cross
ventilation,Inadequate light entry
Total monthly income Of the Family - Rs
Socio – Economic Status -
Mother Tongue -
FAMILY CHARACTERISTICS
NAME
RELATIONSHIP
WITH THE HEAD
AGE/
GENDER
EDUCATION
OCCUPATION
MARITAL STATUS NUTRITIONAL
& DIETARY
HABIT
Mahesh Oraon
Father 65y/M Illiterate - M Non – Veg
Albert Oroan Head of the Family35y/M Class – VII
Failed Tea Estate Worker M No of meals- 3times/day
Deepa Tigga Wife 26y/F
Class – III Tea Estate Worker M Staple food Rice, Wheat
Robert Oraon Son 10y/M Class – IV Student UM Food
Storage is Unhygienic
Jonna Oraon Daughter 3y/F - - UM -
SPECIFIC MORBIDITY
1. Mahesh Oraon is aged person, He has problem in vision. Dental caries
present, Back pain present, He has pain in the Joint.
2. Albert Oroan is a chronic alcoholic
3. Deepa Tigga – Chews pan masala with Zarda (tobacco)
4. Rober Oroan – Nothing significant
5. Jonna Oroan – Minor cough and cold.
SOCIOCULTURAL PRACTICES:
1. BENEFICIAL TO HEALTH :
They are allowed to enter kitchen and cook food during menstruation.
They have no restriction of food items during postuatal period.
2. HARMFUL TO HEALTH :
They offer locally prepared alcohol (made out of rice) to the guest during
marriages and postuafal period.
They consume local alcohol during birth of babies out of happiness.
They tattoo over their forehead and chest as their cultural practices.
ENVIRONMENTAL CONDITION
Electricity facility – Yes available
Drainage - open
Disposal of waste – Unhygienic
Presence of rodents – rats
Animals kept – Nil
Pet Animals – Yes (cow, good)
Kitchen separate – Yes
ASSESSMENT OF FAMILY MEMBERS:
NAME OF FAMILY MEMBERS 1 2 3 4 5
AGE / SEX 65 Y/M 35 Y/M 26 Y/F 10Y/M 3Y/F
BMI
NUTRITIONAL STATUS SATISFACTORY HEALTHY HEALTHY ,,
MAINTAINED
NUTRITIONAL DEFICIENCY NIL
H/O PAST
MEDICAL
ILLNESS
NIL HYPERTENSION NIL NIL NIL
SURGICAL
ILLNESS
NIL
CAESEAREAN
SECTION - -
CHIEF COMPLAINTS BACK PAIN
JOINT PAIN
DENTAL PAIN ITCHING OVER
SKIN
NIL
NIL
NIL
PERSONAL HISTORY a)Hygiene
MAINTAINED
MAINTAINED
DRUG ABUSE -
- - - -
SLEEP/REST ADEQUATE ADEQUATE
ADEQUATE ADEQUATE ADEQUATE
PHYSICAL ACTIVITY SEDENTARY MODERATE MODERATE
HYPERACTIVE -
GENERAL PHYSICAL EXAMINATION (Head to Toe)
GENERAL APPEARENCE NORMAL NORMAL NORMAL NORMAL
NORMAL
MENTAL/EMOTIONAL STATE STABLE ANXIOUS STABLE STABLE
CHANGING
PHYSICAL ATTITUDE/POSTURE NORMAL NORMAL NORMAL NORMAL
NORMAL
PHYSIQUE NORMAL NORMAL NORMAL NORMAL NORMAL
GAIT NORMAL NORMAL NORMAL NORMAL NORMAL
VITAL SIGNS BP-106/78
T-98.4degreeF
p-826/M
