Professional Documents
Culture Documents
Angeles City
College of Nursing
In partial fulfillment
of the requirements in
Submitted by:
Group Leader
BSN III-7
I. Introduction
The family is smallest unit of the society and the natural fundamental core
of the community and consequently, it is considered as the primordial recipient of
the nursing effort, which is contributory to the development, and progress of the
community through active involvement and self – responsibilities of each
constituent. It is composed of Father, Mother and children and it is being molded
to be as one, working hand in hand to maintain a good atmosphere among the
family members. On the other hand, a nucleus controls the functions of the entire
cell and can be thought as the “command center” of the cell. The nucleus as well
has different components which are all needed in order for it and the cell to
function well. The impression or status of each family will always affect the status
of the community as a whole.
It is just to say that community health nursing has a big role in nursing
education. It is in the community where the student nurse learns nursing apart
from the hospital setting as she was exposed to different level of orientation. It
is in the community where the saying “nursing is an art” can be applied as
student nurse tries to give quality service using the available resources in the
health center.
The community is a group of people sharing geographic boundaries
and/or values and interests. (Maglaya, 2004) No two communities are alike. A
nurse exposed in the community learns how to interact and adapt to different
kinds of people. The family is considered as the basic unit of care in the
community health nursing. It is in the family where a member develops his
health values, beliefs and practices. The family is a major influence in the
health behaviors of an individual. With this, it is important that families in a
community are aware of the things and practices pertaining to their health.
`
The family that was assigned to the nurses is a picture of the majority of
the family here in our country. Imagine you living in a poor environmental
condition without enough resources and experiencing lack of knowledge
including health information and other socio-economic related problems. In
behalf of the students accomplishing this, though it is tiring, this makes them feel
the sense of fulfillment as they share their knowledge, skill and time to take
action to uplift the condition of the family.
A. Objective
a. Short Term
Client Centered
After 2 days of home visits, the adopted family shall be able to:
• Have trust and confidence to the student nurse.
• Cooperate with the student nurse.
• Tell the student nurse whether he or she understands the
instruction given.
• Acquire knowledge from the health teaching given and know the
importance on having a good health.
b. Long Term
Student Centered
After 4 days home visits, the Student nurses shall be able to:
• Impart knowledge to the family to make them self reliant.
• Educated the family regarding the importance of proper hygiene.
• Guide the family in identifying actual and potential problems which
may be a hindrance in attaining optimum health.
• Generate interventions considering the nurses, community and the
family’s resources.
• Enhance their ability to interact and communicate with people as
learning from the exposure to the community.
• Evaluate changes in condition after giving interventions.
Client Centered
After 4 days of home visits, the family shall be able to:
• Apply some of the health teaching that the student nurse had
imparted.
• Become self reliant especially when it comes to health matters.
• Attain a level of proper hygiene.
• Maximize the use of resources as needed.
• Identify health problems that can be a threat in attaining optimum
health.
The student nurses were assigned at San Jose, Angeles City. On the first day
of the community exposure, July 14, 2008 Monday, the student nurses had a tour
and familiarize their selves around the community and went to the Barangay
Health Center later on under the supervision of their clinical instructor.
July 15, 2008, a rainy Tuesday morning, the student nurses were tasked
to look for the appropriate family that will qualify under their study. They must be
near poverty level, with existing health problems or threats, and families who are
in need of assistance and health teachings.
Fortunately, they were able to find a family that is accommodating,
responsive, and of course accepted to be the subject of their study, the
Chocolate Family.
On their first home visit, it was a rainy afternoon then; Mrs. Kisses was
sleeping with ChocoBaby while Snickers and Kitkat were found playing outside
their house in front of their Lola Tootsie Roll’s store. Mrs. Kisses was awakened
by Kitkat because of the arrival of the student nurses. They warmly welcomed the
student nurses inside their house. After settling down at Chocolate’s Residence,
the student nurses briefly introduced their selves and explained to the family their
purpose and said, “Ate pwede dakayu po bang ainterview? Para ya keng Family
Case Analysis mi kailangan ya keng skwela ita.” Mrs. Kisses then replied, “Wa
sige ok muh, para nokarin ya wari yan?”
Anyway, the student nurses were able to establish rapport with the present
family members and were able to interview the mother regarding their socio-
economic status, environmental sanitation and the like. They were able to
acquire some information and even exchanged light-hearted conversations with
Mrs. Kisses. The vital signs of the present members were also assessed and
recorded. After an hour or two, the student nurses bid the Chocolate Family
goodbye and told them that they will be back the next day.
The following visit was a sunny morning. The group decided to go to their
assigned family during morning for them to assess ChocoBaby, the youngest
child of Mr. and Mrs. Chocolate, because she usually sleeps every afternoon said
Mrs. Kisses. That day, the only members that the student nurses met were Mrs.
Kisses and ChocoBaby. Kitkat and Snickers at that time were at school. The
group finished assessing ChocoBaby and further interviewed Mrs. Kisses
regarding their health, like the children’s immunization and nutrition status, her
obstetrical history and their history of past and present illness. It is on this day too
that they discussed about the potential and actual problems of the family. Some
of these problems are the presence of accident hazards in their house,
malnutrition, faulty eating habits, etc. After the assessment, the group bid
goodbye to Mrs. Kisses and ChocoBaby.
The group visited the Chocolate Family about 11:00 am. It was a hot
morning then. When they arrived at the Chocolate’s Residence, it was brownout
so Mrs. Kisses requested the group to be back after lunch.
.
Fifth Home Visit (July 29, 2008, Tuesday)
This time, the student nurses arrived at the house of the Chocolate Family
around 1:45 pm. The weather that time is unpredictable because there are
episodes of rainy and hot weather that day. Upon the arrival of the group, all of
the family members present are sleeping. They were just awakened by their
neighboring relatives.
That day, the student nurses continued the final assessment. They also
continued their nursing interventions and implementations. The implementations
done were focused on the sanitation of the house and regarding the hygiene of
the kids. Health teachings were given also for the family to understand the
group’s interventions. The group told the family again about how essential
hygiene is in attaining an optimum level of health, the advantages of having a
good environmental sanitation and how rodents and insects can affect their
health.
This home visit is the last and final one that was conducted. The student
nurses are just finalizing every data that they have obtained starting from their
initial home visit until the very last. They are making sure that they have the
complete data and information needed. The group also reminded the family
about the health teachings that they told them during the recent home visits. The
group also told the family about the potential and actual problems that had been
identified by the student nurses and how to control and avoid them. The family’s
response upon the student nurses is very good and they show much appreciation
towards the student nurses which made the group feel good.
Until the last day of home visit, the group did not have the chance to meet
and assess Mr. Ferrero, Lola Tootsie Roll, Uncle Butterfinger and Brother
Crunch.
The group thanked the Chocolate Family for allowing them to conduct
their study.
II. Family Constellation
T- 36.6 °C
PR- 76 bpm
RR- 24 cpm
BP- 90/70
BMI = 20.97
(Normal)
Kitkat 9 Eldest F Going to Kitkat was wearing
Chocolate y/o daughter school: green shirt and
Grade 4 shorts with slippers
on. She was
conscious, coherent
and awake. Her shirt
is dirty as well as her
hands and feet.
She was sweaty also
because she was
playing outside. She
has a short, thick and
frizzy hair with
pediculosis noted.
She has untrimmed
and dirty fingernails
and with presence of
scars on both her
upper extremities.
Her palpebral
conjunctiva on her
right eye is reddish in
color. She complains
that she is
experiencing pricking
pain on her right eye
and it was red. It was
noted during the third
home visit of the
student nurses and it
started during
weekends.
With yellowish color
of teeth and with
presence of plaque,
tartar and cavities.
With untrimmed and
dirty toenails and
noted scars on lower
extremities and dry
skin.
T- 36.9 °C
PR- 80 bpm
RR- 23 cpm
BMI=17.59
(Underweight)
T- 36.9 °C
PR- 72 bpm
RR- 21 cpm
ChocoBaby 27 Youngest F Never been During the initial visit,
Chocolate mos daughter to school icy was in the room,
sleeping. She was
wearing white sando
and yellow shorts.
She has dirty and
untrimmed
fingernails, with
lesion noted above
her left eyebrow. She
has dry skin and
allergies on the left
fore arm and above
the left knee which
appears to be fresh,
palpable and reddish
in color. It was noted
during the initial
assessment and
started during
weekends, Saturday
prior to the home
visits of the student
nurses according to
Mrs. Kisses and
managed it with
Calamine lotion. Her
toenails are
untrimmed and dirty
and with dirty soles
of feet. She also has
scars on both lower
extremities.
T- 36.7°C
PR- 72 bpm
RR- 23 cpm
FNRI= 12 kg normal
(9.9-15.6 kg)
INITIAL ASSESSMENT
General Appearance
Mrs. Kisses is 30 y/o. She has a thick, long, black hair which is neatly tied up.
She was wearing white sleeveless top and floral shorts with no sleepers on. She
was conscious during the assessment. Her fingernails and toenails were
untrimmed and a dirty. She stands 163 cm and weighs 56 kg. Mrs. Kisses has
dark complexion and normal gait.
Physical Assessment
HEAD
⇒ Hair and Scalp: evenly distributed, long, thick, black hair, no presence
of pediculosis
⇒ Skull and Face: symmetrical, smooth uniform consistency, symmetrical
facial features, palpebral fissures equal in size, symmetrical facial
movements, palpable mass noted on her right cheek
⇒ Eyes and Vision
⇒ External Eye Structures
• Eyebrows: hair evenly distributed, thin eyebrows and are
symmetrically aligned, equal movement
• Eyelashes: equally distributed and slightly curled outward
• Eyelids: skin intact with no discharge noted, lids close
symmetrically, bilaterally blinking
• Bulbar Conjunctiva: transparent, sclera appears white and
pinkish bulbar conjunctiva
• Palpebral Conjunctiva: shiny, smooth. Pallor noted.
• Lacrimal Sac and Nasolacrimal Duct: no edema or tearing
• Cornea: transparent, shiny and smooth, details of iris are visible
• Corneal Sensitivity: client blinks when the cornea is touched on
its side by a wisp of cotton which indicates that cranial nerve no.
