Republic of the Philippines

Tarlac State University

College of Science
Department of Nursing
Lucinda Campus, Brgy. Ungot, Tarlac City Philippines 2300
Accredited Level 3 Status by the Accrediting Agency of Chartered Colleges and Universities in
the Philippines (AACUP), Inc.

LEARNING MODULE
NCM 104
Community Health Nursing (Clinical RLE)

TITLE: Family Health Nursing Process

A Family Case Study presented to the faculty of the

Tarlac State University
College of Science
Department of Nursing

In Partial Fulfillment of the Requirements of the Subject

Community Health Nursing (NCM 104 Laboratory)

Presented by:

Maxene Dhale P. Pabalan

BSN 2-1

PRESENTED TO
Mrs. Hasna Pascual, RN, MAN
Clinical Instructors
September 2021
 TABLE OF CONTENTS

I. INTRODUCTION ---------------------------------------------------------------------1-2
II. OBJECTIVES ----------------------------------------------------------------------------3
III. INITIAL DATA BASE -----------------------------------------------------------------4-
7
a. Family Structure, Characteristics, and Dynamics------------------------------3
b. Genogram
-------------------------------------------------------------------------------4
c. Socio – Economic and Cultural Characteristics-------------------------------5-
6
d. Home Environment ----------------------------------------------------------------6-7
e. Health Status of Each Family Member --------------------------------------- 8-
33
A. Physical Assessment -------------------------------------------------8-
14
B. 13 Areas of Assessment -------------------------------------------15-33
f. Nutritional Assessment ------------------------------------------------------------34
g. Values, Habits, Practices on Health Promotion --------------------------- 34-
35
IV. FAMILY COPING INDEX -------------------------------------------------------- 36-
38
V. TYPOLOGY OF NURSING PROBLEMS ---------------------------------------- 39
VI. RANKING OF PRIORITIZATION OF
IDENTIFIED HEALTH PROBLEMS ------------------------------------------40-43
VII. FAMILY NURSING CARE PLAN ----------------------------------------------43-48
VIII. SUMMARY, EVALUATION,
AND RECOMMENDATIONS -------------------------------------------------- 48-49
IX. DOCUMENTATION ---------------------------------------------------------------50-52
X. GROUP PROFILE ----------------------------------------------------------------- 53-56

1
I. INTRODUCTION
The traditional definition of "family" entailed one man and one woman who
were married, and their children. A grandparent might live with and be a part of the family,
too, although that practice isn't as popular in recent times. In the 1950s, the ideal family was a
father, a mother, and two offspring. The current definition is somewhat open and inclusive. A
family might be two parents of any gender, married or not. Some people even have a family
with more than three parents. The children may have been born to one of the parents, both
parents, or adopted[ CITATION Ash20 \l 1033 ].

The field of public health aims to protect and improve health by addressing the
structures and systems that define a place—and by supporting the people who live and work
there in making healthy choices. Problems are studied, data is collected, and resources are
gathered to help solve those problems[ CITATION Elm18 \l 1033 ].

Nies and McEwen (2019) defined Public Health Nursing and Community Health
Nursing refers to the field of nursing practice that is applied to promote and preserve the
health of populations. It is population - focused, with the goals of promoting health and
preventing disease and disability for all people. It also refers to the engagement of healthcare
through comprehensive nursing care of families and other groups. 

Tarlac is the most multicultural of the Central Luzon provinces. A mixture of four
distinct groups – the Pampangos, Ilocanos, Pangasinenses and Tagalogs – share this province
and living together resulted in offering to the visitors the best cuisine of the places where
their ancestors had come from, namely Bulacan, Nueva Ecija, Zambales, Pangasinan and the
Ilocos Region. Tarlac is also best known for its fine foods and vast sugar and rice plantations.
That it has fine cooking to offer is largely since it is the melting pot of Central Luzon. Its
myriad of historical sites, fine foods, vast sugar and rice plantations, and a beautifully
landscaped golf course plus so many other attractions all make the province of Tarlac one of
the best places to visit in Central Luzon.

The family that was chosen by the student nurse comes from the Lungsod ng
Tarlac of the Philippines—Tarlac City. It is a landlocked province in the Philippines
located in the Central Luzon region, Its capital is the city of Tarlac. It is bounded on
the north by the province of Pangasinan, Nueva Ecija on the east, Zambales on the
west and Pampanga in the south. Tarlac City is the largest city in the province of
Tarlac. It has 76 barangays. Gerona is to its north, Capas to the south, San Jose to the
west and Victoria, Concepcion to the east. According to the 2020 census, it has a
population of 385,398 with 74,429 households Being at the meeting point of
both Kapampangan and Pangasinan languages, cultures, and ethnicities, both
languages are predominantly spoken in the city and environs. Ilocano and Tagalog are
also used by a few city dwellers, especially those
with Ilocano and/or Tagalog ethnicity/ancestry, respectively, with the latter language
also serving as a medium for inter-ethnic communications.

2
II. OBJECTIVE
General:
This study aims to create an environment to help us identify and recognize the
needs of the family which will lead us to develop and understand the health
status of each member of the family. With that, we will be able to formulate
nursing care plans to address the needs of the family, promote care for the
individual and the family, and implement the proper interventions to address
the problems and maintain the health status of the family in the community.
Specific:
1. To establish rapport and build trust between the family and the student nurse.
1. To assess the health status of the chosen family using 13 areas of assessment.
2. To identify problems that can affect the health of the family and the factors
contributing to it.
3. To create a family nursing care plan for achieving optimal health of the family.
4. To perform nursing interventions that will benefit the family and improve their overall
health.
5. To evaluate the family if there are any improvements and changes on the behavioral
aspect towards health using the set objectives as the basis.
Family based:
1. Participate actively in planning
2. Participate actively in interventions given by the group
3. Apply interventions in their daily lives for further improvement of healt

3
III. INITIAL DATA BASE
A. Family Structure, Characteristics, and Dynamics
Family Position in Sex Age Civil Status Education
Member The family attainment
Marlon V. Father M 47y/o Married Undergraduate
Pabalan in College
Zoraida P. Mother F 48y/o Married High School
Pabalan Graduate
Maxene Eldest F 19y/0 Single 2nd Year
Dhale Daughter College
P. Pabalan
Lexter John Middle Son M 18y/o Single 1st Year
P. Collage
Pabalan
Alexa Youngest F 6y/o Single Grade 1
Sophia P. Daughter
Pabalan

Interpretation:
The family structure of the Pabalan family is reckon to be nuclear type of family where they
consist of a mother, a father and three (3) children. Each members of the family have their
own role. Mr. Marlon Pabalan is the head of the family and he has been the provider and
authority figure inside their home while his wife, Zoraida Pabalan has been the caretaker and
responsible for the health and household choirs and also for the emotional side of the family.
Their two Daughter and Son namely Maxene Dhale Pabalan, Lexter John Pabalan, Alexa
Sophia Pabalan are expected to follow the leadership and guidance of their parents they were
being a obedient to their parents and also responsible for their action. For 19 years, they
have been residing at Camella Homes Maliwalo Tarlac City. Both of the parents are working
together to provide for their family’s financial needs. The couple are likely to hold different
positions in the family hierarchy however, both of them are the ones who make the final
decision for the family. When it comes to family’s finances, the family’s income was all
handed to Mrs. Pabalan for the allocation of monthly expenditures of the family
Norms:
Extended family members, especially grandparents, can assist in passing on cultural
teachings and traditions, including language. For example, grandparents can share stories, skills
and teachings during their time with the grandchildren. This is also connected to the children’s
healthy self-esteem[ CITATION Fam19 \l 1033 ].

