CENTRO ESCOLAR UNIVERSITY

MAKATI CAMPUS

DEPARTMENT OF NURSING

FAMILY COMPREHENSIVE NURSING PROCESS

Submitted by:
BSN 2A-2

Camama, Shayne A.
Estepa, Trisha T.
Baccay, Keith Adrian R.

Submitted to:
Mrs. Aubrey Rose J. Casilang, MAN, RN
 Chapter 1 – Initial Data Base

1. Family structure, characteristics and dynamics

Pangalan Eda Kasaria Estad Relasyon sa Relihiyo Elem HS Colleg Trabaho Lugar ng
d n o Sibil kinapanayam n e Kapanga-
nakan
Vilma 67 F Kasal Lola Roman  2nd Labandera Ospital ng
Legarte Catholic Maynila

Joahnne 42 F Kasal Mother/ Head Roman  1st DSWD Fabella

Cesista of the family Catholic
Rosemari 23 F Di Daughter Roman   Slot Fabella
e Cesista Kasal Catholic machine
watcher
Mark 19 M Di Son Roman  2nd Constructio
Joshua Kasal Catholic n worker
Cesista
Charlotte 17 F Single Daughter Roman  NA Fabella
Cesista Catholic
Alexander 15 M Single Son Roman  Currentl Student Fabella
y
Cesista Catholic studying

Client JC, a 43-year-old female, serves as the head of the family which made
them matriarchal. Their family consists of 6 members, this includes the head
client’s children and the grandmother. Clearly, the structure of their family is
extended. The father of the head client, originally, came from Pampanga while
the mother came from Davao. They are residing in Pasay City since birth. All of
them are Roman Catholic. Client RC who is the eldest among the children, is
currently working as watcher in a slot machine. Her age is 23 years old and her
civil status is single. Next is, client JC, a 19-year-old male who is a construction
worker. Followed by client CC, a 17-year-old female who is 32 weeks pregnant.
Then the youngest is client AC, a 15-year-old male who is currently in secondary
level of education. Lastly, the grandmother, client VL who aged 67 years old. She
works as “labandera” and caretaker of the tombs.

2. Socio- Economic & Cultural Characteristics

 Name Job Monthly Income
Vilma Labandera 500
Joahnne DSWD 3000
Rosemarie Watcher 500
Mark Joshua Construction worker N/A
Charlotte N/A N/A
Alexander N/A N/A
Jerkins Cristo sa Sabungan 1000

The monthly income of the family ranges from 1,000 to 5,000 pesos. It is
budgeted by the head of the family, food is their major priority followed by
electricity then water bills. Sometimes, their relatives help them with their
financial needs. Also, they mentioned that they barely participate with the
programs of their respective barangay.

MONTHLY EXPENSES (5,000 PHP)

Miscellaneous Kuryente
11% 11%
Pamasahe Tubig
9% Kuryente
11%
Tubig
Pagkain
Pamasahe
Miscellaneous

Pagkain
57%

The total income of Cesista Family is 5,000 pesos per month. According to Ms.
Joahnne, they spend 150 pesos for food every day. We estimated how much they
spend for a month. Their expenses are as follows: 4,650 for food, 300 for water, 500 for
electricity, and 400 for miscellaneous such as mobile load, etc. Their income is not
sufficient for their needs but they still find a way to pay their bills and sometimes get
help from the relatives, as stated by Ms. Joahnne. In terms of food, sometimes their
budget is not enough to feed the whole family which is why the head of the family does
not eat to give her share to the others.
2.1 Ecomap
The Cesista family has a very close relationship with the physical environment to which
they resides more than 40 years. With the education subsystem, family has a very close
relationship because one of her child is currently studying as high school student which
is a walking distance away from their shelter.

Regarding safety and transportation, the Cesista family has a moderately close
relationship because they do not commute regularly and rather prefer to walk. Also, the
fire station is just in front of the cemetery.

With politics and government, family has a moderately close relationship because they
just go to the barangay hall if necessary or if there is a problem that only barangay can
resolve.

In health and social services, the Cesista family has a moderately close relationship
because rarely go to health center because they go straight to the Pasay General
Hospital.

With the subsystem, communication, which is the church, the Cesista family has a
distant relationship for they do not go to church that much and they are not completely
aware of current events with the society.

In recreational activity, the family rarely visits any place that provides leisure for they
just spend their time staying at home which corresponds to having distant relationship.

Lastly, in economics, the client’s husband has a moderately close relationship because
it is his workplace and it is where his income is mostly earned. Also, it is the closest
place within their area.

3. Home & Environment

 Centro Escolar University
College of Nursing
Makati

Floor Plan with narrative and explanation

The Cesista family lives in Pasay Cemetery where they were residing for more
than 40 years. On top of the tomb is their sleeping area and also the place for
their belongings such as tv, electric fan, drawer and clothes. To make their area
more private, they use a curtain which also serves as their door. They go to their
cousin which is just near their place whenever they need to use the comfort
room. Water supply is from NAWASA and “poso”. They don’t have a drainage
system.

As we have observed their surroundings, their space is insufficient to cater a

family because they made a temporary shelter above the tombs in the cemetery
which is built with light materials. It is not well-ventilated for they have no
windows and uses cloths only to cover their space. The presence of accident
may occur because of the materials used and also their improper storage. They
have cats, dogs, and chickens with them.