5 (trigeminal nerve) is intact
• Pupils: black in color, PERRLA (pupils equally round respond to
light accommodation) when a penlight pass through at about 6
inches far the pupils constrict upon illumination, smooth border,
iris flat and round, pupils converge when near object is move
towards the nose
• Visual Fields: the client has a normal visual field as evidence by
the ability to see object in the periphery even when looking
straight ahead which was done by asking the person to close
one eye then a pen or the index finger in the periphery and ask
if the person can see it without moving his head on the side
direction.
• Visual Acuity: able to read a newspaper 14 inches away with an
unaided eye
⇒ Ears and Hearing
• Auricles: the color of the auricle skin which is dark brown is
same as the facial skin, they are symmetrical, aligned with the
outer canthus of the eye, it is firm not tender, pinna recoils after
it is folded
• External Ear Canal and Tympanic Membrane: with dry cerumen
• Gross Hearing Acuity: normal voice tones audible
• Watch Tick Test: able to hear on the tick of the watch in both
ears with a distance of 3 cm.
⇒ Nose and Sinuses
• Nose: symmetric, straight, no discharge or flaring noted; uniform
in color; not tender and without lesions, air moves freely when
she breaths through the nares, which was done by asking the
person to occlude one of the nares then check for airway
patency on the unoccluded nares (done alternately), the
mucosa is pink, nasal septum intact in midline
• Facial Sinuses: not tender
⇒ Mouth and Oropharynx
• Mouth:
• Lip and Buccal Mucosa: uniform pink color soft, moist, smooth
texture, ability to purse lips
• Teeth and Gums: yellowish color of teeth, with presence of
tartar and plaque noted, cavities are also present; 12 lower
teeth, where in 2 are extracted, minimal dental carries on pre
molars and molars; 14 upper teeth, where in there is 2
extracted teeth, 1 excess tooth, and dental carries on
molars
• Tongue and Floor of Mouth: in central position, pink in color,
moist with thin whitish coating, smooth lateral margins, no
lesions upon observation, raised papillae, tongue moves freely
with no tenderness by asking the person to move her tongue in
different direction, smooth floor of the mouth
• Salivary Glands: same as the color of the buccal mucosa and
the floor of the mouth
• Palates and Uvula: light pink smooth soft palate, lighter pink
hard palate with irregular texture, the uvula is on the midline of
the soft palate
• Oropharynx and Tonsils: pink and smooth posterior wall of
oropharynx , pink tonsils without discharge
NECK
⇒ Neck Muscles: muscles equal in size, head movement are coordinated
and smooth with no discomfort able to flex 45 degrees hyper extend at
60 degrees; head laterally flexes at 40 degrees and laterally rotates at
70 degrees, muscles strength are equal by turning the head to one
side and shrugging the shoulder against the resistance of hands of
the student nurse which was done by asking the person to resist the
pressure of the hands of the student nurse by shrugging her shoulders
⇒ Lymph Nodes ( posterior and below the jaw): not palpable
⇒ Trachea: central placement of the midline of neck by palpation or by
asking the person to swallow
⇒ Thyroid Gland: it is symmetrical and masses are not visible, absence
of bruit
⇒ Neck Veins: not distended (ask the person to turn his head side to side
then check for the neck veins if distended or bloated)
UPPER EXTREMITIES
⇒ Skin and Nails: skin warm to touch, good skin turgor, nails are smooth,
colorless, untrimmed and dirty, and in capillary refill result is normal
because it returns to its usual color less than 4 seconds.
⇒ Muscle Strength and Tone: symmetrical muscle size, no contractures,
no presence of tremor and it is normally firm smooth coordinated
movements.
⇒ Brachial and Radial Pulse: palpable
⇒ Fine Motor Test: repeated and rhythmical touches the nose, can
altenately supinate and pronate hands at rapid phase performs with
coordination and rapidity to the finger nose and to the nurse finger
CHEST and BACK
⇒ Skin: evenly distributed skin color skin intact with uniform temperature
⇒ Chest Shape and Size: anterior-posterior to transverse diameter in
ratio of 1:2 symmetrical in shape, spine is vertically aligned, chest wall
intact
⇒ Lungs: full and symmetric chest expansion, quiet rhythmic and
effortless respiration, full symmetric excursion with bronchial & tubular
breathe sounds
⇒ Heart: no pulsation, symmetric pulse volume
⇒ Spinal Column: straight, right and left shoulders and hips are at the
same height
ABDOMEN
⇒ Skin: unblemished skin, symmetric movements caused by respiration,
stretch marks were noted on left and right lower quadrant
⇒ Abdominal Sounds: audible bowel sound, tympany over the stomach
and gas filled bowels
⇒ Specific Organs: not palpable
LOWER EXTREMITIES
⇒ Skin and Toenails: uniform skin temperature, convex curve and
colorless nail plates, presence of smooth nail texture, highly vascular
nail bed, stretch marks on left and right hips, untrimmed toenails and
intact epidermis
⇒ Gait and Balance: was able to perform all the gait and balance without
any discomfort
Cranial Nerves Assessment
II. Optic Provide adequate lighting The client should She was able to
and ask client to read be able to read with read with each
from a reading material each eye and both eye and both
held at a distance of 36 eyes. eyes.
cm. (14 in.).
III. Oculomotor Reaction to light:
Using a penlight and Illuminated and The illuminated
approaching from the non-illuminated and non-
side, shine a light on the pupil should illuminated pupil
pupil. Observe the constrict. of Mrs. Kisses
response of the constricted.
illuminated pupil. Shine
the light on the pupil
again, and observe the
response of the other
pupil.
FINAL ASSESSMENT
General Appearance
Mrs. Kisses has a thick, long, black untied hair. She was wearing blue tank top
and blue denim shorts with no sleepers on. She was conscious during the
assessment. Her fingernails and toenails were trimmed and a bit dirty. She
stands 163 cm and weighs 56 kg. Mrs. Kisses has dark complexion and normal
gait.
Physical Assessment
Mrs. Kisses’ vital signs were taken and recorded as follow:
Temp: 36.9° C
RR: 21 cycles/min.
PR: 72 breaths/min.
BP : 100/60 mmHg
HEAD
⇒ Hair and Scalp: evenly distributed, slightly thin, black hair, with no
presence of lice
⇒ Skull and Face: symmetrical, smooth uniform consistency, symmetrical
facial features, palpebral fissures equal in size, symmetrical facial
movements, palpable mass noted on her right cheek
⇒ Eyes and Vision
⇒ External Eye Structures
• Eyebrows: hair evenly distributed, thin eyebrows and are
symmetrically aligned, equal movement
• Eyelashes: equally distributed and slightly curled outward
• Eyelids: skin intact with no discharge noted, lids close
symmetrically, bilaterally blinking
• Bulbar Conjunctiva: transparent, sclera appears white and
pinkish bulbar conjunctiva
• Palpebral Conjunctiva: shiny, smooth. Pallor noted.
• Lacrimal Sac and Nasolacrimal Duct: no edema or tearing
• Cornea: transparent, shiny and smooth, details of iris are visible
• Corneal Sensitivity: client blinks when the cornea is touched on
its side by a wisp of cotton which indicates that cranial nerve no.
5 (trigeminal nerve) is intact
• Pupils: black in color, PERRLA (pupils equally round respond to
light accommodation) when a penlight pass through at about 6
inches far the pupils constrict upon illumination, smooth border,
iris flat and round, pupils converge when near object is move
towards the nose
• Visual Fields: the client has a normal visual field as evidence by
the ability to see object in the periphery even when looking
straight ahead which was done by asking the person to close
one eye then a pen or the index finger in the periphery and ask
if the person can see it without moving his head on the side
direction.
⇒ Ears and Hearing
• Auricles: the color of the auricle skin is same as the facial skin,
they are symmetrical, aligned with the outer canthus of the eye,
it is firm not tender, pinna recoils after it is folded
• External Ear Canal and Tympanic Membrane: with dry cerumen
• Gross Hearing Acuity: normal voice tones audible
• Watch Tick Test: able to hear on the tick of the watch in both
ears with a distance of 3 cm.
⇒ Nose and Sinuses
• Nose: symmetric, straight, no discharge; uniform in color; not
tender and without lesions, air moves freely when he breaths
through the nares, which was done by asking the person to
occlude one of the nares then check for airway patency on the
unoccluded nares (done alternately), the mucosa is pink, nasal
septum intact in midline
• Facial Sinuses: not tender
⇒ Mouth and Oropharynx
• Mouth:
• Lip and Buccal Mucosa: uniform pink color soft, moist, smooth
texture, ability to purse lips
• Teeth and Gums: yellowish color of teeth, with presence of
tartar and plaque noted, cavities are also present; 12 lower
teeth, where in 2 are extracted, minimal dental carries on pre
molars and molars; 14 upper teeth, where in there is 2
extracted teeth, 1 excess tooth, and dental carries on
molars
• Tongue and Floor of Mouth: in central position, pink in color,
moist with thin whitish coating, smooth lateral margins, no
lesions upon observation, raised papillae, tongue moves freely
with no tenderness by asking the person to move her tongue in
different direction, smooth floor of the mouth
• Salivary Glands: same as the color of the buccal mucosa and
the floor of the mouth
• Palates and Uvula: light pink smooth soft palate, lighter pink
hard palate with irregular texture, the uvula is on the midline of
the soft palate
• Oropharynx and Tonsils: pink and smooth posterior wall of
oropharynx , pink tonsils without discharge
NECK
⇒ Neck Muscles: muscles equal in size, head movement are coordinated
and smooth with no discomfort able to flex 45 degrees hyper extend at
60 degrees; head laterally flexes at 40 degrees and laterally rotates at
70 degrees, muscles strength are equal by turning the head to one
side and shrugging the shoulder against the resistance of hands of
the student nurse which was done by asking the person to resist the
pressure of the hands of the student nurse by shrugging her shoulders
⇒ Lymph Nodes ( posterior and below the jaw): not palpable
⇒ Trachea: central placement of the midline of neck by palpation or by
asking the person to swallow
⇒ Thyroid Gland: it is symmetrical and masses are not visible, absence
of bruit
⇒ Neck Veins: not distended (ask the person to turn his head side to side
then check for the neck veins if distended or bloated)
UPPER EXTREMITIES
⇒ Skin and Nails: skin warm to touch, dry to moist, with good skin turgor,
nails are smooth, colorless, trimmed and a bit dirty, and in capillary
refill result is normal because it returns to its usual color less than 4
seconds.