R-126/M BP-130/80
T-98.4degreeF
P-786/M
R-126/M BP-100/60
T-98.4degreeF
P-706/M
R-146/M BP-100/70
T-98.4degreeF
P-846/M
R-126/M T-98.4degreeF
P-906/M
R-146/M
HAIR-COLOR, PEDICULOSIS DISTRIBUTION DANDRUFF CLEAN
DANDRUFF DANDRUFF CLEAN CLEAN
HAIR – SHAPE, SCALP,INJURY INFECTION
FACE – EXPRESSION,PAIN,SYMMETRY
EYE-VISUAL ACQUITY,COLOR VISION PERRLA 6/4 WITH
SPECTACLES
6/6
6/6
6/6 NOT RESPONDING WELL
EAR-OTALGIA, OTORRHOEA HEARING LOSS, TINNITUS, VERTIGO ABSENT
ABSENT ABSENT ABSENT ABSENT
NOSEBLOCKAGE,RHINNORHEA,
EPISTAXIS,SNEEZING,LOSS OF SMELL ABSENT
ABSENT ABSENT ABSENT ABSENT
THROAT – PAIN,MASS IN NECK ABSENT
ABSENT ABSENT ABSENT ABSENT
LIPS-ANGULAR STOMATILIS,CHEILOSIS ABSENT ABSENT ABSENT
ABSENT ABSENT
MOUTH-LIP/PALATE (INFANTS) ABSENT
ULCER ABSENT ABSENT ABSENT
ORAL CAVITY GUM,TONGUE,PALATE TOUNSILS, TEETH,OROPHARYNX CARRIES
DENTAL ULCER ABSENT ABSENT ABSENT
NECK-SWELLING OF LYMPH NODES ABSENT ULCER ABSENT
ABSENT ABSENT
BREAST - - NORMAL
SYMMETRICAL - -
AXILLAC –ENLARGED LYMPH NODES ABSENT
ABSENT
ABSENT
ABSENT
ABSENT
CHEST – SHAPE, MOVEMENT,SOUND
ABDOMEN-SHAPE,GIRTH,SCAR BOWELSOWD,DISTENSION/ASCITES 76 CM
90 88 CM NOT PRESENT NO DISTENSION
BACK-SHAPE CURVATURE BEDSORES NORMAL NORMAL NORMAL
NORMAL NORMAL
UPPER EXTREMITY-TREMOR,NAIL BED CLUBBING OF FINGER ROM EXERCISE
ABSENT ABSENT ABSENT ABSENT ABSENT
LOWER EXTREMITY JOINT PAIN NORMAL NORMAL NORMAL
NORMAL
SYSTEM WISE EXAMINATION
CARDIO VASCULAR SYSTEM ANKLE SWELLING,VARICOSE VEIN, OTHERS
ABSENT ABSENT ABSENT ABSENT ABSENT
CHARACTERISTICS 1 2 3 4 5
RESPIRATORY SYSTEM – CHEST
PAIN, DYSPNEA NOCTURNAL,COUGH NIGHT SWEATS, HEMOPTYSIS,CHEST
WALL SHAPE, SOB
NERVOUS SYSTEM – BLACK OUT, DIZZY PARESTHESIA, WEAKNESS, SPASM
HEADACHE, SEIZURES, ORIENTATION, PAIN
INTEGUMENTARY SYSTEM: HISTORY OF ALLERGIES, SKIN-PATEL/YELLOW/GHEE
DRY & NIDASTIC,OTHERS
GASTRO INTESTINAL – PAIN ABDOMEN DYSPEPSIA,NAUSEA, VOMITTING,
ANONEXIA, CONSTIPATION
BLEEDING OF GI,WF LOSS/GAIN BOWEL PATTERN/SOUND, OTHERS
MUSCULOSKELETAL SYSTEM
JOINT PAIN
MOBILITY OTHERS
GENITO,URINARY SYSTEM:
DYSURIA, POLYARIA,NOCTURIA
HEMATURIA, GLYCOSURIA, ALBUMINURIA, MENSTRUAL IRREGULARITY
(women) URETHRAL
DISCHARGE (men) OTHERS
ENDOCRINE SYSTEM
MUSCLE WEAKNESS, COLD INTOLERANCE, HEAT INTOLERANCE INCREASED
SWEATING, PALPITATION
POSTURAL UNSTEADINESS, IMPORTANCE GYNACCOMASTIA, AMENORRHOEA,
GALACTORRHEA
EXCESS HAIR GROWTH, OTHERS
OTHERS :
LEISURE TIME ACTIVITIES
ANY ABUSIVE HISTORY
SL.NO NAMEAGE/SEX DISEASE SIGN SYMPTOM TREATMENT
REMARKS
1.
2.
3.
4.
5.