They usually buy food instead of cooking for their own. They do not have their
own comfort room so they use tarpaulins to have privacy. The main source of
their water is from nawasa which they also drink. They mentioned also, that flood
is present whenever heavy rain occurs since they lack sewages.

They do not practice waste segregation but waste disposal is stated for they
collect it first then turn it into the garbage collector.
With regards to the health facilities, barangay health center is accessible to them
and PGH (Pasay General Hospital) is their primary hospital. Television and social
media is their source of news. Their mode of transportation is jeepney and
tricycle.
4. Genogram

In the genogram, we have based the generation from our OB client to see if
there are possible complications that may occur during her pregnancy. Starting
from her grandparents in paternal side, grandfather is already deceased due to
old age while her grandmother is still alive and is not experiencing any diseases.
Then, her grandparents in maternal side have a history of heart attack which is
her grandfather while grandmother is still alive whom also is our client. Next is
her parents, we do not have data gathered from her father since they are
separated with him however her mother have suffered from asthma before. She
and her sibling do not have any diseases acquired from any of the generation.
 Centro Escolar University
College of Nursing
Makati

Biographical Information

 Name: Vilma Cesista

 Age: 67
 Birthday: February19, 1952
 Birthplace: Ospital ng Maynila
 Height: 150cm
 Weight: 52kg
 Religion: Roman Catholic
 Race: Filipino
 Sex: Female
 Civil Status: Married
 Occupation: Labandera
 Usual Source of Health Services: M. Dela Cruz Health Center

Identifying Data

Mrs. V.L. is a 67 years old female, born on February 19, 1952 at Ilo-Ilo. She is
now residing in a cemetery in Pasay City with her two children. She stands 4’11”
tall and weigh 52 kgs. Mrs. V.M have 4 children. Her income comes from
washing clothes of other people and she is a Roman Catholic.

Chief Complaint

“May bukol ako sa singit” as verbalized by the client.

History of Present Illness

The client didn’t notice immediately the lump in her groin, she felt pain but didn’t
give too much attention in that area, she just thought that it was nothing until now
that the pain gives her a headache. She’s planning to go in the hospital after All
Saints Day to check her condition.

Past Medical History

Mrs. V.L. had 1 miscarriage when she was 37 years old.

Family Health History

The client’s father died because of diabetes and her mother died at the age of 74
because of sinusitis.
Social History

Mrs. VL works as “labandera”. In her free time, she plays snack machine and
play some games in her cellphone.

Physical Assessment

GENERAL APPEARANCE

Mrs. VL has a medium frame body built and has a stooped posture. She can
walk and stand properly. She is appropriately dressed and well groomed.
Clinical Measurements: Height 4’2” Weight 52 kg
Vital Signs: Temperature 36.4°C BP 120/80mmHg RR 18bpm PR 80bpm

MENTAL STATUS

She is conscious and cooperative. She is well – oriented of the time, place and
person she is with.

SKIN

She has a normal skin color. She is warm and smooth to touch, turgor is wrinkle
loss of elasticity and hair is evenly distributed.

NAILS

She has a pink nail beds. Capillary refill back within 3 seconds. Her nail plate
shape is convex 160 and has a smooth texture.

HEAD AND FACE

She has a black and shiny hair but there’s already a presence of white hair. Her
hair is thick and evenly distributed. There are no infestations on her head. Her
skull is proportionate to her body size. Her face is symmetrical and her face
moves easily.
EYES

She has straight normal eyes. There are no fallen eyelashes or eyebrows. Blink
response is present. Eyeballs are symmetrical and firm. Her sclera is white. She
cannot recognize object 12 inches away without her eyeglasses. She has pink
conjunctiva and moist lacrimal apparatus.

EARS

Her ears are of normal racial tone. The pinna recoils when folded. It is elastic and
non-tender. There is presence of some cerumen on the external canal. She
responds to normal and whispered voice.

The ears of the client are within normal racial tone, it is symmetric and elastic.
There is no tenderness. Pinna recoils when folded. External canal has some
cerumen. The client responds to normal voice.

NOSE

Her nose is of normal racial tone. Septum is located in the midline and her
nostrils are both patent. Sinuses are not tender and there are no nasal
secretions.

MOUTH

Her lips are symmetrical and pink. Her tongue rests at midline and rough to
palpate. Oral mucosa is pink in color. Her soft and hard palate are intact.

PHARYNX

The uvula is located in the midline and her tonsils are not inflamed. Her gag
reflex is present and she has incomplete teeth.

NECK

She has a weak neck muscles. Trachea is located in the midline. Thyroid gland
and lymph nodes are not palpable.
BREAST AND AXILLA

Her breast is symmetrical and her nipples is everted. Lymph nodes is not
palpable as reported by client VL.

CHEST AND LUNGS

She has regular breathing pattern. Lung expansion is symmetrical both in

anterior and posterior. Normal breath sounds are heard..

ABDOMEN

She has a normal racial tone abdomen and is flat. There is a scar in her
abdomen due to operative procedure.

UPPER EXTREMETIES

Lymph nodes are not palpable and peripheral pulses are present..

LOWER EXTREMETIES

Lymph nodes are not palpable and peripheral pulses are present.

GENITALIA
This part was not assessed.
PERSON-GORDON APPROACH

PSYCHOSOCIAL

Self Perception- Self Concept Pattern

Mrs. V.M is happy and contented of what she has now. She described herself as
strong and a happy person.