⇒ Muscle Strength and Tone: symmetrical muscle size, no contractures,
no presence of tremor and it is normally firm smooth coordinated
movements.
⇒ Brachial and Radial Pulse: palpable
⇒ Fine Motor Test: repeated and rhythmical touches the nose, can
altenately supinate and pronate hands at rapid phase performs with
coordination and rapidity to the finger nose and to the nurse finger
CHEST and BACK
⇒ Skin: evenly distributed skin color skin intact with uniform temperature
⇒ Chest Shape and Size: anterior-posterior to transverse diameter in
ratio of 1:2 symmetrical in shape, spine is vertically aligned, chest wall
intact
⇒ Lungs: full and symmetric chest expansion, quiet rhythmic and
effortless respiration, full symmetric excursion with bronchial & tubular
breathe sounds
⇒ Heart: no pulsation, symmetric pulse volume
⇒ Spinal Column: straight, right and left shoulders and hips are at the
same height
ABDOMEN
⇒ Skin: unblemished skin, symmetric movements caused by respiration,
slightly distended abdomen, stretch marks were noted on the left and
right lower quadrant
⇒ Abdominal Sounds: audible bowel sound, tympany over the stomach
and gas filled bowels
LOWER EXTREMITIES
⇒ Skin and Toenails: uniform skin temperature, convex curve and
colorless nail plates, presence of smooth nail texture, highly vascular
nail bed,stretch marks on both hips untrimmed and dirty toenails and
intact epidermis, with presence of scars on both extremities
⇒ Gait and Balance: was able to perform all the gait and balance without
any discomfort
⇒ With presence of stretch marks on both extremities
⇒ Fine Motor Test: able to perform normally the fine motor test
Obstetrical Record
Mrs. Kisses got married by the age of 20 and was able to bear three
children in the years 1998, 2001 and 2006. She had her menarche when she
was 11. Currently, her menstrual cycle is a 28-day cycle due to the pills she is
taking. She delivered all her children via normal spontaneous delivery (NSD),
vertex presentation at home. A “madrona” was the one who delivered the baby.
According to her obstetrical record, she has G3P3T3P0A0L3.
She stated that she had all the necessary prenatal check-ups with all her
pregnancies at the health center and no complications were noted. She
continued her usual activities even though she is pregnant and told the group
that she experienced nausea and vomiting during the first trimester of pregnancy.
When she was pregnant, she does not have any unusual belief. She was able to
obtain 2 shots of Tetanus Toxoid vaccine.
She is still in her reproductive age however; she resorted to artificial family
planning with the use of oral contraceptives (Pills) as a form family planning
method to prevent further pregnancies. She started to take pills in the year 1999.
The main reason for this is for proper spacing of her children.
Nutritional Status
BMI = Wt. in kg
Ht in m2
= 56 kg .
2.67m2
= 20.97 (Normal)
Mrs. Kisses is presently in a good health condition and does not have any
health problems. During the interview, she stated that she had not been
hospitalized because of severe illness. However, she had fever, coughs and
colds but had not experienced any serious illness. She told the group that her
management on fever is by means of over the counter medications usually
paracetamol. Whenever her skin is warm to touch and she is feeling dizzy, she
assumes that she has a fever and usually takes a paracetamol tablet. She also
told the group that she does not have any management for cough and colds.
Activities of Daily Living
3:00 am Wake up
3:30- 5:00 Cook foods for the store
5:00- 6:00 Prepare foods for breakfast
(Wake up kids during school days)
6:00- 8:00 Chores
8:00- 12:30 Wash clothes; Take care of ChocoBaby
12:30- 1:00 LUNCH
1:00- 4:00 Sleeping
4:00- 7:00 Stays at the sari-sari store
6:00/7:00- 8:00 DINNER
8:00- 10:00 Watch TV
10:00 pm Sleeping
KITKAT
General Appearance
Kitkat is 9y/o, born on September 30, 1998. She has a thick, black and oily untied
hair. She was wearing green shirt and shorts with no sleepers on. She was
conscious during the assessment. Her fingernails and toenails were
untrimmed and dirty. She stands 141 cm and weighs 35 kg. Kitkat has dark
complexion and normal gait.
INITIAL ASSESSMENT
Temp: 36.9 ° C
RR: 23 cycles/min.
PR: 80 breaths/min.
HEAD
⇒ Hair and Scalp: evenly distributed, thick, black hair, shoulder length,
with presence of lice and hair is frizzy.
⇒ Skull and Face: symmetrical, smooth uniform consistency, symmetrical
facial features, palpebral fissures equal in size, symmetrical facial
movements
⇒ Eyes and Vision
⇒ External Eye Structures
• Eyebrows: hair evenly distributed, thin eyebrows and are
symmetrically aligned, equal movement
• Eyelashes: equally distributed and slightly curled outward
• Eyelids: skin intact with no discharge noted, lids close
symmetrically, bilaterally blinking
• Bulbar Conjunctiva: transparent, sclera appears white and
pinkish bulbar conjunctiva
• Palpebral Conjunctiva: shiny, smooth, reddish.
• Lacrimal Sac and Nasolacrimal Duct: no edema or tearing
• Cornea: transparent, shiny and smooth, details of iris are visible
• Corneal Sensitivity: client blinks when the cornea is touched on
its side by a wisp of cotton which indicates that cranial nerve no.
5 (trigeminal nerve) is intact
• Pupils: black in color, PERRLA (pupils equally round respond to
light accommodation) when a penlight pass through at about 6
inches far the pupils constrict upon illumination, smooth border,
iris flat and round, pupils converge when near object is move
towards the nose
• Visual Fields: the client has a normal visual field as evidence by
the ability to see object in the periphery even when looking
straight ahead which was done by asking the person to close
one eye then a pen or the index finger in the periphery and ask
if the person can see it without moving his head on the side
direction.
⇒ Ears and Hearing
• Auricles: the color of the auricle skin is same as the facial skin,
they are symmetrical, aligned with the outer canthus of the eye,
it is firm not tender, pinna recoils after it is folded
• External Ear Canal and Tympanic Membrane: with dry cerumen
• Gross Hearing Acuity: normal voice tones audible
• Watch Tick Test: able to hear on the tick of the watch in both
ears with a distance of 3 cm.
⇒ Nose and Sinuses
• Nose: symmetric, straight, no discharge or flaring noted; uniform
in color; not tender and without lesions, air moves freely when
he breaths through the nares, which was done by asking the
person to occlude one of the nares then check for airway
patency on the unoccluded nares (done alternately), the
mucosa is pink, nasal septum intact in midline
• Facial Sinuses: not tender
⇒ Mouth and Oropharynx
• Mouth:
• Lip and Buccal Mucosa: uniform pink color soft, moist, smooth
texture, ability to purse lips
• Teeth and Gums: yellowish color of teeth, with presence of
tartar and plaque noted, with cavities present
• Tongue and Floor of Mouth: in central position, pink in color,
moist with thin whitish coating, smooth lateral margins, no
lesions upon observation, raised papillae, tongue moves freely
with no tenderness by asking the person to move her tongue in
different direction, smooth floor of the mouth
• Salivary Glands: same as the color of the buccal mucosa and
the floor of the mouth
• Palates and Uvula: light pink smooth soft palate, lighter pink
hard palate with irregular texture, the uvula is on the midline of
the soft palate
• Oropharynx and Tonsils: pink and smooth posterior wall of
oropharynx , pink tonsils without discharge
NECK
⇒ Neck Muscles: muscles equal in size, head movement are coordinated
and smooth with no discomfort able to flex 45 degrees hyper extend at
60 degrees; head laterally flexes at 40 degrees and laterally rotates at
70 degrees, muscles strength are equal by turning the head to one
side and shrugging the shoulder against the resistance of hands of
the student nurse which was done by asking the person to resist the
pressure of the hands of the student nurse by shrugging her shoulders
⇒ Lymph Nodes ( posterior and below the jaw): not palpable
⇒ Trachea: central placement of the midline of neck by palpation or by
asking the person to swallow
⇒ Thyroid Gland: it is symmetrical and masses are not visible, absence
of bruit
⇒ Neck Veins: not distended (ask the person to turn his head side to side
then check for the neck veins if distended or bloated)
UPPER EXTREMITIES
⇒ Skin and Nails: skin warm to touch, good skin turgor, nails are smooth,
colorless, untrimmed and dirty, and in capillary refill result is normal
because it returns to its usual color less than 4 seconds.
⇒ Muscle Strength and Tone: symmetrical muscle size, no contractures,
no presence of tremor and it is normally firm smooth coordinated
movements.
⇒ Brachial and Radial Pulse: palpable
⇒ Fine Motor Test: repeated and rhythmical touches the nose, can
altenately supinate and pronate hands at rapid phase performs with
coordination and rapidity to the finger nose and to the nurse finger
CHEST and BACK
⇒ Skin: evenly distributed skin color skin intact with uniform temperature
⇒ Chest Shape and Size: anterior-posterior to transverse diameter in
ratio of 1:2 symmetrical in shape, spine is vertically aligned, chest wall
intact
⇒ Lungs: full and symmetric chest expansion, quiet rhythmic and
effortless respiration, full symmetric excursion with bronchial & tubular
breathe sounds
⇒ With presence of productive cough, rales upon auscultation
⇒ Heart: no pulsation, symmetric pulse volume
⇒ Spinal Column: straight, right and left shoulders and hips are at the
same height
ABDOMEN
⇒ Skin: unblemished skin, symmetric movements caused by respiration
⇒ Abdominal Sounds: audible bowel sound, tympany over the stomach
and gas filled bowels
⇒ Specific Organs: not palpable
LOWER EXTREMITIES
⇒ Skin and Toenails: uniform skin temperature, convex curve and
colorless nail plates, presence of smooth nail texture, highly vascular
nail bed, trimmed and dirty toenails and intact epidermis, with
presence of scars on both extremities
⇒ Gait and Balance: was able to perform all the gait and balance without
any discomfort
⇒ Presence of Tendon of Achilles reflex
⇒ Presence of Patellar reflex
FINAL ASSESSMENT
General Appearance
Kitkat has a thick, black, frizzy, and untied hair. She was wearing green shirt and
shorts with no sleepers on. She was conscious during the assessment. Her
fingernails and toenails were trimmed but a bit dirty. She stands 141 cm and
weighs 35 kg. Mrs. Kisses has dark complexion and normal gait.
