JUIPA ROMERO, ANAIS ROMINA (PAE Familiar)
JUIPA ROMERO, ANAIS ROMINA (PAE Familiar)
JUIPA ROMERO, ANAIS ROMINA (PAE Familiar)
ASSESSING
1.1. GENERAL DATA
District: Pillco Marca
Address: Street. Los Vilcos Passage Los Gladiolos Cayhuayna Baja
Religion: Catholic
Number of Family members: 4
Physiological Pathological
Full Name: Bilmer, Juipa Hilario
Date of Birth: 28/11/1970 Childbirth Type: Eutocic Diseases: None
Age: 49 years old Sex: Male Psychomotor Development: Adequate Hospitalizations: None
Place of Birth: Huánuco Place of Origin: Huánuco Growth and development: Apparently Surgical Interventions: None
Instructional Grade: Superior Complete normal Allergy: None
Physiological Pathological
Full Name: Greysi Gelen, Juipa Romero
Date of Birth: 07/05/2005 Childbirth Type: Eutocic Diseases: None
Age: 15 years old Sex: Female Psychomotor Development: Adequate Hospitalizations: None
Place of Birth: Huánuco Place of Origin: Huánuco Growth and development: Apparently Surgical Interventions: None
normal Allergy: None
Father Engineer 3000 – 4000 soles Payment of electricity, water, cable service
ASSESSING
The assessment stage using the NANDA taxonomy and according to the analysis of the domains applied to the family, the following
was evident:
Domain 1. Health promotion
Subjective Data
The family refer “We don't like to exercise but most of the time we felt motivated but due to the quarantine we lost all interest”
The family refer “We feel so tired only we want to sleep all the time, for this reason We don’t cook more elaborate and nutritious
meals”
The family refer “Before the quarantine we went out to the field on the weekends we played volleyball or swam in the pool, but
now we no longer have family recreation”
The family refer “We use a bar soap to wash our hands but we have alcohol gel to use it from time to time”
The family refer "We wash the dishes the next day especially at dinner we feel so tired, we soak the dishes or pots"
The family refer “We don’t talk much among ourselves with respect to the cleaning habits that we must change since it is difficult
for us to reach a mutual agreement”
The family refer "We usually use the same dishes, pots and spoons to serve and eat food"
The family refer “We don’t usually clean much, we no longer have visitor in this quarantine and each of us doesn’t have time”
Objective data
Loss of physical condition
Overweight
Discontent
Boredom on their faces and verbal language
Lack of cleanliness in the kitchen
Low level of family cleanliness
Dusty and poorly ventilated environment
Increased presence of dirt on the floor and windows
Domain 2. Nutrition
Subjective Data
The family refer “We do not usually have a breakfast made only bread and some infusion sometimes breakfast fries are our
favorites, sometimes we do not eat breakfast because we are late for work“
The family refer "We do not prepare salad at lunch or they are very seldom most of the time we eat potatoes, rice, noodles, and a
small portion of meats most of the time they are fried just like potatoes"
The family refers “We do not usually eat anything at dinner most of the time bread and it depends on you each at dinner each one
sees if they eat or not“
The family refer "We have had digestive problems but stomach infections are more frequent"
The family refers “We don't usually drink a lot of liquids and if we do we prefer soda, it feels more refreshing and you feel like it
quenches your thirst”
Objective data
Lack of fruits and vegetables, but more sausages are observed
Determine the degree of overweight of each family member
Domain 3. Elimination and exchange
Subjective Data
The family refer “we sometimes had urinary tract infection problems but we do not know the cause we are cured by increasing fluid
intake”
The family refers "each of us had constipation problems and the doctor told us that we should increase the consumption of fibers
but we prefer to buy laxatives since we do not eat much fiber although we know that it is very good and we need it"
Objective data
Determine the respiratory and kidney problems that each family member may have
Objective data
Observe familiar non-verbal communication: facial expression, body posture.
Explore family members' state of consciousness: alert and quick to respond, drowsy and slow to respond, semi-conscious and
difficult to respond.
Domain 6. Self-perception
Subjective Data
The family refers “We don’t have image disorder problems”, however, a family member stated “During adolescence I had a body
image problem and I stopped eating for that reason, but I have already overcome it”
The family refers “We don't have serious self-esteem problems”, however, the daughters refer “Most of our childhood was hard
due to the absence of our parents and the little interest shown in us and the lack of positive reinforcement which made we were
insecure”
Objective data
Determine disorders of personal image and self-esteem of family members
The father refers "the relationship with my daughters is bad they do not like to talk to me they flee from the conversations and in
this quarantine it has been more difficult even I try to converse" however the daughters stated "To converse with our father is to
argue, no conversation She is calm, he only shouts and he always thinks he is right, so to avoid arguing we prefer not to speak. "
Objective data
Observe relationships and socialization between family and friends.