4
 Analysis:
The V Family is considered as an extended family since the family is composed of
grandparents married partners and offspring. Since the mother has already passed away, Mr V is
classified as widowed and is responsible for decision making like in financial and health which is
considered as Patriarchal.
B. Genogram

Marlon V. Pabalan
Zoraida Pabalan,
47

Maxene Dhale P. Lexter John P.

Alexa Sophia P.
Pabalan, 19y/o Pabalan, 18y/o
Pabalan, 6y/o
(asthma)

1. Family history of health and illness/ (pregnancy)

LEGENDS:

- healthy male -female deceased CoD-cause of death

-male with medical complication

-healthy female

-male deceased -female with medical complication

C. Socio- Economic And Cultural Characteristics

5
Family Member Educational Occupation Ethnic Religion
Attainment Background
Marlon V. College Overseas Ilocano Roman
Pabalan Graduate Filipino Worker Catholic
Zoraida P. High School Business Ilocano Roman
Pabalan Graduate Woman Catholic
nd
Maxene Dhale 2 Year College N/A Ilocano Roman
P. Pabalan Catholic
Lexter John P. 1st Year Collage N/A Ilocano Roman
Pabalan Catholic
Alexa Sophia P. Grade 1 N/A Ilocano Roman
Pabalan Catholic
Marlon V. College N/A Ilocano Roman
Pabalan Graduate Catholic
Table 2: Socio-Economic and Cultural Characteristics of Pabalan Family

Interpretation:
Mr. Marlon Pabalan is the breadwinner and a good provider of the family ever since while
his partner, Zoraida Pabalan also helps him in supporting their family financially by working too
and also, responsible for the allocation of their monthly budget even though Mr. Pabalan can
provide the needs in the house his wife wants to have her own money to help her husband to save
more money for the future of their kids. Mrs. Pabalan was a high school graduate while Mr.
Pabalan was a College student. Both of them weren’t able to finish their studies as they chose to
work instead at a young age to help their parents in their family’s expenses. Mr. Pabalan is a
Overseas Filipino Worker in Saudi Arabia while Mrs. Pabalan sells cosmetic at the market near
their barangay. These were all the sources of their family’s income. The whole family are Roman
catholic where they pay visit to the church when they have spare time on their hands. They are a
believer of God and they praise him for all of his glory, blessings, and love for the family.

Expenditures Estimated Monthly Prioritization (1-10)

6
 Allotted Budget
Food (Groceries) ₱ 5,000 1
Gas ₱ 1,000 6
Education ₱2,000 3
Medical/Health(e.g.medications ₱500 5
)
Clothing ₱500 8
Household expenses (Bills) ₱7,000 4
Transportation ₱200 10
Vices ₱300 9
Savings ₱5,000 2
Other minimal expenses ₱500 7
TOTAL: ₱22,000
Table 3: Monthly Expenditures of the family

Interpretation:
Mrs. Pabalan, the one who’s in charge of the family’s finances rate the prioritization she
does every time she allocates their whole family’s income every month. Their estimated monthly
income for this year is ₱27,000.00. Every time she dispenses their monthly budget, she always
prioritizes giving bigger portion of their income on their their foods (groceries) followed by
savings (Bank Account). Their least priority in the allocation of their monthly budget is
transportation expenses as they don’t usually go out nor travel in a far distance.

7
 Total monthly income of the family
- Marlon →₱ 20,000
- Zoraida →₱ 7,000
Total: ₱27,000
Total Annual/household family income=Total monthly income x 12 months
₱27,000 x 12,000 = ₱324,000
Total annual family income/ number of the members of the family=Total per Capita Income
₱324,000/5= ₱ 64,800
Expenses of each family member → ₱ 64,800
─ Monthly income of the family → ₱27,000
Total ₱ 37,800 [lacking income of the family]
= Estimated monthly income - Estimated total monthly expenditures
=₱ 22,000.00 – ₱27,000
=₱5,000 (not lacking)

As you can notice on the computation above, the family’s income is adequate enough to
suffice the family’s monthly expenditures however, if you will compare the monthly income of
the family to the estimated expenses of each member of the family, it is insufficient to meet each
family member’s needs.

Norms & Standards:

Filipino families earned Php 313 thousand in 2018, on average. In comparison, their
expenditure for the same year was Php 239 thousand, on average. These figures translate to an

8
average annual savings of Php 75 thousand. The average family income ranged from Php 113
thousand for the first income decile (lowest 10 % income group) to Php 867 thousand for the
tenth decile (highest 10% income group). The average annual income of families in the tenth
decile was about eight (8) times of those in the first decile, while nine (9) times of those in the
first decile in 2015. The national per capita income decile is obtained by ranking the per capita
family income of all sample families from lowest to highest and was compiled into ten groups.
The first tenth, meaning those with the lowest income, is called the first decile, the second tenth,
second decile, and so on. (Family Income and Expenditure Survey, 2018)
Analysis:
As you can notice on the computation above, the family’s income is adequate to suffice the
family’s monthly expenditures however, if you will compare the monthly income of the family
to the estimated expenses of each member of the family, it is insufficient to meet each family
member’s needs
D. Home Environment
Type of house Completed; Owned
Overcrowding Absent
Ventilation Satisfied
Lighting Adequate
Kitchen Type Smokeless
Bathroom Owned
Drainage Improper/Stagnant
Source of drinking local water system and water refilling station
Fuel Used Liquefied Petroleum Gas (LPG)
Disposal of Waste they store their garbage in a sack, then a
garbage collector will collect those
Excreta Disposal Closed pit privy
Vectors present flies, roaches, termites and mosquitoes
Power Source Electricity
Table 4: Environmental Aspect of Pabalan Family

The house of Pabalan family is currently residing in Barangay Maliwalo, Tarlac

City in the province of Tarlac, which considered as an urban type of community. It was
year 2002, when they decided to move to their current home right now. Therefore, they

9
inhabit it for almost 19 years already. The house is mainly made with heavy materials like
Dependable Concrete, Bricks, cements, hollow blocks and such. The title of the land in
which the house was built is currently named to the Mr. Marlon Pabalan, the house itself
was owned by the family. The household was surrounded mostly by houses since it is a
subdivision-type location. Because they live in the subdivision in Camella homes their
environment is clean because they are paying monthly for the garbage collector and the
garbage collectors gets garbage three times a week and their monthly payment includes
for the maintenance of their surroundings. Upon entering the house, you will be greeted by
the Garden first and in the garden there are chairs where guests can sit, and Outside the
garden there is a big trash bin where the family can store their daily garbage. After the
garden there is a screen door and a door to their entrance to prevent the mosquito to enter
over the house. Upon entering the house there is a living room and kitchen, It has a four
(4) sliding window and one (1) door at the back for emergency purposes. The area is quite
wide so more than 10 guests can accommodate the guest capacity in the house. On the
lower ground of the house there is a bedroom and has its own comfort room and also there
is a powder room for guests, There is also a staircase to the second floor with two rooms
and a comfort room as well there is an attic for storage of unused/not using items. Each
room has a aircon and electric fan and the bed are very comfortable. The masters bedroom
is on downstairs and the two bedroom upstairs is for their child. Maxene and Sophia are
roommate while Lexter have his own room.