Physical Assessment
Temp: 37 ° C
RR: 22 cycles/min.
PR: 98 breaths/min.
HEAD
⇒ Hair and Scalp: evenly distributed, thick, black hair, shoulder length,
with presence of lice and hair is frizzy
⇒ Skull and Face: symmetrical, smooth uniform consistency, symmetrical
facial features, palpebral fissures equal in size, symmetrical facial
movements
⇒ Eyes and Vision
⇒ External Eye Structures
• Eyebrows: hair evenly distributed, thin eyebrows and are
symmetrically aligned, equal movement
• Eyelashes: equally distributed and slightly curled outward
• Eyelids: skin intact with no discharge noted, lids close
symmetrically, bilaterally blinking
• Bulbar Conjunctiva: transparent, sclera appears white and
pinkish bulbar conjunctiva
• Palpebral Conjunctiva: shiny, smooth.
• Lacrimal Sac and Nasolacrimal Duct: no edema or tearing
• Cornea: transparent, shiny and smooth, details of iris are visible
• Corneal Sensitivity: client blinks when the cornea is touched on
its side by a wisp of cotton which indicates that cranial nerve no.
5 (trigeminal nerve) is intact
• Pupils: black in color, PERRLA (pupils equally round respond to
light accommodation) when a penlight pass through at about 6
inches far the pupils constrict upon illumination, smooth border,
iris flat and round, pupils converge when near object is move
towards the nose
• Visual Fields: the client has a normal visual field as evidence by
the ability to see object in the periphery even when looking
straight ahead which was done by asking the person to close
one eye then a pen or the index finger in the periphery and ask
if the person can see it without moving his head on the side
direction.
NECK
⇒ Neck Muscles: muscles equal in size, head movement are coordinated
and smooth with no discomfort able to flex 45 degrees hyper extend at
60 degrees; head laterally flexes at 40 degrees and laterally rotates at
70 degrees, muscles strength are equal by turning the head to one
side and shrugging the shoulder against the resistance of hands of
the student nurse which was done by asking the person to resist the
pressure of the hands of the student nurse by shrugging her shoulders
⇒ Lymph Nodes ( posterior and below the jaw): not palpable
⇒ Trachea: central placement of the midline of neck by palpation or by
asking the person to swallow
⇒ Thyroid Gland: it is symmetrical and masses are not visible, absence
of bruit
⇒ Neck Veins: not distended (ask the person to turn his head side to side
then check for the neck veins if distended or bloated)
UPPER EXTREMITIES
⇒ Skin and Nails: skin warm to touch, good skin turgor, nails are smooth,
colorless, trimmed and a bit dirty, and in capillary refill result is normal
because it returns to its usual color less than 4 seconds.
⇒ Muscle Strength and Tone: symmetrical muscle size, no contractures,
no presence of tremor and it is normally firm smooth coordinated
movements.
⇒ Brachial and Radial Pulse: palpable
⇒ Fine Motor Test: repeated and rhythmical touches the nose, can
altenately supinate and pronate hands at rapid phase performs with
coordination and rapidity to the finger nose and to the nurse finger
CHEST and BACK
⇒ Skin: evenly distributed skin color skin intact with uniform temperature
⇒ Chest Shape and Size: anterior-posterior to transverse diameter in
ratio of 1:2 symmetrical in shape, spine is vertically aligned, chest wall
intact
⇒ Lungs: full and symmetric chest expansion, presence of rales on
both lung fields upon auscultation.
⇒ With presence of productive cough
⇒ Heart: no pulsation, symmetric pulse volume
⇒ Spinal Column: straight, right and left shoulders and hips are at the
same height
ABDOMEN
⇒ Skin: unblemished skin, symmetric movements caused by respiration
⇒ Abdominal Sounds: audible bowel sound, tympany over the stomach
and gas filled bowels
⇒ Specific Organs: not palpable
LOWER EXTREMITIES
⇒ Skin and Toenails: uniform skin temperature, convex curve and
colorless nail plates, presence of smooth nail texture, highly vascular
nail bed, trimmed and slightly dirty toenails and intact epidermis,
with presence of scars on both extremities
⇒ Gait and Balance: was able to perform all the gait and balance without
any discomfort
⇒ Presence of Tendon of Achilles reflex
⇒ Presence of Patellar reflex
Nutritional Status
BMI = Wt. in kg
Ht in m2
= 35 kg .
1.99 m2
= 17.59 (Underweight)
Kitkat stands 141 cm and weighs 35 kg. Her BMI is 17.59 which is
considered as underweight,
History of Past and Present Illness
Kitkat experienced fever, cough and colds, and diarrhea that can be
managed by means of “over the counter” medications. Mrs. Kisses usually gives
her Tempra Syrup for fever and packet oresol for diarrhea. She does not have
any management for cough and colds. Kitkat also had chicken pox, rubella and
mumps. Mrs. Kisses mentioned that she already forgot the date when Kitkat
experienced them because she told the group that it was already a long time
ago.
Two years ago, last September; Kitkat had a minor surgery at ONA
(Ospital ning Angeles). She complained for pain in her right ear while her mom
fixes her hair. Her mother assessed the affected ear and observed some swelling
present on the inner canal. With Kitkat’s complaint, they brought her at ONA
where she had the operation and was only confined there overnight. Both Mrs.
Kisses and Kitkat forgot what the diagnosis is. For home management, she was
prescribed with an ear dropper which they cannot remember what exact
medication it is and was ask to comply for antibiotic therapy.
Recently, during the home visits of the student nurses, Kitkat complained
that she is having sore eyes on her right eye followed by sore throat. The group
assessed Kitkat and noted that the palpebral conjunctiva is reddish in color. This
was noted during the 3rd home visit and she told the group the student nurses
that it started during the weekends. She did not have any management for this.
They also Kitkat’s tonsils and noted that they are inflamed and Kitkat verbalized
that it is painful everytime she swallows. She took Strepsils as management for
the sore throat.
Activities of daily living
5:00 am Waking up
5:00- 5:30 Breakfast
5:30- 6:00 Bathing
6:00- 7:00 Grooming
7:00- 7:10 Arrival to school
7:10- 10:00 First half of school
10:00- 10:45 Recess
10:45- 12:00 noon Second half of school
12:00-12:30 Arrival at home
12:30- 1:00 Lunch
1:00- 1:30 Stays at Lola Tootsie Roll's sari-sari store
1:30- 3:00 Watching t.v/ playing
3:00- 4:00 Taking a nap
4:00- 6:00 Stays at Lola Tootsie Roll's sari-sari store
6:00- 7:00 Dinner
7:00 Sleeping time
SNICKERS
INITIAL ASSESSMENT
General Appearance
Snickers a seven- year old boy, wearing a gray shirt and red shorts with
no slippers on. He was seen playing outside the house with his elder sister,
cousin and some playmates before the initial assessment. His shirt, shorts, as
well as his arms and feet, are dirty. His fingernails and toenails are also
long and untrimmed. He was conscious, coherent and awake during the first
visit. His hair was short and there are some lice noted.
Physical Assessment
T- 36.9 °C
PR- 72 bpm
RR- 21 cpm
HEAD
⇒ Hair and Scalp: evenly distributed, slightly thin, short, black hair, with
presence of lice, hair is frizzy
⇒ Skull and Face: smooth uniform consistency, symmetrical facial
features, palpebral fissures equal in size, symmetrical facial
movements
⇒ Eyes and Vision
⇒ External Eye Structures
• Eyebrows: hair evenly distributed, thin eyebrows and are
symmetrically aligned, equal movement
• Eyelashes: equally distributed and slightly curled outward
• Eyelids: skin intact with no discharge noted, lids close
symmetrically, bilaterally blinking
• Bulbar Conjunctiva: transparent, sclera appears white and
pinkish bulbar conjunctiva
• Palpebral Conjunctiva: shiny, smooth. Pallor noted.
• Lacrimal Sac and Nasolacrimal Duct: no edema or tearing
• Cornea: transparent, shiny and smooth, details of iris are visible
• Corneal Sensitivity: client blinks when the cornea is touched on
its side by a wisp of cotton which indicates that cranial nerve no.
5 (trigeminal nerve) is intact
• Pupils: black in color, PERRLA (pupils equally round respond to
light accommodation) when a penlight pass through at about 6
inches far the pupils constrict upon illumination, smooth border,
iris flat and round, pupils converge when near object is move
towards the nose
• Visual Fields: the client has a normal visual field as evidence by
the ability to see object in the periphery even when looking
straight ahead which was done by asking the person to close
one eye then a pen or the index finger in the periphery and ask
if the person can see it without moving his head on the side
direction.
⇒ Ears and Hearing
• Auricles: the color of the auricle skin is same as the facial skin,
they are symmetrical, aligned with the outer canthus of the eye,
it is firm not tender, pinna recoils after it is folded
• External Ear Canal and Tympanic Membrane: with dry cerumen
• Gross Hearing Acuity: normal voice tones audible
• Watch Tick Test: able to hear on the tick of the watch in both
ears with a distance of 3 cm.
⇒ Nose and Sinuses
• Nose: symmetric, straight, no discharge or flaring noted; uniform
in color; not tender and without lesions, air moves freely when
he breaths through the nares, which was done by asking the
person to occlude one of the nares then check for airway
patency on the unoccluded nares (done alternately), the
mucosa is pink, nasal septum intact in midline
• Facial Sinuses: not tender
FINAL ASSESSMENT
General Appearance
Snickers is a seven year-old boy white shirt and blue shorts with no
slippers on. His fingernails now are quite cleaner compared before. His feet are
clean as well. He was conscious, coherent and awake during the final
assessment. His hair was short and the presence of lice were still noted. He
has an abrasion on left face, below the outer canthus.