Role Relationship Pattern

Mrs. V.M lives with her two children. The most important person in her life is her
family, they make her happy in many ways. She verbalized that her income is not
enough for their needs. She knows the location of the health center in their
barangay but she doesn’t go there for check-up.

Sexuality and Reproductive pattern

She has an OB score of G5P4(3114). Her first menstruation was when she was
12 years old. Her period usually lasts for 5 days. Her first menstruation was when
she was 13 years old. She got menopause when she was 50 years old.

Cognitive Perceptual Pattern

Mrs. V.M has no hearing and visual difficulty. She is experiencing memory loss.
She verbalized pain in her groin and she plan to go to hospital for check-up this
November.

Coping Stress and Tolerance Pattern

Mrs. V.M verbalized that whenever she's anxious and stress, she's just playing
games in her cellphone. She always talks to her family to get some advice.

Value Belief Pattern

The client is a Roman Catholic and she rarely go to church. Their family has no
religious practices that affects hospitalization.

ELIMINATION

The client defecates twice a day and she urinates 4-5 times a day approximately
500cc.
REST AND ACTIVITY

The client has no exercise program. She does household chores and taking care
of her grandson.

SLEEP AND REST

Mrs. V.M has a maximum sleep of 8 hours. She's not using any supportive aids
and devices everytime she's sleeping.

SAFE ENVIRONMENT

The client is living in the cemetery. She has no known food and medication
allergies.

OXYGENATION

The client has no problem with her airway clearance. She has a normal
respiration and no changes in skin, nails and lips.

NUTRITION

Mrs. V.M likes vegetables, fish, fruits and meat. Their budget with food is not
enough for them to get a good nutrition and they rather cook in the house rather
than buying outside. The client drink lot of water usually more than 8 glasses a
day.
 Centro Escolar University
College of Nursing
Makati

Biographical Information
 Name: Joahnne Cesista
 Age: 43 years old
 Birthday: July 30, 1976
 Birthplace: Pasay City
 Height: 158 cm
 Weight: 71 kg
 Religion: Roman Catholic
 Race: Filipino
 Sex: Female
 Civil Status: Married
 Occupation: None
 Usual Source of Health Services: Pasay General Hospital

Identifying Data

Client JC is 43 years old, female. She was born on 30 th of July 1976. She
formerly works in DSWD (Department of Social Welfare and
Development). She is a mother of 6 children and is separated to her
husband. Roman Catholic is their religion.

Chief complaint

Client JC complains for bloody vaginal discharge whenever stressful

activity is done.

History of Present Illness

Client JC reported that she was admitted last July and was discharge on
August. Her blood was monitored in the hospital, the bleeding occurs
when client underwent activities that are heavy to handle.

History of Past Illness

 Client JC sometimes experience sinusitis which she inherit from her
mother. It is usually triggers by a pleasant smell and dusts all over
the area which causes her to a non-stop sneezing.

Family History

Client JC’s mother side has a history of diabetes and asthma while her
father’s side has history of hypertension.

Personal and Social History

Client JC is advised by the doctor to rest, she is currently taking

medication via intramuscular for 6 months. Before she works in
DSWD, she mentioned that they are the ones who pack the relief goods.
Their family is included on the DSWD’s 4Ps. Client JC did not finished
her secondary level of education. She also works before as watcher
in a slot machine but now their family serve as the caretakers of the
tombs. Client JC smokes.

PERSON-GORDON APPROACH

PSYCHOLOGICAL

Self-Perception – Self-concept Pattern

Client JC describes herself as independent for she had raised her children
by her side without any help from her husband. She also mentioned that
she is a straight-forward person who chooses to say what is wrong. These
past few months, client JC feels anxious because of the continuous bloody
vaginal discharge. For her to somehow disregard the stress she smoke
and then rest. Also, she thinks of her children.

Role Relationship Pattern

Client JC’s main support system is her children and her mother. Client JC
is the head of the family, she guides and advices her children with the also
by her mother. When it comes to finances, client JC admitted that it is
 really insufficient to provide the needs of the family since she do not work
for now and their source of income came mostly from her working children
who also provide for their own families.

Sexuality and Reproductive Pattern

Client JC’s last sexual intercourse was on March 2019 before she is
completely admitted in the hospital by July until August. She underwent
dilation and curettage procedure for about three months to determine the
cause of abnormal uterine bleeding. In the result, client said that it is found
in the result; a small-sized cyst filled with water. Client is advised by the
doctor to undergo hysterectomy but client refuses due to financial reasons
and also her fear.

Cognitive Perceptual Pattern

Client JC do not have hearing difficulty. She uses glasses for her visual
problem. Whenever there is discomfort felt, client chooses to rest.

Coping Stress Tolerance Pattern

Client JCfeel the stress most of the time but does not focus on the
problem and chooses to rest instead. But at times wherein immediate
action is needed, she mentioned that she do the prioritization. Her main
source of motivation is her children.

Value Belief Pattern

Client JC is satisfied with her life as long as she is with her children and
her mother by her side. When it comes to nutrition, she refuses to eat
tulingan for she believed that it causes “balisa”. In terms of family and
social value, being “mapagbigay” is her dominant attitude towards people
that are significant to her. One that influenced their life is having a deep
connection with God.