Domain 8. Sexuality
Subjective Data
The family refer “We know our defined sexual orientation and we are identified with our gender and sex”
Objective data
Observe family behavior according to gender and sex
Objective data
Observe the family's reaction to a stress factor
Objective data
Observe attitudinal changes in the family regarding their habitual behavior.
Objective data
Observe the external environment of the family and explore the occupational risks to which parents are exposed
The family refers “We miss our friends to tell them about our concerns and problems, we feel alone since there are topics that are
usually discussed with people of our age and not with the family”
Objective data
Observe the comfort level of each family member and their intrapersonal relationships
DIAGNOSIS
Domain 1. Health promotion
Domain 1. Health promotion Diagnosting
Subjective Data Class 1. Health awareness Recognition of normal function and well-being
00168 Sedentary lifestyle
The family refer “we don't like to exercise but
most of the time we felt motivated but due to Defining characteristics
the quarantine we lost all interest”
- Loss of physical condition
Related factors
Objective Data
- Insufficient motivation to carry out physical activity
Loss of physical condition
Overweight
Nursing Diagnosis:
-Boredom
Nursing Diagnosis:
Decreased involvement in recreational activities related to
The usual environment doesn’t allow to get involved in the
activity evidenced by Boredom
Domain 1. Health promotion Diagnosting
Nursing Diagnosis:
Objective Data
Ineffective health maintenance related to Ineffective
Dusty and poorly ventilated environment
communication skills evidenced by Lack of interest in
Increased presence of dirt on the floor and windows
improving health behaviors
PLANNING
Assessing
Subjective Data
The family refer “we don't like to exercise but most of the time we felt motivated but due to the quarantine we lost
all interest”
The family refer “We feel so tired only we want to sleep all the time, for this reason We don't cook more elaborate
and nutritious meals”
Objective Data
Loss of physical condition
Overweight
Diagnosting 1 NOC NIC
Class 1. Health awareness Expected Results Long-term or Expected Objective Long-term 1. Intervention. Promoting
Recognition of normal Measurement Scale exercise
The family Pass from Rarely (2) to Sometimes (3) of Participation in
function and well-being the exercise for 6 days 1.Never demonstrate Activities
00168 Sedentary lifestyle interest
Expected Results Short-term or Expected Objective Short-term Help the family set short and
Defining characteristics 2. Rarely demonstrate long term goals of the exercise
a. The family Pass from Rarely (2) to Sometimes (3) of Set realistic interest program.
- Loss of physical condition short-term goals like: do morning stretch for 3 days
3.Sometimes Encourage the family to start
Related factors b. The family Pass from Rarely (2) to Sometimes (3) of Set realistic demonstrate interest or continue the exercise
long-term goals like: increase muscle strength and decrease
- Insufficient motivation to carry tiredness for 3 days 4. Frequently Help the individual integrate of
out physical activity demonstrate interest family the exercise program
c. The family Pass from Rarely (2) to Sometimes (3) of Balances life into their weekly routine.
routine to include exercise for 3 days 5. Always demonstrate
Nursing Diagnosis: interest
Target Score
Sedentary lifestyle related to Keep to: Rarely demonstrate interest 8
Insufficient motivation to Increase to: Sometimes demonstrate interest 12
carry out physical activity
evidenced by Loss of physical
condition
EVALUATING 1
Evaluating of Results Long-term
Result met: The family star the exercise the first and second days with morning stretches and warm up exercise for 10 minutes , on the third and fourth
day include in the routine run around their house for 15 minutes and on the fifth and sixth day increase the time because the family did morning
stretches and warm up exercise for 25 minutes and they include run around their house for 25 minutes
At the end of the execution time the following results were obtained: The family Pass from Rarely (2) to Frequently (4) of Participation in the exercise at
the end of the 6 days being better than the expected results.
b. Result met: The family manifested that during the first day they felt sore, on the second day a little lighter their muscles did not hurt much and on the
third day there was no pain or it was mild, at the end of the three days they manifested feeling lighter and with more energy.
At the end of the execution time the following results were obtained: The family Pass from Rarely (2) to sometimes (3) of Set realistic long-term goals
term like: increase muscle strength and decrease tiredness for 3 days
c. Result met: The family during the first day did not show much enthusiasm with exercising since they had to get up early at around 6 in the morning, on
the second day they noticed that getting up early so that they had more time to carry out their activities and on the third day they were able to getting up
faster but with slight difficulty stated that including the exercises in their routine was not difficult and at the end of the exercises they felt more motivated
At the end of the execution time the following results were obtained: The family Pass from Rarely (2) to Sometimes (3) of Balances life routine to include
exercise in 3 days
Target Score
Initial score: 8
Final score: 13
The score of expected result was 12, however it was exceeded, the result finale was better than the expected
result.