Physical Assessment
T- 37.1 °C
PR- 78 bpm
RR- 21 cpm
HEAD
⇒ Hair and Scalp: evenly distributed, thin, short, brownish color of hair,
with presence of lice and hair is not clean because he was playing
with his chick in the soil outside their house prior to the assessment.
⇒ Skull and Face: smooth uniform consistency, absence of nodules,
symmetrical facial features, palpebral fissures equal in size,
symmetrical nasolabial folds, symmetrical facial movements
⇒ Eyes and Vision
⇒ External Eye Structures
⇒ With abrasion on left face, below the outer canthus
• Eyebrows: hair evenly distributed, thin eyebrows and are
symmetrically aligned, equal movement
• Eyelashes: equally distributed and slightly curled outward
• Eyelids: skin intact with no discharge and discoloration, lids
close symmetrically, bilaterally blinking
• Bulbar Conjunctiva: transparent, sclera appears white and
pinkish bulbar conjunctiva
• Palpebral Conjunctiva: shiny, smooth and pinkish in color
• Lacrimal Sac and Nasolacrimal Duct: no edema or tearing
• Cornea: transparent, shiny and smooth, details of iris are visible
• Pupils: black in color, PERRLA (pupils equally round respond to
light accommodation) when a penlight pass through at about 6
inches far the pupils constrict upon illumination, smooth border,
iris flat and round, pupils converge when near object is move
towards the nose
• Visual Fields: the client has a normal visual field as evidence by
the ability to see object in the periphery even when looking
straight ahead which was done by asking the person to close
one eye then a pen or the index finger in the periphery and ask
if the person can see it without moving his head on the side
direction.
⇒ Ears and Hearing
• Auricles: the color of the auricle skin is same as the facial skin,
they are symmetrical, aligned with the outer canthus of the eye,
it is firm not tender, pinna recoils after it is folded
• External Ear Canal and Tympanic Membrane: with presence of
dry cerumen, in grayish in color
• Gross Hearing Acuity: normal voice tones audible
• Watch Tick Test: able to hear on the tick of the watch in both
ears with a distance of 3 cm.
⇒ Nose and Sinuses
• Nose: symmetric, straight, no discharge or flaring uniform in
color not tender and without lesions, air moves freely when he
breaths through the nares, which was done by asking the
person to occlude one of the nares then check for airway
patency on the unoccluded nares (done alternately) ,the
mucosa is pink, nasal septum intact in midline
• Facial Sinuses: not tender
⇒ Mouth and Oropharynx
• Mouth: with presence of dental caries like plaque and
tartar
• Lip and Buccal Mucosa: uniform pink color soft, moist, smooth
texture, ability to purse lips
• Teeth and Gums: yellowish color of teeth, with presence of
tartar and plaque noted, with cavities present; 12 lower
teeth, where in 1 is extracted (premolar) due to cavities; 12
upper teeth, where in there is also 1 tooth extracted
(premolar)due to cavities as well, and cavities on both upper
and lower molars, and dental caries on molars
• Tongue and Floor of Mouth: in central position, pink in color,
moist with thin whitish coating, smooth lateral margins, no
lesions upon observation, raised papillae, tongue moves freely
with no tenderness by asking the person to move her tongue in
different direction, smooth floor of the mouth
• Salivary Glands: same as the color of the buccal mucosa and
the floor of the mouth
• Palates and Uvula: light pink smooth soft palate, lighter pink
hard palate with irregular texture, the uvula is on the midline of
the soft palate
• Oropharynx and Tonsils: pink and smooth posterior wall of
oropharynx , pink tonsils without discharge
NECK
⇒ Neck Muscles: muscles equal in size, head movement are coordinated
and smooth with no discomfort able to flex 45 degrees hyper extend at
60 degrees; head laterally flexes at 40 degrees and laterally rotates at
70 degrees, muscles strength are equal by turning the head to one
side and shrugging the shoulder against the resistance of hands of
the student nurse which was done by asking the person to resist the
pressure of the hands of the student nurse by shrugging her shoulders
⇒ Lymph Nodes ( posterior and below the jaw): not palpable
⇒ Trachea: central placement of the midline of neck by palpation or by
asking the person to swallow
⇒ Thyroid Gland: it is symmetrical and masses are not visible, absence
of bruit
⇒ Neck Veins: not distended (ask the person to turn his head side to side
then check for the neck veins if distended or bloated)
UPPER EXTREMITIES
⇒ Skin and Nails: skin warm to touch, good skin turgor, nails are smooth,
colorless, trimmed, and in capillary refill result is normal because it
returns to its usual color less than 4 seconds.
⇒ Muscle Strength and Tone: symmetrical muscle size, no contractures,
no presence of tremor and it is normally firm smooth coordinated
movements.
⇒ Brachial and Radial Pulse: palpable
CHEST and BACK
⇒ Skin: evenly distributed skin color skin intact with uniform temperature
⇒ Chest Shape and Size: anterior-posterior to transverse diameter in
ratio of 1:2 symmetrical in shape, spine is vertically aligned, chest wall
intact
⇒ Lungs: full and symmetric chest expansion, quiet rhythmic and
effortless respiration, full symmetric excursion with bronchial & tubular
breathe sounds
⇒ Heart: no pulsation, symmetric pulse volume
⇒ Spinal Column: straight, right and left shoulders and hips are at the
same height
ABDOMEN
⇒ Skin: unblemished skin, symmetric movements caused by respiration
⇒ Abdominal Sounds: audible bowel sound, tympany over the stomach
and gas filled bowels
⇒ Specific Organs: not palpable
LOWER EXTREMITIES
⇒ Skin and Toenails: uniform skin temperature, convex curve and
colorless nail plates, presence of smooth nail texture, highly vascular
nail bed, trimmed and intact epidermis, with presence of scars on
both lower extremities
⇒ Presence of Achilles reflex
⇒ Presence of Patellar reflex
At the school-going stage, the child extends beyond the home to the
school and the emphasis is on academic performance. There is a movement
from play to work. If before the child could play at activities with little or almost no
attention given to the quality of results, now he needs to perform and produce
good results. The child learns that he can gain recognition from parents, teachers
and peers by being efficient in his school work. The attitudes and opinions of
others become important. If children are praised for doing their best and
encouraged to finish tasks then work enjoyment and industry may result.
Children's efforts to master school work help them to grow and form a positive
self-concept and find themselves, who they really are.
Source: psychology.about.com
During the latent period, the child begins around the time that children
enter into school and become more concerned with peer relationships, hobbies,
and other interests. The latent period is a time of exploration in which the sexual
energy is directed into other areas such as intellectual pursuits and social
interactions. This stage is important in the development of social and
communication skills and self-confidence.
Source: psychology.about.com
Snicker’s attention is diverted to his school mates, play mated and other
activities and interests. He is focused and attentive on things that matters his
school and the people around him. This stage is important because through
these, his social skills, communication, and self-confidence are developed. The
people around him will determine who he will be in the future.
Nutritional Status
BMI = Wt. in kg
Ht in m2
= 18 kg .
1.33 m2
= 13.53 (emaciated)
Snickers did not experience any major illness aside from fever, cough and
colds and diarrhea. The management that Mrs. Kisses usually do is just the
same with Kitkat. Tempra and Oresol are usual management given for fever and
diarrhea respectively. Mrs. Kitkat does not have any management when Snickers
is having cough and colds. He also had chicken pox, rubella and mumps before.
Right now, Snickers has an abrasion on left face, below the outer canthus but
does not have any complains of discomfort or pain because of it.
INITIAL ASSESSMENT
General Appearance
Choco Baby, two years of age, was asleep during the initial visit. She was
wearing a white sando and yellow shorts. She has dirty and long fingernails
and toenails. The soles of her feet were dirty as well. She also has dry skin.
There are also presence of allergies on her left fore arm and above the left
knee. They appear red and palpable.
Physical Assessment
Temp: 36.7° C
RR: 23 cycles/min.
CR: 72 breaths/min.
HEAD
⇒ Hair and Scalp: evenly distributed, slightly thin, black hair, with no
presence of lice
⇒ Skull and Face: smooth uniform consistency, symmetrical facial
features, palpebral fissures equal in size, symmetrical facial
movements
⇒ Eyes and Vision
⇒ External Eye Structures
• Eyebrows: hair evenly distributed, thin eyebrows and are
symmetrically aligned, equal movement, lesion seen above the
left eyebrow
• Eyelashes: equally distributed and slightly curled outward
• Eyelids: skin intact with no discharge noted, lids close
symmetrically, bilaterally blinking
• Bulbar Conjunctiva: transparent, sclera appears white and
pinkish bulbar conjunctiva
• Palpebral Conjunctiva: shiny, smooth.
• Lacrimal Sac and Nasolacrimal Duct: no edema or tearing
• Cornea: transparent, shiny and smooth, details of iris are visible
• Corneal Sensitivity: client blinks when the cornea is touched on
its side by a wisp of cotton which indicates that cranial nerve no.
5 (trigeminal nerve) is intact
• Pupils: black in color, PERRLA (pupils equally round respond to
light accommodation) when a penlight pass through at about 6
inches far the pupils constrict upon illumination, smooth border,
iris flat and round, pupils converge when near object is move
towards the nose
⇒ Ears and Hearing
• Auricles: the color of the auricle skin is same as the facial skin,
they are symmetrical, aligned with the outer canthus of the eye,
it is firm not tender, pinna recoils after it is folded
• External Ear Canal and Tympanic Membrane: with dry cerumen
⇒ Nose and Sinuses
• Nose: symmetric, straight, no discharge or flaring noted; uniform
in color; not tender and without lesions, air moves freely when
he breaths through the nares, which was done by asking the
person to occlude one of the nares then check for airway
patency on the unoccluded nares (done alternately), the
mucosa is pink, nasal septum intact in midline
• Facial Sinuses: not tender
⇒ Mouth and Oropharynx
• Mouth:
• Lip and Buccal Mucosa: uniform pink color soft, moist, smooth
texture
• Teeth and Gums: yellowish color of teeth, no cavities present
• 8 teeth on the upper and 8 on the lower
• Tongue and Floor of Mouth: in central position, pink in color,
moist, smooth lateral margins, no lesions upon observation,
raised papillae, tongue moves freely with no tenderness by
asking the person to move her tongue in different direction,
smooth floor of the mouth
• Salivary Glands: same as the color of the buccal mucosa and
the floor of the mouth
• Palates and Uvula: light pink smooth soft palate, lighter pink
hard palate with irregular texture, the uvula is on the midline of
the soft palate
• Oropharynx and Tonsils: pink and smooth posterior wall of
oropharynx , pink tonsils without discharge
NECK
⇒ Neck Muscles: head movement are coordinated and smooth with no
discomfort
⇒ Lymph Nodes ( posterior and below the jaw): not palpable
⇒ Trachea: central placement of the midline of neck by palpation or by
asking the person to swallow
⇒ Thyroid Gland: it is symmetrical and masses are not visible, absence
of bruit
⇒ Neck Veins: not distended (ask the person to turn his head side to side
then check for the neck veins if distended or bloated)
UPPER EXTREMITIES
⇒ Skin and Nails: skin warm and dry, good skin turgor, nails are smooth,
colorless, untrimmed and dirty, and in capillary refill result is normal
because it returns to its usual color less than 4 seconds.