ELIMINATION
 Bowel and urinary elimination is normal since the client defecates daily
and urinates from time to time without any severe odor. Her bowel
elimination occurs every afternoon and frequent urination is also
reported because client excesses her water intake.

REST AND ACTIVITY

I. Activity Exercise Pattern

Client JC do not have any exercise done before and in current state,
instead she do household chores that she can tolerate.

II. Sleep Rest Pattern

Client JC sleeps around 10 in the evening and wakes up 4 in the morning.

Usual reason of client for disturbance of sleep is the frequent urination.

SAFE ENVIRONMENT

Client JC has no known allergies but sneezing excessively when

fragrance is encountered and also dusts. Client also showed her eczema
which is for her due to washing clothes in a forceful manner.

OXYGENATION

Client can tolerate daily activities. Nasal cavities are both patent.
Respiration pattern is regular. No changes in color of the skin, nails, and
lips. No edemas are present.

NUTRITION

Client usually buys food. She said that they are able to eat three times a
day. Her food recall for the last 24-hour period include spaghetti for
breakfast then “tortang talong” for lunch and the coffee and “biko” for
dinner.
 Centro Escolar University
College of Nursing
Makati

Biographical Information
 Name: Charlotte Cesista
 Age: 17
 Birthday: February 7, 2002
 Birthplace: Fabella, Manila
 Height: 157cm
 Weight: 70kg
 Religion: Roman Catholic
 Race: Filipino
 Sex: Female
 Civil Status: Single
 Occupation: NA
 Usual Source of Health Services: M. Dela Cruz Health Center

Identifying Data

Ms. CC, 17 years old female was born on February 7, 2002 at Fabella, Manila.
Presently residing at Pasay City. She is the third among the 6 siblings. She is 7
months pregnant and this is her first pregnancy. She stands 157cm and weighs
70kg. She is a Roman Catholic. The interview was conducted on October 21,
2019 at Pasay Cemetery.

Chief Complaint

NA

Present Illness

NA

Past Medical History

Patient has no known allergies on food or medications.

Personal and Social History

Ms. CC is the 5th among the 6 siblings. She usually spends her day either doing
household chores such as doing the laundry or watching vlogs on youtube. They
don’t have any superstition belief that could affect their health but they make use
 of first aid such as betadine as their primary healing aid. She finished her primary
level of education and decided not to continue her secondary level of education
because of financial issues. According to her, she does not had any conflicts with
her neighbors but chose not to participate in their barangay activities.

PERSON-GORDON APPROACH

PSYCHOLOGICAL

Ms. CC said she was happy with her life despite the hardships they are
going through. She believes that everything happens for a reason and the
sufferings they are experiencing now will turn into a beautiful life one day.

She also prefers to be alone for some time and does not want to socialize
when she is sad, because according to her most of her neighbors are
“chismosa” and she does not want to be talked about. She is friends with
almost everyone in their community.

She has no hearing and visual difficulty. She manages her stress by
roaming around the neighbourhood. She simply enjoys talking with her
friends and family. She is in a 2 years of relationship with her boyfriend,
the father of her child. She used to drink and smoke but stopped when she
became pregnant. Because of their financial crisis, whenever they felt
something wrong with their health, they chooses to self-medicate such as
taking biogesic whenever they have a fever.

ELIMINATION

Ms. CC urinates more than 6 times a day with no accompanying

discomfort. She defecates once a day every morning. She does not
perspire excessively.

REST AND ACTIVITY

She used to watch television and listen to the music when she gets tired.
Her usual Activity of Daily Living includes doing the chores, and doing the
laundry. But she had lessened her activity and prefers to rest because she
is afraid of getting into accident while she is pregnant
 SAFE ENVIRONMENT

Ms. CC feels comfortable with their place. She lives in a cemetery on top
of the tomb.

OXYGENATION

Ms. CC used to have asthma when she was 7 years old. Because of her
constant drinking of water, she cured her own asthma according to her.
Whenever she had difficulty of breathing, she just drinks water.

NUTRITION

Mr. C used to cook and eat vegetables and put the leftovers in the refrigerator to
heat in the morning.

24 Hour Diet Recall

Breakfast: 1 cup of coffee
1 cup of rice and adobo
Lunch: 2 cups of rice and pakbet
Dinner: 2 cups of rice and adobong kangkong

OB ASSESSMENT

HISTORY

Ms. CC had her menarche at the age of 14. This is her first pregnancy.
She’s currently seven months pregnant, third trimester. Her Last
Menstrual Period was March 9, 2019. The expected date of confinement is
on December 16, 2019. Her Age of Gestation is 32 weeks and 2 days. Her
GPTPAL is G1 P0 T0 P0 A0 L0.

INITIAL PHYSICAL ASSESSMENT

Her Initial Physical Assessment’s data came from Breast, Nipples, and
Abdomen. Her Breast is equal in size and symmetrical. According to her,
her nipples are everted and no discharges present. Her abdomen has the
presence of linea nigra and striae gravidarum. According to the client
there was no problem in her perineum and no discharges present but
 sometimes she feels painful contractions but lasts not more than 15
seconds.

ANTHROPOMETRIC MEASUREMENT AND VITAL SIGN

Her height is 157 cm, Weight is 70 kg, her fundic height is 28 cm. Her
blood pressure is 100/60 mmHg, Pulse Rate is 78 bpm, Respiratory Rate
is 16 cpm, Temperature is 35.8⁰C.