Their kitchen have exhaust fan and they are cooking on a smokeless one thus, it is
free from smoke generated when they are cooking. Instead of traditional way of cooking,
they use Liquefied Petroleum Gas (LPG) as their fuel for cooking. To supply the household
with water, they have the local water system as their source and for drinking water they
have a supply for mineral water. They usually store drinking water in a water dispenser.
For power source, their main power supply within the household is through electricity. For
the food preparation, they use refrigerator, freezer, a basket, and their cabinet to prevent
any contamination and spoilage of the foods . The family have a one dog on their
household . As the inspection and roaming around there are a some mosquitoes found
inside and outside the house and some flies outside their house . Flies were commonly seen
outside their house where all their garbage were piled up in a sack. Due to the weather
since it’s rainy season today some water are accumulates and mosquitoes live there,
mosquitoes tend to inhabit it. As we observe there is no any presence of termites in the
house because every two months the maintenance are spraying an anti-termites. The
communication tools within the household are cellphones, telephone and television. Their
means of transportation is through their owned car

CROWDING SPACE
STANDARD: (Concepts and Guidelines in COPAR, 1ST Edition, 2005 by Untalan)

10
Formula:
Total Floor Area (TFA)
TFA = length x width of the house
TFA = 7.2m x 5.1m = 36.72 sq. m
Total Space Requirement (TSR)
Standard:
Adults – 3.0 sq. m
Children – 1.5 sq. m
Infant ─ 0

No. of adults in Pabalan family = 3 x 3.0 sq. m = 9 sq. m

No. of children in Pabalan family = 2 x 1.5 sq. m = 3 sq. m
TSR = 12 sq. m

Interpretation:
TFA>TSR = not overcrowded
TSR>TFA = overcrowded TFA (36.72) > TSR (12): NOT OVERCROWDED

VENTILATION
Interpretation:
20% - Satisfactory
18% - 19% - Fair Below
18 % - Poor

TFA = 36.72 sq. m Total

No. of windows: 6

Formula:
Ventilation = TWO / TFA x 100
TWO: total area of windows (L x W)

Computations:
WO (window openings)
W1 = 0.45m x 1.15m = 0.51 sq. m
W2 = 0.85m x 1.15m = 0.98 sq. m
W3 = 0.85m x 1.15m = 0.98 sq. m
W4 = 0.45m x 1.15m = 0.51 sq. m
W5 = 0.55m x 0.60m = 0.33 sq. m
W6 = 0.55m x 0.60m = 0.33 sq. m
Total Window Opening (TWO) = 3.64 sq. m

Ventilation = TWO/TFA x100

= 3.64 sq. m ÷ 36.72 sq. m x 100
= 0.099 sq. m x 100 = 9.91 = POOR VENTILATIO

11
NORMS:
According to Maglaya book 4th edition typical normal family living in a proper
housing is not overcrowded and ventilation must be above 20%. They must have a
good sleeping pattern completing 8 hrs. of required sleep. Free from all presence of
vectors sites that causes diseases in each family members. They should have proper
storage food and water sanitary condition. Need to segregate garbage and put in on
proper trash bags and proper drainage system. (Nursing Practice in the community by
Dra. Araceli S. Maglaya)

ANALYSIS:
Pabalan Family’s house is not overcrowded, which means that it has enough
space to accommodate their family size of five (5). However, it has satisfied
ventilation. The sleeping pattern of each member is normal. The house of the family
has a good accommodation and the kids are very comfortable on their life they have
a place to be with when they want to breath because there are so many plants and
tress on their backyard. They have proper storage for foods and these are all in good
condition. They are able to maintain the cleanliness and good ventilation also of
their drinking water. When it comes to their garbage, they compiled everything in a
sack and routinely collected by the garbage collectors in their subdivision every three
times a week . The drainage system within their area are all open, yet, they are still
clean and free-flowing.

12
 A.Health Status of each family member
13 Areas of Assessment
Marlon V. Pabalan
Age: 47y/0
Area of assessment Findings
Social Status Mr. Pabalan is 47 years old,
born on January 07, 1874,
He is the foundation of the
family and also a good
provider of their family.
He’s working as a Overseas
Filipino Worker in Saudi
Arabia for 15 years. Based
on his statement, He’s
having a vacation for one
month in the Philippines
every year and he stated that
when he is in the Philippines
his only focus is his family.
As well he is socially active
since he has a lot of friends
particularly with his
workmates. He had a good
relationship with his wife
and children.
Mental Status
> General During the initial visit, his
Appearance and clothes are all in good
Behavior condition. Upon checking
his appearance, it is
noticeable that his hair is
newly cut, skin is not dry,
fingernails are clean but the
toenails looks quite dirty,
and he has no facial hair. As
stated by Mr. Pabalan, he
was a undergraduate in
college, he can still read and
write. He’s very cooperative
during the whole interview
Norms Analysis
Children’s status- Mr. Pabalan has a good
expectations about others relationship with his
were unrelated to beliefs workmates and neighbor,
about their own status, friends, and his family.
suggesting children more When in times of stress,
readily apply category- his family and friends help
based status beliefs to him to cope up.
others than to themselves.
Children’s use of race and
gender as cues to social
status. Rhodes M (2020)
The patient should
appear relaxed with the
appropriate amount of He still has a good
concern for the educational background.
assessment. The patient However, there were
should exhibit erect limitations on the
posture, smooth gait and questions being asked. It
symmetrical body shows that he he is good in
movement. The patient communication. As for his
should be clean and well- general appearance, he is
groomed and should wear properly groomed at the
appropriate clothing for time of the visit
age, weather, and
socioeconomic status.
Facial expressions should
be appropriate to the
13
 session. There are some content of the conversation
questions. In the interview and should be symmetrical
he is good in communication (Jensen, 2019)
skills.