⇒ With allergies present on the left fore arm, fresh and reddish in
color
⇒ Muscle Strength and Tone: symmetrical muscle size, no contractures,
no presence of tremor and it is normally firm smooth coordinated
movements.
⇒ Brachial and Radial Pulse: palpable
CHEST and BACK
⇒ Skin: evenly distributed skin color skin intact with uniform temperature
⇒ Chest Shape and Size: anterior-posterior to transverse diameter in
ratio of 1:2 symmetrical in shape, spine is vertically aligned, chest wall
intact
⇒ Lungs: full and symmetric chest expansion, quiet rhythmic and
effortless respiration, full symmetric excursion with bronchial & tubular
breathe sounds
⇒ Spinal Column: straight, right and left shoulders and hips are at the
same height
ABDOMEN
⇒ Skin: unblemished skin, symmetric movements caused by respiration
⇒ Abdominal Sounds: audible bowel sound, tympany over the stomach
and gas filled bowels
⇒ Specific Organs: not palpable
LOWER EXTREMITIES
⇒ Skin and Toenails: uniform skin temperature, dry to touch, convex
curve and colorless nail plates, presence of smooth nail texture, highly
vascular nail bed, untrimmed and dirty toenails and intact epidermis,
with presence of scars on both lower extremities
⇒ With allergies above the left knee, fresh and reddish in color
⇒ Presence of Tendon of Achilles reflex
⇒ Presence of Patellar reflex
Final Assessment
General Appearance
ChocoBaby was conscious, coherent and awake during the final assessment.
She wears a blue sando and a maong shorts. Her fingernails and toenails are
clean as well as his feet. The allergies noted on her left fore arm and above
the left knee are now dry and doesn’t appear red.
Physical Assessment
Temp: 36.9° C
RR: 22 cycles/min.
CR: 76 breaths/min.
HEAD
⇒ Hair and Scalp: evenly distributed, slightly thin, black hair, with no
presence of lice
⇒ Skull and Face: symmetrical, smooth uniform consistency, symmetrical
facial features, palpebral fissures equal in size, symmetrical facial
movements
⇒ Eyes and Vision
⇒ External Eye Structures
• Eyebrows: hair evenly distributed, thin eyebrows and are
symmetrically aligned, equal movement, lesion above the left
eyebrow
• Eyelashes: equally distributed and slightly curled outward
• Eyelids: skin intact with no discharge noted, lids close
symmetrically, bilaterally blinking
• Bulbar Conjunctiva: transparent, sclera appears white and
pinkish bulbar conjunctiva
• Palpebral Conjunctiva: shiny, smooth.
• Lacrimal Sac and Nasolacrimal Duct: no edema or tearing
• Cornea: transparent, shiny and smooth, details of iris are visible
• Corneal Sensitivity: client blinks when the cornea is touched on
its side by a wisp of cotton which indicates that cranial nerve no.
5 (trigeminal nerve) is intact
• Pupils: black in color, PERRLA (pupils equally round respond to
light accommodation) when a penlight pass through at about 6
inches far the pupils constrict upon illumination, smooth border,
iris flat and round, pupils converge when near object is move
towards the nose
NECK
⇒ Neck Muscles: muscles equal in size, head movement are coordinated
and smooth
⇒ Lymph Nodes ( posterior and below the jaw): not palpable
⇒ Trachea: central placement of the midline of neck by palpation or by
asking the person to swallow
⇒ Thyroid Gland: it is symmetrical and masses are not visible, absence
of bruit
⇒ Neck Veins: not distended (ask the person to turn his head side to side
then check for the neck veins if distended or bloated)
UPPER EXTREMITIES
⇒ Skin and Nails: skin warm and dry, good skin turgor, nails are smooth,
colorless, trimmed and clean, and in capillary refill result is normal
because it returns to its usual color less than 4 seconds.
⇒ With allergies present on the left fore arm, dry and grayish in
color
⇒ Muscle Strength and Tone: symmetrical muscle size, no contractures,
no presence of tremor and it is normally firm smooth coordinated
movements.
⇒ Brachial and Radial Pulse: palpable
CHEST and BACK
⇒ Skin: evenly distributed skin color skin intact with uniform temperature
⇒ Chest Shape and Size: anterior-posterior to transverse diameter in
ratio of 1:2 symmetrical in shape, spine is vertically aligned, chest wall
intact
⇒ Lungs: full and symmetric chest expansion, quiet rhythmic and
effortless respiration, full symmetric excursion with bronchial & tubular
breathe sounds
⇒ Heart: no pulsation, symmetric pulse volume
⇒ Spinal Column: straight, right and left shoulders and hips are at the
same height
ABDOMEN
⇒ Skin: unblemished skin, symmetric movements caused by respiration
⇒ Abdominal Sounds: audible bowel sound, tympany over the stomach
and gas filled bowels
⇒ Specific Organs: not palpable
LOWER EXTREMITIES
⇒ Skin and Toenails: uniform skin temperature, dry to touch, convex
curve and colorless nail plates, presence of smooth nail texture, highly
vascular nail bed, trimmed and clean toenails and intact epidermis,
with presence of scars on both lower extremities
⇒ With allergies above the left knee, dry and grayish in color
⇒ Gait and Balance: was able to perform all the gait and balance without
any discomfort
Presence of Tendon of Achilles reflex
Presence of Patellar reflex
Source: psychology.about.com
psychology.about.com
In this stage, the role of the parents is of importance. Mrs. Kisses trained
Chocobaby in the toiletry at the right age. She is no longer wearing her diapers
and uses the toilet properly and whenever needed. Mrs. Kisses was neither too
strict nor too lenient that is why Chocobaby was trained properly that she knows
the right time for using the toilet.
Immunization Status
ChocoBaby is considered as a fully immunized child because she had 1
dose of BCG, 3 doses DPT, 3 doses of OPV, 3 doses Hepa B and 1 dose of
Measle Vaccine before her first birthday at the Barangay Health Center.
Nutritional Status
Age: 27 months
Weight: 12 kg
ChocoBaby only experienced fever, cough and colds and diarrhea. Mrs
Kisses gives her some Tempra when she has fever and Oresol for diarrhea and
does not have any management for cough and colds. She also had rubella and
mumps. Right now, she had allergies on her left fore arm and above her left
knee. During the initial assessment they were fresh, itchy and reddish in color.
Mrs. Kisses managed it with Calamine lotion and during the final assessment
they already appeared dry and grayish in color and were no longer itchy as
verbalized by Mrs. Kisses.
8:00 am Waking up
8:00- 8:10 Breakfast
10-10:15 Bathing
10:15- 12:30 Watching tv
12:30- 1:00 Lunch
1:00- 5:00 Sleeping time
5:00- 6:00 Eating snacks
6:00- 8:00 Playing time
8:00- 8:30 Dinner
8:30- 10:00 Playing time
10:00 pm Sleeping time
LOLA TOOTSIE ROLL
The student nurses were not able to assess Lola Tootsie Roll because she
stays in her sari-sari store the whole day starting from 5:00 am to 8:00 pm.
UNCLE BUTTERFINGER
The student nurses was not able to assess uncle butterfinger because he
is not around during the house visits
BROTHER CRUNCH
The student nurses was not able to assess brother crunch because he is
not around during the house visits
IV. SOCIO ECONOMIC, CULTURAL AND ENVIRONMENTAL ASSESSMENT
A. Type of Family
Mr. Ferrero and Mrs. Kisses Chocolate goes hand in hand in terms of
decision-making, they consult each other in terms of planning and budgeting for
their family, they also discuss matters concerning their children’s schooling
financially and emotionally. When problem arises, they make sure that both of
them will handle and solve the problem. But then, in terms of matter concerning
health Mrs. Kisses is more dominant. She makes sure that she will comply with
the appropriate regimen regarding the condition that arises and she has greater
awareness regarding health matters compared to Mr. Ferrero. An example of
health matters wherein Mrs. Kisses is more responsible for is immunization. This
is so because Mr. Ferrero is also busy at his work giving Mrs. Kisses to decide on
matters that needs an urgent decision.
The Chocolate family’s main source of income is coming from Mr. Ferrero.
Lola Tootsie Roll does have contributions as well in the house expenses.
Sometimes, Uncle Butterfinger shares some in the budget only when he has
work.
On a daily basis, Mr. Ferrero gives Mrs. Kisses Php 200.00. This amount
is for the utilization of their daily needs like foods and allowances of the children.
It is used in buying over the counter medications when necessary. Lola Tootsie
Roll’s contribution was not specified but as stated by Mrs. Kisses, she told the
student nurses that Lola Tootsie Roll is the one who pays the Electric bills and
sometimes buys for the food they eat. Their monthly electric bill is about Php 600
to Php 700, and water bill costing about Php 300. Mrs Kisses also told the group
that Mr. Ferrero is still paying for his tricycle every month but she does not know
how much is the exact amount.
But with Mr. Ferrero’s daily income, the group can say that this is not
enough to shoulder every expense they have in the household. According to
NEDA, each individual should at least have Php 2768.60 when the total monthly
income of the family is divided among the total family members. The total
monthly income of Mr. Ferrero is about Php 5,200 and when divided among the 8
members, it is only Php 650. With these, they were considered poor. Mrs. Kisses
also told the student nurses that they do not have any financial assets at hand in
case of emergency; they just usually borrow money from their relatives,
neighbors or sometimes “five, six”.