ANTEPARTUM ASSESSMENT, HEAT ACETIC TEST AND BENEDICTS TEST

We conducted the Leopold’s Maneuver, we ask the client to void first in

preparation of the Leopold’s Maneuver and let her do the midstream catch
urine for our Heat Acetic and Benedict’s test. On the first maneuver, the
superior surface of the fundus is soft, which means that it is the buttocks
and is a cephalic presentation. The second maneuver, we palpated both
sides of the uterus and the fetal back is on the right lower quadrant of the
abdomen. On the third maneuver, we determine that the fetus is not
engaged. Fourth maneuver, there is no attitude palpated because the
client is still in her 7th month of pregnancy.

The interpretation of the result of Heat Acetic test is negative

because there is no visible cloudiness seen. While in Benedict’s test it is a
trace because there is a presence of green opacity without precipitate
formed.

Name of the procedure Purpose Result

1. Heat Acetic Acid A test used for the
Test presence of protein in No visible cloudiness
the urine.
2. Benedict’s Test A test used for the
presence of reducing
sugars such as glucose, Trace
lactose and fructose, but
not sucrose in the urine.

PHYSICAL ASSESSMENT
GENERAL APPEARANCE

Client CC has a medium frame body built with an upright posture and walks in a
smooth rhythmic gait. She is appropriately dressed, neat without body odor. No
obvious signs of physical deformity noted.
Clinical Measurements: Height 5’2” Weight 70kg
Vital Signs: Temperature 35.8°C BP 100/60mmHg RR 16bpm PR 78bpm
MENTAL STATUS

Client CC is conscious, coherent and cooperative . She is well-oriented of the

time, place and person she is with.

SKIN

Her skin is of normal racial tone, warm and smooth to touch. Turgor is elastic and
mobile and hair is evenly distributed.

NAILS

Her nail plate shape is normal (convex 160) and in smooth condition. Her nail
bed is pink in color. Capillary refill within three seconds, upon administration of
blanche test.

HEAD AND FACE

With black hair, straight barber's cut, evenly distributed. No infection or

infestation and dandruff seen. Pubertal hair starts to grow.

EYES

Thick eyebrows and eyelashes are evenly distributed and symmetrical. Skin
surrounding the eyes is intact without any discoloration. The sclera is white,
palpebral conjunctiva is shiny, smooth, and pinkish while bulbar conjunctiva is
clear. No edema or tenderness on the lacrimal glands. Pupils are reactive to light
and accommodation and both eyes move in unison.

EARS
 Auricle is in normal racial tone, symmetrical and aligned with outer canthus of
eye. Upon palpation, auricles are mobile, firm and not tender. Pinna recoils when
folded. Ms. CC responds to normal voice and to whispered voice of 2 feet away.

NOSE

With symmetrical and straight nares without discharge. Septum is located in the
midline and her nostrils are both patent. Air moves freely through the nares as
the client breathes. Sinuses are not tender and there are no nasal secretions.
MOUTH

Lips and buccal mucosa are uniform and pink in color, soft and smooth in texture.
Have complete teeth. Her tongue rest in the midline.

PHARYNX

The uvula is in the midline. Hard and soft palate are intact, and tonsils are not
inflamed.

NECK

She has a strong neck muscle. Muscles are equal in size with no tenderness.
Head movement is coordinated, smooth without discomfort. There is equal
muscle strength and non-palpable lymph nodes.
.

BREAST AND AXILLA

Instructed patient to palpate her breast. No masses palpated according to

patient.

CHEST AND LUNGS

She has regular breathing pattern. During auscultation, normal breath sound
were heard. No tenderness and masses upon palpation.

ABDOMEN

OB tool was used to assess this part.

UPPER EXTREMETIES
 Due to inadequate equipment motor strength and muscle tone is not
assessed. There is no presence of lesions and no obvious deformities.
Peripheral pulses are normal and lymph nodes are not palpable.

LOWER EXTREMETIES

Due to inadequate equipment motor strength and muscle tone is not

assessed. There is no presence of lesions and no obvious deformities.
Peripheral pulses are normal and lymph nodes are not palpable.

GENITALIA
This part was not assessed.

Centro Escolar University

College of Nursing
Makati
Biographical Information

 Personal Data Name: Alexander Cesista

 Age: 15 years old
 Sex: Male
 Race: Fiipino
 Religion: Roman Catholic
 Birth Date: June 1, 2004
 Birth Place: Fabella
 Present Address: Pasay City
 Usual source of health services: M. Dela Cruz Health Center
 Date of Interview: October 21, 2019 at 2: 00 pm

Chief Complaint
None

History of Present Illness

None

Past Medical History

Alexander was hospitalized when he was 3 years old due to dehydration. His
mother reported that he had completed all the immunizations before he reached
10 years of age.

Family History
Genogram

Personal and Social History

Client Alexander is a shy person, he won’t talk to people unless they talked to
him first. He loves his family so much that he does not want anyone to bother
them. He has several girlfriends in school and just recently broke up because
according to him “bigla nalang kami hindi nag-usap”. He usually spends his day
studying in school or playing basketball when he doesn’t do anything. He also
earns his own money during “undas” because he’s good in lettering in the tomb.
Sometimes he takes care of the grave and the people will pay him for keeping it
clean.