The message's The client is well-oriented

>Level of content should correspond to time and place during
consciousness and He was coherent, well- to the patient's level of the assessment. Some
orientation oriented and cooperative education. The patient explanations coming from
during the whole interview should be able to answer him are well verbalized.
session. He was able to questions accurately and He responds to the
respond to each question identify all of the objects questions aptly thus, his
thrown at him aptly but there as instructed. Denial and mental capabilities is
are times where he seeks poor eye contact are functioning well, but some
clarifications. However, he common reactions during questions are repeated
was able to respond the first conversation, especially if they are not
accurately and quickly when which may be attributed to familiar with the words
asked about his name, their anxiety over meeting a being asked.
address, his line of work, his stranger or an attempt to
children, his wife and other screen or dismiss
vital question concerning his unwanted truths by
self and most importantly, refusing to acknowledge
his family. them. (Jensen, 2019)

>SPEECH The patient should He has good

be able to produce communication skills but
His way of delivering speech spontaneous, coherent still needs some
is audible to ear but some speech (Jensen, 2019) improvements especially
words are not clearly said. for the clarity of words
He was still able to deliver being said.
concrete messages when
being asked.
Emotional Status Mr. Pabalan stated that he During adulthood, The client shows a normal
does not get bother by fear, here is some support for emotional status . His
anxiety, and grief, but he the view that people do support system during
stated that sometimes he’s undertake a sort of time of stress is his family
feeling emotional and lonely emotional audit, reevaluate and they were able to help
when he is in Saudi because their priorities, and emerge him to feel at ease.
he express felt that he with a slightly different
misses so many years orientation to emotional
without his family. He regulation and personal
shows no sign of tremors, interaction in this time
uncertainty, irritability, period (Lumen, 2017).
panic, and tension. His
support system is his family

14
 and they always help him in
coping with stress.
Sensory Perception
Sense of sight Based on observation, his
eyes are color brown without
any lesions, swelling or
discharge. His pupils are
equal, round and
symmetrical. It constricts
and equally move to cross
when pen light was slowly
move closer to his nose and
when shine the light in from
the side in each eye. His
sclera is white and shiny not
jaundice. His conjunctiva is
pink and not red and
swollen. While performing
near visual test, the student
nurse asked him to read the
words on the paper that was
14 inches away from the
client’s eyes. He was able to
read the words on the paper
clearly.
Normal vision is
considered 20/20. A visual He has a normal sense of
acuity of 20/50 indicates sight as well as external
that the patient can read appearance of the eyes.
from 20 ft what a person The data gathered shows
with normal acuity (20/20 that he has normal visual
vision) can read from 50 ft acuity, extraocular muscle
(Shultz et.al., 2016). movements, pupillary
response and the client is
not color blind.
A person usually
identifies the taste of
bitter, sweet, sour, and
salty. By the use of our
sense of taste, we can fix
or adjust the taste of our
food based on our capacity
(Blue, 2018).

Sense of Taste Auditory acuity: The The sense of taste of the

After asking Mr. Pabalan to
cover both his eyes, he was
asked to differentiate
different food tastes in
which the student nurse used
sugar for sweet, coffee for
bitter, salt for salty taste, and
droplets of calamansi juice
Sense of Smell for sour. The client was able
to differentiate each taste
Patency of nostrils was
noted. Tenderness,
discharge, trauma, bleeding,
lesions, masses, swelling
and asymmetry were not
clarity or clearness of
hearing, a measure of how
well a person hears.
Auditory acuity is
measured in order to
determine a person's need
for a hearing aid (Stoppler,
2021).
A person usually
identifies the taste of
bitter, sweet, sour, and
salty. By the use of our
sense of taste, we can fix
or adjust the taste of our
food based on our capacity
client is normal which
indicates that his taste
buds were functioning
well.
The client was able to
recognize what aromatic is
being asked. Therefore, he
has a normal sense of
smell as well as external
appearance of the nose

15
 observed. His internal nose
was clean. Smell test was
used and he was able to
differentiate the odor of
coffee and the smell of
perfume.
Tactile
The client was asked to
close his eyes and then the
student nurse asked him to
hold things like paper and
cloth. He was able to
differentiate the two based
on its texture. The SN also
used a test tube with hot or
cold water and then pat it on
the skin of client. He was
able to identify if it is cold
or hot
Motor Stability During the assessment, the
student nurse observed that
Mr. Pabalan is able to stand
on his own and has good
balance. While walking, he
shows no sign of difficulty
in moving from one place to
another. The Range of
Motion (ROM) was also
assessed through rotating or
bending of shoulders and
elbows, flexing of knees,
ankles, and feet. He was able
to move the different parts
of the body being asked.
(Blue, 2018)
Touch consists of
several distinct sensations
communicated to the brain
through specialized
neurons in the skin.
Pressure, temperature,
light touch, vibration, pain
and other sensations are all
part of the touch sense and
are all attributed to
different receptors in the
skin (Bradford, 2017). The sensory transmission
of the client is functioning
well.
Stability skills are The gait and balance of
a type of gross motor skill Mr. Pabalan are well
involving balance and coordinated. He has no
weight transfer. To master difficulty in moving his
these skills, children must body parts and can
be able to maintain various perform ROM.
body positions, as well as
adjust them, without
falling. It takes muscle
strength and body
awareness (or
proprioception) to be able
to gain balance and hold it
while moving around, or
even staying still. (H.
16