D. Working Hours
The Chocolate family resides and all grew up in Barangay San Jose,
Angeles City. All of them are affiliates of Roman Catholic. Mrs. Kisses even
mention that they do not attend the Holy Mass every Sunday but she told the
student nurses too that Kitkat usually attends mass with her cousin and go to
mall afterwards.
The most significant persons involved in their lives are the aunt of Mrs.
Kisses living just beside their house, some close family friends which resides
within the vicinity area, and in some cases where in there is no one they can turn
to, they borrow money from the “five, six”.
G. Health habits/beliefs
The family still believes in the power of tawas or hilot. They first consult
in a mananawas or manghihilot whenever a family member gets sick. If the
situation gets worse, they go to their barangay health center and in severe cases,
they go to Ospital Ning Angeles and seek for help.
H. Family’s involvement in community activities
The Chocolate Family enjoys the facilities available in the community like
the basketball court; the barangay health center, where in the children had their
immunization and where Mrs. Kisses avails her contraceptive pills. Kitkat and
Snickers also studied in the Day Care Center in their Barangay. They also
consult the Barangay Captain or any official in the Barangay Hall in times of
problems.
J. Housing condition
The house only has 2 windows which basically does not sustain the
adequate ventilation needed by the family. The reason why the group considered
the ventilation of the family as inadequate is because the windows are obstructed
and air is not free flowing inside the house. Some clothes are also hanged in
front of the windows blocking the passage of air.
The house has 2 rooms with bed. Mr. Ferrero and Mrs. Kisses together with
Choco Baby sleeps on the room at the left side while Uncle Butterfinger sleeps
on the right room. Lola Tootsie Roll, Brother Crunch, Kisses and Snickers sleeps
at the sala. They use mattress and “banig.”
Lola Tootsie Roll goes to the market for their food every day. Though they
have a stove, they prefer to use charcoal because they cannot avail the Liquid
Petroleum Gas. Mrs. Kisses and Lola Tootsie Roll were the ones who usually
prepares the food. They cook at the back of their house beside the comfort room.
It is where their “dirty kitchen” is located. The food that they usually eat is
sardines and other canned goods. They also eat the leftovers from the merienda
that they cooked. When it comes to storing their food, they just cover their left
over with plate. But in some cases, they ask their relatives to let their leftovers
store in their refrigerator. In terms of cooking facilities the family is equip with
casserole, “sandok”, frying pan and knives.
L. Water Supply
NAWASA is the family’s source of water. They use a jar, which is covered
to store their drinking water. According to them the water is very much potable.
M. Toilet Facility
N. Drainage System
The drainage system of the family is open type. It is dirty and has a stinky
smell. There are some rice grains noted on the drainage. Molds are also noted.
There is no obstruction present at the drainage system, which makes the flow
continuous.
The family does not own any cell phones or telephone. They usually
borrow their neighbor’s or relatives’ cell phone if they need to text someone. Mr.
Ferrero has a tricycle which until now is not fully paid. He pays for it at installment
basis. Mrs. Kisses did not specify the amount regarding how much Mr. Ferrero
pays for the tricycle because she too does not know. It is their main mode of
transportation other than the public utility jeepneys.
V. PROBLEM IDENTIFICATION
Duration
> The family has a current
▼ management on the problem since
Mrs. Kisses helps Lola Tootsie
Current Roll's store which help them to
Management suffice their daily needs on food.
▲
Duration
>The problem is considered to be
▼ severe AEB after computing the
share of each family member on
Current their living space it shows that upon
Management
dividing the whole floor area of the
▼
Chocolate Family’s house, each of
High -risk Group the family member yields only
▲ _________ showing that the total
floor area of the house is
inadequate as to compare with the
prescribed by the National Building
code of the Philippines R.A 6541
that each of the family must have at
least a share of 3 m2, therefore if it
will be further divided considering
the space occupied by their
furniture it will yield a more lower
results.
Duration
> The problem is considered to be
▼ severe due to the following
reasons:
Current The awareness of the family
Management
to this problem is not evident.
▼
2 of the family member are
High -risk Group affected by the problem.
▲
>The problem exists years before
since the Snickers is now 7 years
old wherein ideally he must
completed the vaccine for Hepa B
when he was only 1 year old. With
Mrs. Kisses years have already
passed and she did not got her
third dose of Tetanus Toxoid
vaccine.
Total Score 2
INTERVENTION PLAN
ANALYSIS OF THE METHOD
CUES OBJECTIVES OF RESOURCES EXPECTED
PROBLEM NSG. INTERVENTIONS RATIONALE
FAMILY REQUIRED OUTCOME
CONTACT
S> "wa ating Inability to Short Term: >Explore the > To obtain a The family
dagis keni provide a family’s ideas baseline data H Family shall have
daramadama home After 2° of on rodents and for the health O Resources: recalled the
n mila kening environment, NI the family insect control teachings to be M other
bubungan, which is will be able through given to the E >Manpower methods of
egana gana conducive to to recall the interview. family. resources controlling the
atang insekto health other V such as time proliferation
atin keni" as maintenance methods of >Discuss with >To increase I and effort. of rodents
verbalized by due to controlling the family the the family’s S and insects
Mrs. Kisses inadequate the causes and awareness I >Physical presented to
knowledge of proliferation consequences about vector- T and chemical them via
O> The the other of rodents of different borne S resources health
student means of and insects vector- borne diseases. such as teaching, as
nurses have controlling presented to diseases. insecticides, evidenced by
observed the the them via cleaning the family will
following: proliferation health >Reinforce the > To increase/ articles such enumerate
of rodents teaching, as family’s suffice the as broom the methods
>Presence of and insects. evidenced knowledge on inadequacy of and presented.
breeding by the family rodent’s and the family’s broomsticks
ground of will insect control knowledge and dustpan. The family
cockroach. enumerate through health about rodents shall have
the methods teachings such and insect demonstrated
>Presence of presented. as maintaining control. Student the methods
mosquitoes a good Nurses of rodents
and flies. Long Term: sanitation Resources: and insect
condition of the control
After 4 days environment. >Knowledge, presented to
of NI the skills, time them.
family will be >Inform the > To avoid and effort of
able to family about accidents due the student
demonstrate proper handling to improper nurses.
the methods of insecticides. handling of
of rodents insecticides
and insect such as
control poisoning.
presented to
them. >Explore the > To measure
family’s the
reaction about understanding
the health of the health
teachings teachings
given. presented.
Problem# 2 Presence of Pediculosis
INTERVENTION PLAN
S> Mrs. Inability to Short Term >Explore the > To obtain a H The family
Kisses provide family’s idea baseline data for O Family shall have
have adequate After 2° of NI of how the health M Resources: demonstrated
verbalized nursing care the family will pediculosis teachings to be E understanding
the to the be able to occurs and given to the >Manpower of the health
following: infected demonstrate their family. V resources teachings
member of understanding management I such as time given about
“ay makutu the family of the health to control it. S and effort. Pediculosis
ya i due to teachings I such as
Hershey inadequacy given about > Provide the > to increase/ T >Physical methods to
[Kitkat]” of time r/t Pediculosis family with the suffice the S resources control
Mrs. Kisses such as information inadequacy of such as pediculosis as
“anyang ADL. methods to regarding knowledge of the cleaning and evidenced by
control Pediculosis family regarding grooming Mrs. Kisses
anak ya pa Inability to pediculosis as including the pediculosis. article e.g. will be able to
provide a evidenced by management shampoo, restate the
i Hershey home Mrs. Kisses that could be comb, soap health
environment will be able to done to and the like. teachings
[Kitkat] atin conducive to restate the control the given
personal health disease. according to
neng kutu, I development teachings Student her
due to given >Provide the > To promote Nurses understanding.
Ivan inadequate according to family with personal hygiene Resources:
[Snickers] knowledge her health to the family. The family
about understanding teachings >Knowledge, shall have
mehawa hygiene and . regarding skills, time practiced the
sanitation. personal and effort of methods of
yamu Long Term: hygiene the student controlling
especially hair nurses. pediculosis.
kaya.” After 2 days of care.
NI the family Community
will be able to > Instruct the > To have a resources:
practice the family to visit proper
O> The
methods of the health pharmacological Availability of
student
controlling center for management of the Barangay
nurse have
pediculosis. consultation. the problem. health center
observed
for
the
>Explore the > To measure consultation.
following:
family’s the
reaction about understanding of
> Presence
the health the health
of
teachings teachings
pediculosis
given. presented.
upon
inspection
of Kitkat
and
Snickers
hair.
S> “ay sira Inability to Short Term >Explore the > To obtain a H The family
sira la reng provide a family’s idea of baseline data O Family shall have
ipan ku” as home After 2° of NI how dental for the health M Resources: demonstrated
verbalized by environment the family will caries occurs, teachings to E understanding
Mrs. Kisses conducive to be able to their be given to >Manpower of the health
“sira la rin pu personal demonstrate knowledge of the family. V resources teachings
deng ipan ng development understanding the I such as time given about
Ivan[Snickers] due to of the health consequences S and effort. Dental Caries
” as verbalized inadequate teachings of having a I such as its
by Kitkat knowledge given about dental caries T >Physical cause;
about Dental Caries and their S resources methods to
O> The personal such as its management such as control and
student nurse hygiene. cause, to control it. tooth prevent dental
have observed methods to brushes and caries as
the following: control and > Provide the > To increase/ toothpaste. evidenced by
prevent dental family with the suffice the Mrs. Kisses
> Presence of caries as information inadequacy of will be able to
dental caries evidenced by regarding knowledge of Student restate the
upon the Mrs. Kisses Dental Caries the family Nurses health
inspection of will be able to including the regarding Resources: teachings
Mrs. Kisses restate the management Dental Caries. given
and her three health that could be >Knowledge, according to
children’s teachings done to skills, time her
mouth. given control the and effort of understanding.
according to disease, and the student
her the nurses. The family
understanding consequences shall have
. that may arise performed
such as tooth Community methods of
Long Term: loss and Resources: controlling and
infection. preventing
After 2 days of Availability of dental caries
NI the family >Provide the > To promote the such as proper
will be able to family with personal Barangay cleaning of
perform health hygiene to the Health teeth.
methods of teachings family. Center for
controlling and regarding consultation.
preventing personal
dental caries hygiene
such as proper especially
cleaning of mouth care,
teeth. the frequency
of cleaning the
teeth.