REVIEW OF SYSTEMS

Growth and Development

Psychosexual Theory by SIGMUND FREUD

Client is a 15 years old male. He is on the Genital stage. The ego in the genital
stage is well-developed. It uses secondary, process thinking, which allows for
symbolic gratification. This symbolic gratification may include the formation of
love relationships, development of families, or acceptance of responsibilities
associated with adulthood.

Analysis:

In relation to the patient, he is now adjusting from adolescent of adulthood changes. He

already had 4 girlfriends all of which he considered as “ex”.

Psychosocial Theory by ERIC ERICKSON

Client is in Identity vs role confusion Stage. The adolescent is newly concerned

with how they appear to others. As they make the transition from childhood to
adulthood, adolescents ponder the roles they will play in the adult world. Initially,
they are apt to experience some role confusion- mixed ideas and feelings about
the specific ways in which they will fit into society- and may experiment with a
variety of behaviors and activities.

Analysis:

In relation to the patient, Alexander is now on Grade 7 and has verbalized that he wants
to help his mother earn money by doing lettering on the tomb every Undas.

Cognitive Theory by JEAN PIAGET

Alexander is in the Formal Operation Phase. During concrete operation, they can
solve concrete problems. Formal operation Phase describes that child uses
rational thinking, reasoning is deductive and futuristic. (Kozier and Erb ed pg 357,
2008)

Analysis:

Client demonstrated logical reasoning when assessed about the concepts such as time,
money and application of addition and subtraction. This implies that the client acquires
knowledge from his formal education and applies it to the real situation of life.
Moral Development by LAWRENCE KOHLBERG

Most of the adolescent is spent in the Conventional Phase. Behavior is based on

familial and peer group beliefs, and conformity the norm is common. Following
school regulations, respecting teachers, and viewing justice as a means of fair
play are all important

Analysis:

He has good relationship with his friends “Pag walang pasok, inaaya nila ako
magbasketball or tumambay lang at magkwentuhan sa labas”.

PHYSICAL ASSESSMENT

GENERAL APPEARANCE

Client AC has a small body built with an upright posture. He is appropriately

dressed. Client has neither body odor nor bad breath odor. No obvious physical
deformity.
Clinical Measurements: Height 4’5” Weight 34kg
Vital Signs: Temperature 35.9°C BP 90/70mmHg RR 21cpm PR 81bpm

MENTAL STATUS

The client is conscious and coherent, with good affect, oriented to date, time,
person, and place. Uses simple words.

SKIN

The client's skin is of normal racial tone, which is brown, has warm temperature
except palm, which is cold to touch. Client's skin is smooth and has good skin
turgor. No lesions noted and hair is fine that is evenly distributed.

NAILS

The client’s nail plate shape is concave 1600. it has a smooth texture, pinkish
nail bed. Capillary refill exceeds 30 seconds. No presence of Beau’s line.
Capillary refills within 3 seconds upon doing blanche test.
HEAD AND FACE

Hair is evenly distributed, thick and shiny. No infection or infestation were seen.
The client's skull is proportionate to his body size and has a smooth texture. The
scalp is non-tender and white. Hair is equally distributed, thin and is free from
any infestations. No presence of nodules or masses noted. The face as well as
the facial movements is symmetrical. Head has a hard consistency.

EYES

The client's eye condition is straight normal and eyebrows are thick. He has
equal distribution of eyelashes. The eyelids has no discharge and close
symmetrically. He has a bilateral blink response. Eyeballs are symmetric and
firm. Bulbar and palpebral conjunctivas are clear. Pupils are equally reactive to
light and accommodation. Lacrimal apparatus are moist.

EARS

Client's auricle are of normal racial tone, whitish is brown, same with the color of
the face, symmetrical in size and position. The alignment of pinna is in line with
the outer canthus of the eye. It is elastic and nontender. Pinna recoils when
folded. There’s presence of some cerumen, which is light brown in the extemal
meatus. Absence of discharge and there no swelling or redness observed.

NOSE
The patient's extemal nose is of normal racial tone color, brown, the same as
with the face, septum at midline, nares are symmetrical. Pink nasal mucosa,
nares both patent and nasal cavity is moist. Sinuses are nontender.
.

MOUTH

The patient's lips are symmetrical and dry. Buccal mucosa is dry. The tongue is
at midline, moves freely, rough and pink. Client's permanent tooth has erupted.
Gums are pink, tonsils are not inflamed.

PHARYNX
 The uvula is in the midline. Hard and soft palate are intact, and tonsils are not
inflamed.

NECK

The client's neck muscles are equal in size. Preauricular, post auricualar,
cervical, and supra davicular lymph nodes are not palpable. Trachea is at midline
of neck with no deviation noted and thyroid gland is not palpable.
.

BREAST AND AXILLA

There no masses palpated. Nipples are light brown in color, dry and symmetrical.
The axilla is color brown, dry and presence of hair starts to grow.

CHEST AND LUNGS

The client's chest is of normal racial tone, brown color. Lung shape is AP lateral
ratio of 1:2. Lung expansion is symmetrical anterior to posterior. Fremitus
is found to be symmetrical and decreasing in both sides. Vesicular,
bronchial, and bronchovesicular breath sounds are heard. He has a
regular breathing pattern. Resonance was heard upon percussion.
The costal angle of the client is 45 degrees. The client's apical pulse is
equal in rate and symmetrical with regular rhythm and strength. HR-81
bpm, however it was only observed to be increased during the interview
but it was reassessed after 15 minutes and the result went back to 80
bpm. The apical and radial pulse has equal rate and rhythm.