st
Body Temperature 1 day of Assessment:
37.2 ⁰C
2nd day of Assessment:
37.1 ⁰C
3rd day of Assessment:
36.9⁰C
Respiratory Status 1st day of Assessment:
18 bpm
2nd day of Assessment:
17bpm
3rd day of Assessment:
17bpm
Shoulders were at the same
level as he inhaled and
exhaled. No increased
respiratory effort was noted.
Breathing is fine and
respirations are regular and
in rhythm. But the client
often uses cigarettes
Circulatory Status 1st day of Assessment:
PR: 102 bpm
BP: 116/74 mmHg
2nd day of Assessment:
PR: 89 bpm
BP: 112/78 mmHg
3rd day of Assessment:
PR: 90 bpm
BP: 120/72 mmHg
Nutritional Status According to the client, he
usually eats 3 times a day.
His diet includes a wide
range of foods such as meat
(fish, pork, and chicken),
Catherine, 2020)
Normal axillary
temperature is within 36.4
to 37.4 degrees Celsius. A
single temperature reading
does not always indicate a
fever (Potter, et al, 2021)
Respiration rates
may increase with
exercise, fever, illness, and
with other medical
conditions. When checking
respiration, it's important
to also note whether you
have any trouble
breathing. Normal
respiration rates for an
adult person at rest range
from 12 to 20 breaths per
minute (URMCR, 2021).
The normal cardiac
rate for an adult is 60-100
beats per minute while for
a normal reading of blood
pressure, it needs to show
a top number (systolic
pressure) that’s between
90 and less than 120 and a
bottom number (diastolic
pressure) that’s between
60 and less than 80.
(Kozier, 2017).
Adequate food
intake consists of a
balance of nutrients such
as water, carbohydrates,
proteins, fats, vitamins,
17
The recorded temperatures
from all the day of
assessment are within the
normal range.
The respiratory rate of Mr.
Pabalan is within the
normal range. No
abnormal signs in
breathing but the
respiratory might get
affected soon if he will
continuously smoke
cigarettes.
During the 1st day of
assessment, the cardiac
rate of the client exceeds
within normal range. This
might be due to his vice of
frequently smoking
cigarette. The cardiac rate
on the following days
were normal. His blood
pressure is normal on all
days of assessment
The food diet of Mr.
Pabalan is considered
normal since it includes
different types of food.
But his vices can interfere
 green and leafy vegetables, and minerals. The normal in him having a good
fruits, and rice. He usually eating pattern of a person nutritional status.
prefers eating vegetables is a minimum of three
during meals than meat. He times per day depending
drinks 8 glasses of water upon the metabolic
each day. He has vices demand and needs of the
which includes smoking patient. Most of the
cigarettes and drinking school-age slum children
alcohol. in our study had a poor
nutritional status.
Interventions such as
skills-based nutrition
education, fortification of
food items, effective
infection control, training
of public healthcare
workers and delivery of
integrated programs are
recommended. (Kozier &
Erb's, 2018 and Potter, et
al, 2021)
Elimination Status As stated by the client, he Normal urinary The elimination status of
usually defecates one times a output of a person is 2 Mr. Pabalan is normal
day. As for his urination, he liters per day and should since the frequency in
usually voids 3 times a day typically defecate from defecation and voiding is
and described the color as once a day to every 3 to 5 within the normal and
clear to yellowish brown days. Feces are normally usual range.
with no strong odor. brown in color and soft but
formed. (Kozier & Erb's,
2018)
Reproductive The client stated that he had Menarche usually His reproductive status is
Status been circumcised at the age begins between the ages of normal. As indicated on
of 12. He and his wife 9–15, about two years the number of children, he
already have 3 children. No after the onset of puberty. and his wife are sexually
recorded sexually The average age of active.
transmitted disease. menarche is 12–13, but it
can be normal for it to
happen earlier or later.
(Yermachenko, 2018).
Sleep-rest Pattern He stated that his usual Getting enough The total sleeping hours of
sleeping pattern starts from sleep is essential for the client is usually about
around 10:00 pm in the helping a person maintain 8 hours of sleep each day.
evening until 6:00 am in the optimal health and well- As compared to the norms,
morning. He usually wakes being. When it comes to Mr. Pabalan still has a
up 6:00am in the morning to their health, sleep is as normal number of sleeping
prepare for the his work. vital as regular exercise hours and was able to rest

18
 After a long day in work, he
usually rest for a while as he
arrives home.
State of Skin As the student nurse
Appendages assessed the client, it was
observed that the client has
fair complexion of skin that
was warm to touch and not
tender. No localized or
systemic edema and
tenderness observed.There
are no IV sites on the hands
of the client and no presence
of phlebitis. The
conjunctivae of the client are
pinkish on both side and not
dry. The nails on both
fingers and toes of the client
are trimmed and only the
fingernails looked clean. The
skin looks smooth and not
dry. The hair of the client is
color black with slightly
heavy even-distributed hair
strands. The scalp of the
client has dandruff.
and eating a balanced diet despite bunch of works.
(Fletcher, 2019).
The skin He has a normal condition
appendages are epidermal of skin appendages. No
and dermal-derived abnormalities were found
components of the skin during the assessment
that include hair, nails,
sweat glands, and
sebaceous glands. Each
component has a unique
structure, function, and
histology. This article
describes the unique
characteristics of each of
these components and
provides insight into tissue
preparation for
microscopic evaluation
and the clinical
significance of these
structures (Yousef, Miao,
et al. 2021).
19
 Zoraida P. Pabalan
Age: 48 y/o
Area of assessment Findings Norms Analysis
Social Status Mrs. Pabalan is 48 years old, Social status is the Mrs. Pabalan maintains a
born on 12nd day of January position one hold's in a good relationship with her
1975. She is currently group or community. It is family, friends, neighbors
residing in Camella Homes, social support that builds and even on her
Maliwalo,Tarlac City people up during times of customers. During stress,
together with her kids . She stress and often gives she’s able to manage it
currently has a small business them the strength to carry through the help of her
with her sister and works as a on and even thrive support system which is
cosmetic product in the (Cherry, 2020) her family.
market near their barangay.
Since she is a seller in a
market, she has time to
socialize with others
particularly on her customers.
Within their home, she is
strict with her children but
she is still able to interact
with them. Sometimes when
she got home and his husband
is drunk he create a argument
but the client stated that they
were in the good term it’s that
he is just being concern on
her husband health. In their
neighborhood, she is able to
interact with her neighbors
every day. Her support
system is her family, friends,
and her mother.
Mental Status

> General Upon interviewing Mrs. Appearance is described On her educational

Appearance and Pabalan, it is noticeable that
Behavior her clothes are all clean. Her
hair was neat . Both of her
fingernails and toenails are
clean and trimmed. As she
stated, she was only able to
graduate with high school
degree. She said that she can
read and write. She
cooperates well and even
as background, it is on a
wellgroomed/disheveled, normal state. Even though
how they are dressed, she was not able to finish
demeanor in interview, her studies, she’s still able
level of eye contact. In to read, write and
males - shaving. As understand the things
appropriate, physical being said to her. She
behavior such as looked presentable during
restlessness, motor the assessment
Activity (retardation/over

20
 accompanied the student
nurse all throughout the
assessment days.
>Level of She was coherent, well-
consciousness and oriented and cooperative
orientation during the whole interview
session. She was able to
respond to each question
thrown at her aptly. She was
able to respond accurately
and quickly when asked
about her name, their address,
her line of work, her children,
her husband and other vital
question concerning herself
and most importantly, her
family.
>SPEECH
She is very articulate and she
doesn't exert too much effort
in talking and explaining
things. Her way of talking
was loud and clear and
understandable
activation) Level of co-
operation, any evidence
of aggression or hostility.
Overfamiliarity, for
instance touching
interviewer
inappropriately (MSE,
n.d)
She is well oriented to
The normal state of time and place that she is
consciousness comprises in. She was able to answer
either the state of well during each
wakefulness, awareness, assessment and cooperates
or alertness in which well with the student
most human beings nurse.
function (Tindall, 1990).
Being oriented to place
and time means that you
know who you are,
where you are, where
you live, and what time it
is. When consciousness
is decreased, your ability
to remain awake, aware,
and oriented is impaired
(Lights, 2019)
Rate ranges from Her way of
"poverty of speech" with communication through
few utterances to verbal manner is normal
"pressure of speech", and can easily be
spontaneity with little or understood.
no spontaneous
utterances to
circumstantiality with
overinclusion of detail,
volume: from low to
high, rhythm:
monotonous, without
variation or inflection;
staccato, with frequent
pauses between fluent
speech and normal., tone:
ranges from low to high
21