Assessing
Subjective Data
The family refer “before the quarantine we went out to the field or despite the weekends we played volleyball or
swam in the pool, but now we no longer have family recreation”
Objective Data
Discontent
Boredom on their faces and verbal language
Diagnosting 2 NOC NIC
Class 1. Health awareness Expected Results Long-term or Expected Objective Long-term Measurement Scale 1. Intervention. Play therapy in
Recognition of normal function and the family environment
well-being The family Pass from Rarely (2) to Sometimes (3) of participation in 1.Never demonstrate
00097 Decreased involvement in leisure activities and recreational activities for 6 days. interest Activities
recreational activities
Expected Results Short-term or Expected Objective Short-term 2. Rarely demonstrate Support formal and informal
Defining characteristics interest group play activities through
a. The family Pass from Rarely (2) to Sometimes (3) of Choose board games in the family to
-Boredom leisure activities of interest for 3 days 3.Sometimes encourage sharing, cooperation,
demonstrate interest commitment and leadership
Related factors b. The family Pass from Rarely (2) to Sometimes (3) Identification of
recreational options for 2 days 4. Frequently Facilitate open communication
- The usual environment doesn’t demonstrate interest between family members at
allow to get involved in the activity c. The family Pass from Sometimes (3) to Frequently (4) Expresses meals or throughout the day
satisfaction with games activities for 3 days 5. Always demonstrate
Nursing Diagnosis: interest Examine family attitudes during
Decreased involvement in play games to determine the
recreational activities related to Target Score degree of satisfaction
The usual environment doesn’t Keep to: Rarely demonstrate interest 9
allow to get involved in the Increase to: Sometimes demonstrate interest 13
activity evidenced by Boredom
EVALUATING 2
b. Result met: The family on the first day can identify what were the board games they used to play before and choose Monopoly and Chess, on the
second day they include in the routine watch a family movie for 2 hours.
At the end of the execution time the following results were obtained: The family Pass from Rarely (2) to Sometimes (3) of Identification of recreational
options for 2 days
c. Result met: The family on the first day and second days manifested feel happier and comfortable, on the third day they felt manifested felt more
comfortable and relaxed.
At the end of the execution time the following results were obtained: The family Pass from Sometimes (3) to Frequently (4) of Expresses satisfaction with
games activities for 3 days
Target Score
Initial score: 9
Final score: 14
The score of expected result was 13, however it was exceeded, because the result finale was better than the
expected results.
Assessing
Subjective Data
The family refer “We use a bar soap to wash our hands but we have alcohol gel to use it from time to time”
The family refer "We wash the dishes the next day especially at dinner we feel too tired to do so we soak the dishes or
pots"
The family refer "We usually use the same dishes, pots and spoons to serve and eat food"
Objective Data
Class 2. Health management Expected Results Long-term or Expected Objective Long-term 1. Intervention.
00078 Ineffective health Encourage family
Measurement Scale
The family Pass from Rarely (2) to Sometimes (3) of actions for better
management 1.Never demonstrate interest
Participation in healthcare decisions in 6 days health
Defining characteristics
- Ineffective decisions in daily 2. Rarely demonstrate interest
Expected Results Short-term or Expected Objective Short-term Activities
life to achieve health goals
Identify family health
3.Sometimes demonstrate
a. The family Pass from Rarely (2) to Sometimes (3) of concerns, strengths,
Related factors interest
Identifies priorities of health outcomes for 3 days and priorities with
- Decision conflict
community members.
4. Frequently demonstrate
b. The family Pass from Never (1) to Rarely (2) of Identify
Nursing Diagnosis: interest
obstacles to achieve the desired result for 3 days Make each member of
the family commit to
Ineffective health management c. The family Pass from Rarely (2) to Sometimes (3) of Identifies 5. Always demonstrate interest change their harmful
related to Decision conflict available support to get the results desired for 3 days habits by showing their
evidenced by Ineffective participation in
decisions in daily life to achieve obtaining results
health goals Target Score
Keep to: Rarely demonstrate interest 7 Participate in dialogue
Increase to: Sometimes demonstrate interest 11 to serve as a mediator
between family
members to define the
health interests of the
family and develop
action plans.
EVALUATING 3
Evaluating of Results Long-term
Result met: The family on the first and second days discussed the steps they will take to improve family health care on the third and fourth They star to
included hand washing always before meals using gel soap and discarded bar soap ,on the fifth and sixth days They decided that everyone should wash
their plates and glasses after each meal and dry them before storing them to avoid the formation of fungus.