ABDOMEN

The client's abdomen is of normal racial tone color that is brown, flat
contour and with symmetrical abdominal movements.Bladder is not
distended. Liver is not palpable. Upon percussion, tympany was
heard.

UPPER EXTREMETIES
 The client's motor strength is 5/5. Client can move his extremities freely. He has
no physical deformity. Bronchial and radial pulse is present. Lymph nodes
are not palpable. No inflammation noted.

LOWER EXTREMETIES

Client can move his extremities freely. He has no physical deformity. No

inflammation noted.

GENITALIA

This part was not assessed.

Nutritional Assessment
 Name Age Weight Height BMI Classification
(kg) (cm)

Vilma 67 52 150 23 Overweight

(Grandmother)
Joahnne 43 71 158 28 Overweight
(Mother. Head of
Family)
Charlotte 17 70 157 28 Overweight
(Daughter)
Alexander (Son) 15 34 136 18 Underweight

The table shows the classification of each member of the family depending on their
age, weight, height, and BMI. All members are overweight except client AC which
shows that there is malnutrition. Malnutrition includes two types which is
undernutrition and overnutrition. In undernutrition, client has low height and weight
for his age and may lack also with important vitamins and minerals. In overnutrition,
client may acquire diet-related diseases such as heart disease, diabetes, and
cancer.

5. Values, Habit and Practices

Immunization status of Family members

Members Atbp. (Flu
of the BCG DPT OPV HEPA B MMR vaccine,
family Pneumococcal,
Tetanus
toxoid)
Vilma     

Joahnne     

Charlotte     

Alexander     

Each member of the family is fully immunized as stated by the head of the family
since health record of each member is no longer available.
Healthy Lifestyle Practices
 To meet the nutritional needs of the family, the head of the family prefer buying
cooked vegetables from carinderia since it is more affordable and enough to
distribute for each member of the family. They do not take vitamins and do not
perform exercises. The family uses “tsinelas”,”bota”, and ”katol”. Whenever
heavy rain occurs, mosquitos are abundant within their area so they use “bota”
and “katol”.

Sapat Kulang
Pagtulog 

Pamamahinga 

Ehersisyo 

Gawaing nakakapagpakalma:

1. Paglalakad-lakad
2. Pakikipagkwentuhan sa kapitbahay

Family has sufficient sleep and rest for they complete the 8-hour-sleep every day. The
family admitted that they are lacking with exercise because it is not their primary concern
and they will always choose to rest than to exert effort to such activities.

Use of promotive-preventive health services

As of now, client CC make use of the services in M. Dela Cruz Health Center for her
pregnancy. She is currently taking pre-natal vitamins such as Calcium, Ferrous Sulfate, and
Folic Acid. Overall, the family rarely visits health center not unless the condition needs
urgent action because they usually go straight to the Pasay General Hospital (PGH).

FAMILY APGAR
 (Adaptability, Partnership, Growth, Affection and Resolve)

COMPONENT SCORE JUSTIFICATION

Adaptation 1 “Minsan naaasahan
naming ang isa’t isa pag
may problema”, as
verbalized by the head
of the family.
Partnership 1 “Pare-pareho kaming
nagdedesisyon tungkol
sa mga desisyon na
kailangan dito sa bahay
kagaya ng sa pagkain,
kung ano uulamin o
bibilhin pero pag
usapang kalusugan di
namin masyado pinag-
uusapan dahil wala
naman kaming sapat
nap era para doon”, as
verbalized by the head
of the family.
Growth 1 “Si nanay dahil siya ang
matanda, tinuturuan niya
ako tungkol sa paano
gagabayan ang aking
mga anak, na yun din
naman ang aking
tinuturo kay Charlotte
dahil magkakaanak na
siya. Sinasabi ko rin kay
Charlotte na ipagpatuloy
niya ang pag-aaral niya
pagkatapos niya
manganak”, as
verbalized by the head
of the family.
Affection 2 “Pag galit ako o
malungkot, lagi silang
andiyan pag gusto ko ng
 makakausap”, as
verbalized by the head
of the family.
Resolve 1 “Minsan kahit wala yung
ibang miyembro ng
pamilya nakakapagbigay
pa din sila ng pera
pandagdag sa gastusin
naming dito sa bahay”,
as verbalized by the
head of the family.