Emotional Status After asking for her
condition, she said that she is
feeling well. The student
nurse asked if there is
something that bothers her
like fear of something,
anxiety, or grief. And she
stated that there is nothing
specifically that bothers her.
Her support system in case of
stress is mainly her Child.
She also stated that she is an
optimistic type of person.
Sensory Perception
Sense of sight For the near visual acuity test,
Mrs. Pabalan was asked to
read the words on a paper
with a distance of about 14
inches. She was able to read
the different words written on
that paper. When a light was
pointed towards the pupil of
client using a penlight, both
pupils were able to constrict.
Upon checking the
appearance of the eyes, it was
noted that both eyes are
symmetrical. The sclera is
color white. The eyes are
moving symmetrically while
performing the extraocular
muscle movement test. The
client is able to state the right
names of color that was
presented to her. There are no
lesions or swelling on both
eyes
Sense of Taste
The student nurse used
different types of food for
assessing the sense of taste.
(MSE, n.d)
During adulthood, here is
some support for the
view that people do
undertake a sort of
emotional audit,
reevaluate their priorities,
and emerge with a
slightly different
orientation to emotional
regulation and personal
interaction in this time
period (Lumen, n.d).
Normal vision is
considered 20/20. A
visual acuity of 20/50
indicates that the patient
can read from 20 ft what
a person with normal
acuity (20/20 vision) can
read from 50 ft (Shultz
et.al., 2016)
A person usually
identifies the taste of
bitter, sweet, sour, and
salty. By the use of our
22
e support for the view that
people do undertake a sort
of emotional audit,
reevaluate their priorities,
and emerge with a slightly
different orientation to
emotional regulation and
personal interaction in this
time period (Lumen, n.d).
Her emotional status is
normal since there is
nothing that bothers her.
She has a good support
system to help her cope up
during stress
The client has a normal
vision as indicated in the
near visual test. The
extraocular muscle
movements are normal as
well as the pupillary
response of both eyes. The
client is not color blind.
The client’s sense of taste
is normal.
 These include sugar for
sweet, coffee for bitter, salt
for salty taste and calamansi
juice for sour. The client’s
eyes were covered during the
assessment. She was able to
differentiate each taste
Sense of hearing
The appearance of her
external ears are clean, free
from tenderness, swelling,
thickening, lesions, and they
are symmetrical in size. For
auditory sense, a noninvasive
test was used such as the
voice test (whisper test). She
was asked to repeat all the
words whispered by the
student nurse on each ear.
After the nurse whispered, the
client was able to repeat all
the words and she stated that
she heard those words clearly.
Sense of Smell
Patency of nostrils was noted.
Tenderness, discharge,
trauma, bleeding, lesions,
masses, swelling and
asymmetry were not
observed. Her internal nose
was clean. Aromatics like
coffee and perfume were used
for olfactory test. Both of her
eyes were covered first before
assessing. Mrs. Pabalan was
able to identify the aromatics
being asked.
Tactile
sense of taste, we can fix
or adjust the taste of our
food based on our
capacity (Blue, 2018).
The hearing acuity of Mrs.
Pabalan is normal and no
An adult is classified as signs of abnormalities are
having normal hearing recorded
ability if their responses
indicate they heard
noises between 0 and 25
dB across the frequency
range (Mroz, 2020). For
auditory acuity, the
patient should be able to
repeat the words
whispered from a
distance of two feet.
(Estes, 2014)
Client was able to
recognize each smell
which indicates that the
To determine the olfactory sense is normal.
presence of smell, have
the patient close both
eyes and describe or
identify a particular scent
that you wave under the
nose. The scent should be
one that the patient is
familiar with and able to
identify under normal
circumstances (Shultz
et.al., 2016). Nose must
be symmetrical and along
of the face. Each nostril
must be patent and
recognize the smell of an
object (Estes, 2014) The sensory signals were
23

After covering both eyes, the
student nurse used paper and
cloth for the test. She was
asked to hold the items and
differentiate or identify each
based on the texture. A test
tube with hot/cold water was
also used and was placed on
the skin of the client. The
client was able to identify
whether the test tube contains
hot or cold water.
Motor Stability While the client is standing, it Balance is not only
was observed that she can
stand on her own and has a
good balance. Her walking
ability shows no sign of
difficulty as she moves from
one place to another. The
Range of Motion (ROM) was the head, torso, or limbs
also assessed through rotating (Adolph, 2003). There
or bending of shoulders and
elbows, flexing of knees,
ankles, and feet. Mrs. Pabalan of motion exercise.
can move the body parts
being asked in a normal range
of motion.
Body Temperature 1st day of Assessment:
36.9 ⁰C
2nd day of Assessment:
36.8 ⁰C
rd
3 day of Assessment:
37.1 ⁰C
transmitted immediately
along the sensory
pathways which indicates
Tactile receptors identify a normal state of the
the sensation of touch client’s sense of touch.
and are all over our
bodies in our skin. Some
areas of our skin have
more tactile receptors
than other areas e.g.
mouth and hands. The
tactile senses are
important for identifying
touch, pressure, pain,
temperature and texture
(Sensory Processing
Resource, 2021)
The gait and balance of the
important for relatively client are well coordinated
stationary positions such and normal. She shows no
as sitting and standing, sign of difficulty in
but also it provides the moving his body parts and
necessary stable base to no discomfort felt during
support movements of ROM exercise. No signs
of abnormal body
formation was found.
should be absence of
discomfort during range
(Estes, 2006)
Normal body The axillary temperature
temperature varies by of the client on all days of
person, age, activity, and assessment is normal.
time of day. The average
normal body temperature
is generally accepted as
98.6°F (37°C). Some
studies have shown that
the "normal" body
temperature can have a
wide range, from 97°F
(36.1°C) to 99°F
(37.2°C). (MedlinePlus,
2021)
24
Respiratory Status 1st day of Assessment:
17 bpm
2nd day of Assessment:
20 bpm
3rd day of Assessment:
19 bpm
Shoulders were at the same
level as she inhaled and
exhaled. No increased
respiratory effort was noted.
Breathing is fine and
respirations are regular and in
rhythm.
Circulatory Status 1st day of Assessment:
PR: 88 bpm
BP: 118/74 mmHg
2nd day of Assessment:
PR: 92 bpm
BP: 120/76 mmHg
3rd day of Assessment:
PR: 86 bpm
BP: 118/70 mmHg
Nutritional Status As stated by the client, she
eats 3 times a day and drinks
up to 10 glasses of water each
day. She does not have
history of condition that
affects her diet. She had a
regular diet which consists
mainly of vegetables, meats
such as fish, chicken and
pork, fruits, rice, and dairy
products like milk and
cheese. As per her also, she
has no bad habits in diet and
no vices.
Respiration rates may The respiratory rate is
increase with exercise, considered normal on all
fever, illness, and with days of assessment. No
other medical conditions. abnormal conditions were
When checking noted.
respiration, it's important
to also note whether you
have any trouble
breathing. Normal
respiration rates for an
adult person at rest range
from 12 to 20 breaths
The normal cardiac rate The cardiac rate of the
for an adult is 60-100 client on the 1st, 2nd and
beats per minute while 3rd day of assessment is
for a normal reading of normal as well as her
blood pressure, it needs blood pressure
to show a top number
(systolic pressure) that’s
between 90 and less than
120 and a bottom number
(diastolic pressure) that’s
between 60 and less than
80. (Kozier, 2017)
Nutritional status is a The nutritional status of
requirement of health of the client is considered
a person convinced by normal since she usually
the diet, the levels of eats all types of food that
nutrients containing in supplies her body with
the body and normal enough nutrients. Her
metabolic integrity. status is not affected by
Normal nutritional status any vices and bad habits
is managed by balance
food consumption and
normal utilization of
nutrients (NSRA, 2021).
Normal eating pattern is
considered to be at least
three times a day
depending on the
metabolic demands and
25
 needs of the patient.
Fluid intake should be 8-
10 glasses per day
(Monahan, 2017
Elimination Status Mrs. Pabalan usually defecate Normal bowel movement The elimination status of
once a day and voids up to 4 of a person must be 1 to Mrs. Romano is normal
times a day. She described 2 times a day and voiding since she has enough urine
her stool with brown color in 3 to 4 times a day with output and her stool is
and not watery in consistency an output of 1200 to normal. The frequency of
while her urine is light yellow 1500mL a day. A normal elimination is in normal
in color; she has no difficulty stool is brown in color range.
in voiding or defecating. and well formed, urine is
clear to yellowish in
color. (Kozier, 2017)
Reproductive She stated that her first It occurs approximately The onset of her menarche
Status menstruation occurred when every 28 days, with a occurred within the normal
she was on her first year in range from every 21 to age. Her reproductive
high school, around 13 years every 45 days. The status is considered as
of age. She has an OB score average age of onset of normal.
of G4T4P0A0L4. No history menarche is 12.4 years
of sexually transmitted (Lacroix, 2020).
disease.
Sleep-rest Pattern The client stated that she is Sleep refers to altered The sleeping pattern of
already asleep at 9:00 pm in consciousness with Mrs. Pabalan is considered
the evening and wakes up at general slowing of as normal since it did she
5:00 am in the morning to physiological process meet the normal range of
prepare before going into the while rest refers to sleeping hours.
market for her business. relaxation and calmness,
Since she is usually tired after both mental and physical.
work, she regains energy by A typical sleeper will
getting some sleep in the pass through 7 to 9 hours
afternoon for about 30 of sleep and take a rest
minutes to 1 hour. using some relaxation
activities such as reading,
telling stories and others
(Daniels, 2015)
State of Skin During assessment, it was During assessment, it The texture and color of
Appendages noticed that the skin was noticed that the skin her skin is normal. There
complexion of the client is complexion of the client is a localized tenderness
warm to touch. There are no is warm to touch. There on the wound on her left
sites for IV injections and no are no sites for IV foot.
phlebitis observed. Both injections and no
conjunctivae of the eyes are phlebitis observed. Both
pinkish and not dry. The nails conjunctivae of the eyes
of the client are trimmed and are pinkish and not dry.
clean. Her skin is not dry. Her The nails of the client are