MAHESH ORAON
ALBERT ORAON
DEEPA TIGGA
ROBERT ORAON
JONNA ORAON
65Y/M
35Y/M
28Y/M
10Y/M
3Y/M
DENTAL CARIES
EYES (VISION)
ALCOHOLIC
ULCER ORAL CAVITY (CHEW PAIN
MASALA)
-TOOTH ACHE
-REFRACTORY ERRORS
-BACK PAIN
-JOINT PAIN
-NO SUCH SIGH
SYMPTOMS
-NO SUCH SYMPTOMS OTHER THAN ULCER IN ORAL CAVITY
NIL
COUGH & COLD
TRADITIONAL
-
NIL
DOESN’T SUBSIDE
-
-
NIL
NATURE OF MEDICAL AID UTILIZED:
Private – Tea Estate Hospital
Traditional method of medicine
FAMILY PLANNING
Number of Eligible Couple – 01
Family Planning Status – withdrawl, method
Significant Assistance – Tea Garden Doctor/Nurse
Labours – Normal, Vaginal
Neonatal History – Breast fed soon after delivery
Particulars of Death within one year – Nil
HEALTH CARE GROUPS
IMMUNIZATION STATUS
1.ROBERT ORAON 2. JONNA ORAON
PRIMARY IMMUNIZATION
COMPLETS
NO HISTORY OF NURSING
IMMUNIZATION
VITAMIN A OIL ALSO GIVEN
COMPLETE
COMPLETS
GIVEN
MILESTONE
ACHIEVED AS PER AGE ACHIEVING ACCORDINGLY
IMMUNIZATION CARD
AVAILABLE AVAILABLE
GERIATRIC GROUP (> 60yr)
PSYCHOSOCIAL ISSUES:
Mental changes: Memory loss, depression
Living with Spouse/Son/Daughter/Relative/Others
Emotional Disorder – Insecurity
ACTIVITIES OF DAILY LIVING (IADL)
• Toileting : Yes/No
• Bathing
• Dressing
• Eating
• Moving around
• Voluntary control over the urine & fecal discharge
• Transferring to & from the bed
• If No, specify who is helping to perform these activities
ASSESSMENT NURSING DIAGNOSIS OBJECTIVE NURSING DIAGNOSIS
EVALUATION
Subjective Data.
Child has not received Vitamin ‘A’ oil
Subjective data child runs whole day here & there doesn’t feel tired
Objective data
Body wf Eats
Rice and Dal no vegetables
Subjective data
Objective Data
Risk for developing Vitamin ‘A’ deficiency diseases related to incomplete
vaccination
Risk for home accidents related to hyperactivity of the child
Impaired proper growth related to improper/inadequate dietary intake as
evidenced by low body weight
Risk for infection related to improper menstrual hygiene
Improper knowledge regarding hygienic preparation of food as evidenced by
faulty method of food preparation adopted by the mother
To prevent child from developing Vitamin ‘A’ deficiency syndromes
To avoid accidents
To promote normal growth & development & eating habit
To impart knowledge
About importance of
Maintaining menstru
-al hygiene
To educate
mother
1)Assessed the immunization status of the child
2)Informed about the child’s need of vaccination
3)Health education given about importance of Vitamin rich diet especially
Vitamin – ‘A’
1)Assessed the home environment to assess the sources of accident such as;
Knives, doors of the bathroom whether locked etc
2) Advice to draw/make fencing at her door, keep the main door closed always
1)Observed child eating his lunch
2) Adviced mother to include vegetables and fruits/dry fruits into the child’s
diet.
1)Established a good rapport
2)Assessed her knowledge about importance & methods of maintaining a good
menstrual hygiene
3) Adviced to use sanitary pads also available at Govt sectors
4)Sunday the cloth she uses under proper sunlight
5)Change pad/cloth every 3-4 luly
6)Adviced to take bath everyday especially during periods
1)Assessed the nutritional status of the family
2)Assessed the technique of preparation of food
3)Educated mother about the proper cooking techniques
4)Informed about the techniques of food values preservation
5)Taught about hygiene preparation of food
Mother ensured to take her child to the centre on time
The ensured she will keep hazardous things/articles away
Mother responded well
She agreed to the advices
She expressed the understanding