At the end of the execution time the following results were obtained: The family Pass from Rarely (2) to Frequently (4) of Participation in healthcare
decisions in 6 days
b. Result met: The family on the first day and second talked about why there was very good collaboration in cleaning the home and the reason was that
only he and daughter 1 were the ones who mostly cleaned and the tasks corresponding to each one were distributed, on the third day he family feels
closer and they do the cleaning together to finish it faster
At the end of the execution time the following results were obtained: The family Pass from Never (1) to Sometimes (3) of Identify obstacles to achieve the
desired result for 3 days
c. Result met: The family on the first day and second were able to identify what they needed for effective cleaning of their home by comparing
disinfectants and alcohol and gel soaps as well as disposable towels for kitchen cleaning and began cleaning, on the third day The family continued
cleaning routine continued and they were more motivated after seeing the changes in their home
At the end of the execution time the following results were obtained: The family Pass from Rarely (2) to Sometimes (3) of Identifies available support to
get the results desired for 3 days
Target Score
Initial score: 7
Final score: 13
The score of expected result was 11, however it was exceeded, because the result finale was better than the
expected results.
Assessing
Subjective Data
The family refer “we do not usually clean much, we no longer have views in this quarantine and each of us does not have time”
The family refer “we do not talk much among ourselves with respect to the cleaning habits that we must change since it is difficult
for us to reach a mutual agreement”
Objective Data
Class 2. Health management Expected Results Long-term or Expected Objective Long-term 1. Intervention.
00099 Ineffective health The family Pass from Sometimes (3) to Frequently (4) of Measurement Scale
Health promotion behavior in 6 days Activities
maintenance
1.Never demonstrate Assist the family in planning
Defining characteristics
Expected Results Short-term or Expected Objective Short- interest strategies to avoid the
- Lack of interest in improving health
term inappropriate manifestation of
behaviors
2. Rarely demonstrate anger.
a. The family Pass from Never (1) to Rarely (2) of Uses interest
Related factors
effective stress reduction techniques like: meditation and Help develop adequate
- Ineffective communication skills
playful exercise in 3 days 3.Sometimes demonstrate communication between the
interest family and control anger
b. The family Pass from Sometimes (3) to Frequently (4) of through methods of expressing
Nursing Diagnosis:
Effective family communication 3 days 4. Frequently demonstrate anger (affirmation and
interest declaration of feelings).
Ineffective health maintenance c. The family Pass from Sometimes (3) to Frequently (4) of
related to Ineffective Perform sanitary habits correctly 3 days 5. Always demonstrate Encourage the family to
communication skills evidenced interest actively participate in mutual
by Lack of interest in improving Target Score collaboration in solving health
Keep to: Sometimes demonstrate interest 10 problems.
health behaviors
Increase to: Frequently demonstrate interest 14
Reduces family stress through
meditation and playful
exercise promoting family fun
EVALUATING 4
Evaluating of Results Long-term
Result met: The family on the first and second days discussed what were the behaviors that make cleaning habits deficient improve family health care on
the third and fourth day use a positive reinforcement that includes a dose of sweets if the cleaning task entrusted as: cleaning the kitchen, washing and
drying the dishes was carried out, on the fifth and sixth days the family continued with new cleaning habits, including cleaning the floor of windows and
mirrors
At the end of the execution time the following results were obtained: The family Pass from Sometimes (3) to Frequently (4) of Health promotion behavior
in 6 days
b. Result not met: The family on the first day and second tried to have a communication without discussion, looking for common discussion between
them, managing to maintain a communication without screaming or complaining., on the third day The family continued tried to talk between them but
no one had an interest in establishing a deeper communication, it was only limited to the exchange of cordial words and some more ideas the
conversation was not fluid but rather forced
At the end of the execution time the following results were obtained: The family don’t Pass from Sometimes (3) to Frequently (4) of Effective family
communication the number stayed doesn’t low while the 3 days passed
c. Result met: The family on the first day and second stated to change the harmful habits they had acquired, which included continuous cleaning of the
environment allowing ventilation as well as the use of soaps and gel, disposable towels in the kitchen, cleaning of windows and mirrors and continuous
cleaning of the floors, on the third day The family continued cleaning routine continued and they were more motivated after seeing the changes in their
home
At the end of the execution time the following results were obtained: The family Pass from Sometimes (3) to Frequently (4) of Perform sanitary habits
correctly for 3 days
Target Score
Initial score: 10
Final score: 14
The score of expected results was 14, managing to obtain the same results despite the fact that not all the
expected results were met in the short term, because the short-term results were better than the expected results,
which helped to increase the score .