26
hair is black in color and has
even distribution of hair
strands. The scalp has limited
dandruff found. She has small
wound in her left leg.
trimmed and clean. Her
skin is not dry. Her hair
is black in color and has
even distribution of hair
strands. The scalp has
limited dandruff found.
She has small wound in
her left leg.
27
 Maxene Dhale P. Pabalan
Age: 19y/o
Area of assessment Findings
Social Status Maxene Dhale is 19 years old,
born on July 23, 2002. She is
currently living together with
his parents and two siblings.
She is now in 2nd year college
and able to communicate with
her classmates using online
tools. As she stated, she has an
interactive relationship with
her siblings, they sometime
play and have fun through
mobile gaming. When it
comes to her parents, she is
more close to the father than
the mother but they still able
to interact with each other
without hesitation. She has a
lot of friends in their neighbor
and they always play together
using their phones.
Mental Status
> General During the initial assessment,
Appearance and Her hair is newly cut and neat;
Behavior skin is smooth and not dry;
and both of her fingernails and
toenails are cleaned and
trimmed. She is currently in
college and was able to read
and write. She was able to
respond on questions being
asked but there are some
questions that she needs to
consult her parents first before
answering
28
Norms Analysis
Social status is the She gets along with
position one hold's in a his family, colleagues,
group or community. It and classmates well.
is social support that
builds people up during
times of stress and often
gives them the strength
to carry on and even
thrive (Cherry, 2020).
Appearance is described The general
as appearance of John
wellgroomed/disheveled, Lloyd is normal and
how they are dressed, he’s properly
demeanor in interview, groomed. His answers
level of eye contact. In to the questions was
males - shaving. As matched on his
appropriate, physical educational level.
behavior such as
restlessness, motor
Activity
(retardation/over
activation) Level of co-
operation, any evidence
of aggression or
hostility.
Overfamiliarity, for
instance touching
interviewer
inappropriately (MSE,

>Level of During interview, she was able
consciousness and to communicate and can
orientation answer most of the questions
such as her name, their
address, her parents, and other
vital question concerning
herself and most importantly,
her family. It is noticeable that
he is alert when the student
nurse asks questions.
>SPEECH
Her way of talking to the
student nurse when being
asked was clear and
understandable. She was able
to elaborate his answers
appropriately
Emotional Status She was asked on what She
feels at the moment. As what
She stated, there is nothing
that bothers her at the time of
29
n.d)
She was able to
The normal state of answer all the
consciousness comprises questions including
either the state of the time, date, and
wakefulness, awareness, place correctly. She is
or alertness in which aware of her
most human beings surroundings and able
function (Tindall, 1990). to respond
Being oriented to place immediately when
and time means that you asked
know who you are,
where you are, where
you live, and what time
it is. When
consciousness is
decreased, your ability
to remain awake, aware,
and oriented is impaired
(Lights, 2019).
Rate ranges from She has good
"poverty of speech" with communication skill
few utterances to toward other people.
"pressure of speech", He was able to deliver
spontaneity with little or the message of what
no spontaneous he wanted to say
utterances to
circumstantiality with
overinclusion of detail,
volume: from low to
high, rhythm:
monotonous, without
variation or inflection;
staccato, with frequent
pauses between fluent
speech, and normal.,
tone: ranges from low to
high (MSE, n.d)
During adulthood, here The emotional status
is some support for the of the client is normal.
view that people do She has good stress
undertake a sort of coping mechanism
 the assessment and insisted
that she is okay and feeling
well. The presence of fear,
anxiety, grief, tremors,
uncertainty, irritability, panic,
and tension were all negative.
At the time of stress, she was
able to manage it by himself or
sometimes she asks her family
for guidance.
Sensory Perception
emotional audit,
reevaluate their
priorities, and emerge
with a slightly different
orientation to emotional
regulation and personal
interaction in this time
period (Lumen, n.d).