INTERVENTION PLAN
ANALYSIS OF METHOD
CUES OBJECTIVES OF RESOURCES EXPECTED
THE PROBLEM NSG. INTERVENTIONS RATIONALE
FAMILY REQUIRED OUTCOME
CONTACT
S> Mrs. Inability to Short Term: >Explore the > To obtain a Mrs. Kisses
Kisses have make family’s ideas baseline data Family shall have
verbalized decisions After 2° of NI about a good for the health Resources: restated
the following: with respect Mrs. Kisses lighting teachings to be H actions that
to taking will be able to condition given to the O >Manpower could be done
“dati neng appropriate restate actions family. M resources to improve
madalumdum action due that could be E such as time their lighting
ing bale, to negative done to >Discuss with >To increase and effort. condition as
anyang anak attitude improve their the family the the family’s evidenced by
ku pa towards the lighting importance of awareness >Physical Mrs. Kisses
makanini ne” problem. condition as having a good about good resources will be able to
evidenced by lighting lighting V such as repeat the
“sindyan ke Mrs. Kisses condition its condition and I fluorescent teachings
mu ing sulu will be able to benefits such promote a S lamps. given
madalumdum repeat the as it prevents good attitude I according to
eh” teachings straining of the towards the T Student her own
given eye, and also problem. S Nurses understanding.
O> The according to the Resources:
student her own consequences The family
nurses have understanding of having a >Knowledge, shall have
observed the . poor lighted skills, time showed an
following: house. and effort of improvement
Long Term: the student on their
> Dark lit >Reinforce the > To increase/ nurses. lighting
rooms (living After 6 days of family’s suffice the condition as
room, and NI the family knowledge on inadequacy of evidenced by
bedrooms) will be able to ways on how to the family’s removal of the
show an provide a well knowledge clothes that
> Obstructed improvement lighted house about other obstruct the
window on their ways of windows and
lighting improving their changing their
condition as lighting light bulbs with
evidenced by condition. fluorescent
removal of the lamps.
clothes that >Explore the > To measure
obstruct the family’s the
windows and reaction about understanding
changing their the health of the health
light bulbs with teachings teachings
fluorescent given. presented.
lamps.
Problem# 5 Poor Ventilation Condition
INTERVENTION PLAN
ANALYSIS OF METHOD
CUES OBJECTIVES OF RESOURCES EXPECTED
THE PROBLEM NSG. INTERVENTIONS RATIONALE
FAMILY REQUIRED OUTCOME
CONTACT
S> Mrs. Inability to Short Term: >Explore the > To obtain a Mrs. Kisses
Kisses have make family’s ideas baseline data Family shall have
verbalized decisions After 2° of NI about a good for the health Resources: restated
the with respect Mrs. Kisses ventilation teachings to be H actions that
following: to taking will be able to condition. given to the O >Manpower could be done
appropriate restate actions family. M resources to improve
“ay action due that could be E such as time their
malisangan to negative done to >Discuss with >To increase and effort. ventilation
keni alang attitude improve their the family the the family’s condition as
hangin towards the ventilation importance of awareness evidenced by
lulub” problem. condition as having a good about good Student Mrs. Kisses
evidenced by ventilation ventilation V Nurses will be able to
“malwat ne Mrs. Kisses condition its condition and I Resources: repeat the
yan, anyang will be able to benefits such promote a good S teachings
anak ku pa repeat the as it prevents attitude I >Knowledge, given
makanyan teachings easy transfer of towards the T skills, time according to
ne yan given diseases, and problem. S and effort of her own
matatakpan according to also the the student understanding.
ne keng her own consequences nurses.
harap mi” understanding of having a The family
. poor ventilation shall have
O> The condition. showed an
student Long Term: improvement
nurses have on their
observed After 6 days of >Reinforce the > To increase/ ventilation
the NI the family family’s suffice the condition as
following: will be able to knowledge on inadequacy of evidenced by
show an ways on how to the family’s removal of the
> improvement provide a well knowledge clothes that
Obstructed on their ventilated about other obstruct the
window ventilation house ways of windows.
condition as improving their
evidenced by ventilation
removal of the condition.
clothes that
obstruct the >Explore the > To measure
windows. family’s the
reaction about understanding
the health of the health
teachings teachings
given. presented.
VII. FAMILY COPING INDEX
Initial Final
Category Justification
1 3 5 1 3 5
1. PHYSICAL
INDEPENDENCE Initial Visit:
This category is concerned During the initial visit, the group had
with the ability to move observed that Mrs. Kisses has failed
about, to get out of bed, to to provide required personal care for
take care of daily grooming, herself and her children as
walking, etc. Note that it is evidenced by the presence of lice
the family competence that infestation, poor hair care and long
is measured- even though fingernails of the children. The
an individual is clothes of her children too are soiled
independent, if the family is with sweat and dirt.
able to compensate for this.
The family is important-
hence, if the focus of care Final Visit:
is poor, for instance, if the
mother is giving care to a The Student nurse had given them
handicapped child that she health teachings about the
shared with other members importance of proper hygiene; the
of the family, the family was cooperative to fully
independence might be comply with it. The mother has
considered incomplete. The allotted time and effort to manage
causes of independence the hygiene of herself and her
may vary however. Lack of children. The fingernails of her
independence in the family children were trimmed and they
may be due to actual were also seen wearing their
physical incapacity, the slippers most of the time especially
inability of “know-how”, the when they are outside the house.
willingness or fear of doing
necessary tasks.
2. THERAPEUTIC Initial Visit:
COMPETENCE
The group gave the family a score of
three because Mrs. Kisses gives
This category includes all some over the counter medications
to her children or other family
the procedures or
members when needed. She
treatment prescribed for the sometimes asks for the opinions of
care of illness, such as health workers at the health center.
giving medications and They are not able to provide other
using appliances, therapeutic measures to some
dressings, exercises, and illness like cough and colds because
relaxation and special of their financial limitation and lack
of knowledge as well.
diets.
Final Visit:
3. KNOWLEDGE ON
HEALTH CONDITION Initial Visit:
4. APPLICATION OF
PRINCIPLES OF
GENERAL HYGIENE Initial Visit:
Final Visit:
5. HEALTH ATTITUDES
Initial Visit:
This category is concerned
with the way the family Mrs. Kisses benefits from the
feels about health care in
services offered by the Barangay
general, including
preventive services, care of Health Center. She never fails to
illness and public health seek medical advice whenever her
measures. children need it.
Final Visit:
7. FAMILY LIVING
Initial Visit:
This category is concerned
largely with the All of the members of the family get
interpersonal or group along. However, sibling rivalry
aspects of family life- how cannot be eliminated in the family.
Mrs. Kisses told the group also that
well the members of the
she and Mr. Ferrero also
family get along with one experiences petty fights but
another, the ways in which managed to solve them immediately.
they make decisions
affecting the family as a
whole, the degree to which
they support one another Final Visit:
and do things as a family,
the degree of respect and The group taught the children that
affection the show for one petite fights may be normal but they
another, the ways in which should know that they should be
the manage the family patient with each other especially
budget, the kind of the older ones. Kitkat as the eldest
discipline that prevails. agreed to what the student nurses
said.
8. PHYSICAL
ENVIRONMENT Initial Visit:
9. USE OF COMMUNITY
FACILITIES Initial Visit:
Assessment is the very crucial part of doing the family case analysis, with
all the data that you will gather throughout the assessment process, there you
will derived the problems you will intervene to correct this problems.
The most important thing that a student nurse must have is the initiative,
time, effort, and patience, without those things you will not be able to gather all
the information you need, the client’s cooperation and compliance is also a vital
ingredients for the success of making a family case analysis.
Legends:
Home Satisfaction
Assessment & Rapport
Nursing Interventions
First Home Visit (July 15, 2008, Tuesday)
During the initial home visit, the student nurses went to the Chocolate’s
Residence for the first time and they have a vague feeling about meeting them
because they don’t know what to expect towards the response of the family upon
their arrival. Upon meeting them, they started to establish rapport and told the
family about the purpose of their study. The family responded towards the
student nurse’s request though it is obvious that they were not that comfortable
with each other yet.
Second Home Visit (July 16, 2008, Wednesday)
At the second home visit, the student nurses started the thorough
assessment of the two kids, Kitkat and Toblerone. They also imparted initial
health teaching regarding the existence of potential and actual problems that
may threaten the health of each family member. During this home visit, the group
is not yet that confident regarding their relationship with the family.
Third Home Visit (July 21, 2008, Monday)
During this home visit, the group assessed Mrs. Kisses and Baby Ruth.
They also imparted more health teachings to the family. This time the group is
more at ease with the family.
Fourth Home Visit (July 22, 2008, Tuesday)
During the 4th home visit, this time, the student nurses started their final
assessment at the same time they started implementing the plan of actions
regarding the problems diagnosed during the earlier home visits. The family’s
and the group’s relationship by now is very much established.
Fifth Home Visit (July 29, 2008, Tuesday)
During the 5th home visit, the student nurses continued assessing the
family and put their plan into action by means of implementation. They also gave
some health teachings that day.
Sixth Home Visit (July 30, 2008, Wednesday)
This is the last and final home visit conducted. The student nurses this
time assured that all data needed are complete and they gave further health
teachings regarding the potential and actual problems that may threaten their
health.
During this time, the family showed satisfaction and appreciation for what
the student nurses are doing. The group as well gave them a positive feedback
and thanks them for allowing the group to conduct the study with their
participation.
X. SPOT MAP AND DOCUMENTATION
F. Lazatin
San Fabian
St. Jude
Chocolate’s Residence
Cuevas, F. et. al. Public Health Nursing in the Philippines. 10th ed. Philippines:
2007
http://wisdomquotes.com
http://psychology.about.com/od/theoriesofpersonality/ss/psychosexualdev.htm
http://psychology.about.com/od/theoriesofpersonality/a/psychosocial.htm
Handouts from:
Primary Health Care II (2007-2008)