Total: 6 - Moderately dysfunctional family

SCORES:
Almost Always - 2 points
Some of the time - 1 point
Hardly ever - 0 point

INTERPRETATION:
7 to 10 points Suggests a highly functional family
4 to 6 points Moderately dysfunctional family
0 to 3 points A severely dysfunctional family

References:
Mott, SR et al. (1985)
Rasaki O. Shittu et al. Scientific Research ( 2014)

FAMILY COPING INDEX

1- No competence
3- Moderate competence
5- Complete competence
Family: CESISTA Date: October 28 2019
Address: Health Dept:
Family Coping Point Scale Assessed Justification
Areas Problems Statement
1 2 3 4 5 No problem The family is healthy
1. Physical present enough to do their
Independence  ADLs with no
assistance.
1 2 3 4 5 The family lacks Due to their low
2. Therapeutic knowledge monthly income, the
Competence regarding to food that they eat
 proper nutrition. doesn’t suffice all of
their nutritional
needs.
1 2 3 4 5 -Infrequent visits The family knows
3. Knowledge of to the health when someone is
Health Condition center sick and they do self-
 medication. They
only go to a hospital
or health center
when there is a
severe illness.
1 2 3 4 5 -Excessive food The family members
4. Application of intake is either overweight
Principles of -Inadequate rest or underweight.
General Hygiene  for the mother

1 2 3 4 5 -Infrequent visits The family self-

5. Health to health medicates.
Attitudes  center/hospital The family only goes
to their health
center/hospital when
a member already
shows signs of a
severe illness.
1 2 3 4 5 No problem The family’s
6. Emotional relationship is good
Competence  and they don’t have
much family
 relationship
problems.
1 2 3 4 5 No problem The family has a
7. Family Living good relationship
 and supports each
other. During the
interview, they
showed their
affection towards
one another.
1 2 3 4 5 -Accident The family lives in
8. Physical hazards/Fire the cemetery and
Environment hazards evacuates when
needed.
 -prone to short circuit
-Broken glass is
found everywhere

1 2 3 4 5 Inactive The family failed to

9. Used of participant of 4Ps regularly visit health
Community centers and attend to
Resources  family development
sessions which may
disqualify them to
avail the grant.

CHAPTER II – Priority Setting

Prioritization of Family Problems

HEALTH PROBLEMS

1. Unhealthy personal habits

CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION

1) Nature of the Unhealthy personal
problem habits is considered
as health threat
because cigarette
 smoking causes
Health threat 2/3 x 1 0.67 harmful effects to
the family and
secondhand smoke
can affect the OB
patient.
The problem is
2) Modifiability of easy modifiable
because the client
the problem 2/2 x 2
can abstain
2 smoking by
Easy considering other
members of the
modifiable
family and also by
the help of health
teaching.
The mother knows
that this is bad for
her health and her
3) Preventive 3/3 x 1 1
family.
Potential

Highly
Preventive

It needs immediate
4) Salience attention but the
family is having a
1/2 x 1 0.5
hard time reducing
Recognized and the cigarette
not needing smoking.
immediate
attention
Total: 4.17

2. Presence of breeding sites

CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION

1) Nature of the There is lack of
problem 2/3 x 1 0.67 drainage system
because even a
slight rain causes
Health threat flood.
The family wants to
2) Modifiability of 1/2 x 2 1 eradicate the
 the problem presence of vectors
by using “katol” but
cannot afford it all
Partially
the time.
modifiable
The family wants to
prevent the
condition but does
3) Preventive 2/3 x 1 0.67
not have enough
Potential budget.

Moderately
Preventive
It needs immediate
4) Salience attention to prevent
vector-borne
2/2 x 1 1
diseases that can
Not perceived affect the members
of the family,
particularly the ob
client

Total: 3.34

3. Unsanitary waste disposal

CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION

1) Nature of the There are garbages
problem 2/3 x 1 0.67 present within their
area that are not
properly disposed.
Health threat
The family stated
2) Modifiability of 1/2 x 2 1 that not all the
garbages were
the problem
 collected by the
Partially garbage truck and
some are still left
modifiable
uncollected.
The family tries to
3) Preventive 2/3 x 1 0.67 dispose the
garbage in a plastic
Potential
but not all were
properly disposed.
Moderate
The family knows
4) Salience 1/2 x 1 0.5 that this needs an
immediate attention
but do not have the
Recognized knowledge about
and not proper waste
disposal.
needing
immediate
attention
Total: 2.84

4. Loss of job

CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION

1) Nature of the This is considered
problem 1/3 x 1 0.33 as forseeable crisis
because the head
of the family lost
Forseeable her job because of
crisis complication felt.
It is partialy
2) Modifiability of 1/2 x 2 1 modifiable because
other members of
the problem
the family could be
a help for family
Partially income and
 modifiable expenses.
Stated that it could
3) Preventive 1/3 x 1 0.33 not easily be
prevented because
Potential
the head of the
family is the one in
Low charge of providing
the needs of the
Preventive
family.
It needs immediate
4) Salience 1/2 x 1 0.5 attention because
they are having
financial crisis since
Recognized there will be an
and not additional member
of the famly
needing
immediate
attention
Total: 2.16

5. Hazards

CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION

1) Nature of the This is considered
problem 2/3 x 1 0.67 as health threat
because their life
could be at stake if
Health Threat fire occurs since
light materials were
used for their
shelter.
It is non-modifiable
2) Modifiability of 0/2 x 2 0 because family do
not have permanent
the problem
place to live due to
lack of financial
 Non- sources.
modifiable
Preventive potential
3) Preventive 1/3 x 1 0.33 is low because
family have
Potential
insufficient budget
for upgrading their
Low space.

Preventive
The family do not
4) Salience 0/2 x 1 0 considered this as
problem because
they were
Not perceived accustomed with
this situation.

Total: 1

PRIORITIZATION

RANK PROBLEM SCORING

1 Unhealthy personal 4.17

habits
2 Presence of breeding 3.34
sites

3 Unsanitary waste 2.84

disposal

4 Loss of job 2.16

5 Fire hazards 1