Sense of sight The student nurse performed a Normal vision is She has normal vision
near visual test. The client was considered 20/20. A as shown in the near
asked to read the words visual acuity of 20/50 visual test. She also
written on a paper with a indicates that the patient has normal
distance of 14 inches and she can read from 20 ft what extraocular muscle
was able to read them a person with normal movements and
correctly. The iris of his eyes acuity (20/20 vision) can pupillary response to
is black in color, both his eyes read from 50 ft (Shultz light. The client is
are symmetrical in shape and et.al., 2016) also not considered as
is round, has white sclera, and color blind
no lesions and tenderness were
noted. The extraocular muscle
movement test shows that her
eyes are moving symmetrical
with each other. The student
nurse also used color cards to
ask the patient on what color is
being presented. The client
was able to answer all the
colors correctly. Upon striking
a light into the pupils of the
client, it was able to constrict
as it reacts to the light.
Sense of Taste A person usually
The client was asked to identifies the taste of The gustatory sense of
identify the taste of the food bitter, sweet, sour, and the client is normal
given to her while her eyes salty. By the use of our and able to
were covered. The student sense of taste, we can fix differentiate the taste
nurse prepared sugar for or adjust the taste of our of the foods given to
sweet, coffee for bitter, salt for food based on our him which indicates a
salty taste, and calamansi juice capacity (Blue, 2018) normal functioning of
for sour. She was able to her taste buds.
determine and differentiate
what is what because of their

30
 contrasting taste.
To determine the
Sense of hearing presence of smell, have
Patency of nostrils was noted. the patient close both The olfactory sense of
Tenderness, discharge, trauma, eyes and describe or the client is normal
bleeding, lesions, masses, identify a particular and able to recognize
swelling and asymmetry were scent that you wave an object through its
not observed. Her internal under the nose. The smell.
nose was clean. The student scent should be one that
nurse used different aromatics the patient is familiar
like coffee and perfume. The with and able to identify
client was asked to cover his under normal
eyes and determine the item he circumstances (Shultz
smells. He was able to identify et.al., 2016). Nose must
which of those is the coffee or be symmetrical and
perfume. along of the face.

Sense of Smell To determine the

presence of smell, have
Patency of nostrils was noted. the patient close both The olfactory sense of
Tenderness, discharge, trauma, eyes and describe or the client is normal
bleeding, lesions, masses, identify a particular and able to recognize
swelling and asymmetry were scent that you wave an object through its
not observed. Her internal under the nose. The smell
nose was clean. The student scent should be one that
nurse used different aromatics the patient is familiar
like coffee and perfume. The with and able to identify
client was asked to cover his under normal
eyes and determine the item he circumstances (Shultz
smells. He was able to identify et.al., 2016). Nose must
which of those is the coffee or be symmetrical and
perfume. along of the face. Each
nostril must be patent
and recognize the smell
of an object (Estes,
2014)
Tactile

Tactile receptors identify

She was asked to close both the sensation of touch The sensory
his eyes and hold the item that and are all over our transmission functions
the student nurse will give to bodies in our skin. Some of the client are
him. The items include paper areas of our skin have normal.

31
 and cloth. John Lloyd was able
to identify what are those he is
currently holding. The next
test was for differentiating
what is cold and what is hot.
Test tube with hot/cold water
was used for assessment and
then patted it on the skin of the
client. He was asked on what
he feels and answered
correctly on which of the test
tube has hot or cold content.
Motor Stability She stands on his own without
the help of any support. She
was able to move from one
point to another without any
hassle or complaint. Her
Range of Motion (ROM) was
assessed through rotating or
bending of shoulders and
elbows, flexing of knees,
ankles, and feet. she was able
to move without complaining
for discomforts
Body Temperature 1st day of Assessment:
36.8 ⁰C
2nd day of Assessment:
36.7 ⁰C
3rd day of Assessment:
37.1 ⁰C
Respiratory Status 1st day of Assessment:
19bpm
2nd day of Assessment:
20 bpm
32
more tactile receptors
than other areas e.g.
mouth and hands. The
tactile senses are
important for identifying
touch, pressure, pain,
temperature and texture
(Sensory Processing
Resource, 2021).
Balance is not only Her gait and balance
important for relatively is normal and
stationary positions such wellcoordinated.
as sitting and standing, There is no sign of
but also it provides the difficulty during range
necessary stable base to of motion exercise.
support movements of
the head, torso, or limbs
(Adolph, 2003). There
should be absence of
discomfort during range
of motion exercise.
(Estes, 2006)
Normal body The axillary
temperature varies by temperature of the
person, age, activity, and client on all days of
time of day. The average assessment is normal.
normal body
temperature is generally
accepted as 98.6°F
(37°C). Some studies
have shown that the
"normal" body
temperature can have a
wide range, from 97°F
(36.1°C) to 99°F
(37.2°C). (MedlinePlus,
2021)
Respiration rates may The respiratory rate is
increase with exercise, considered normal on
fever, illness, and with all days of
other medical assessment. No
conditions. When abnormal conditions
checking respiration, it's were noted.
 3rd day of Assessment:
19 bpm
Shoulders were at the same
level as she inhaled and
exhaled. No increased
respiratory effort was noted.
Breathing is fine and
respirations are regular and in
rhythm.
Circulatory Status 1st day of Assessment:
PR: 87 bpm
BP: 118/74 mmHg
2nd day of Assessment:
PR: 92 bpm
BP: 120/76 mmHg
3rd day of Assessment:
PR: 86 bpm
BP: 118/70 mmHg
Nutritional Status According to her and her
parents, the usual diet that they requirement of health of
have in their home includes
variety of vegetables, fruits,
pork, chicken, fish, dairy
products, and rice. He does not the body and normal
have any vices. He was able to metabolic integrity.
consume 7-9 glasses of water
every day.
Elimination Status The client defecates at least
important to also note
whether you have any
trouble breathing.
Normal respiration rates
for an adult person at
rest range from 12 to 20
breaths
The normal cardiac rate The cardiac rate of the
for an adult is 60-100 client on the 1st, 2nd
beats per minute while and 3rd day of
for a normal reading of assessment is normal
blood pressure, it needs as well as her blood
to show a top number pressure
(systolic pressure) that’s
between 90 and less than
120 and a bottom
number (diastolic
pressure) that’s between
60 and less than 80.
(Kozier, 2017)
Nutritional status is a The food diet in their
family is normal since
a person convinced by it gives them adequate
the diet, the levels of nutrients for their
nutrients containing in everyday lives. There
are no factors, coming
from vices, than may
Normal nutritional status affect his health.
is managed by balance
food consumption and
normal utilization of
nutrients (NSRA, 2021).
Normal eating pattern is
considered to be at least
three times a day
depending on the
metabolic demands and
needs of the patient.
Fluid intake should be 8-
10 glasses per day
(Monahan, 2017)
Normal bowel Based on the
33
 once a day, usually after lunch. movement of a person assessment, the
He urinates about 4 times a must be 1 to 2 times a elimination status of
day and his urine do not have day and voiding in 3 to 4 the client is
strong, foul odor and is times a day with an considered normal.
yellowish in color output of 1200 to
1500mL a day. A normal
stool is brown in color
and well formed, urine is
clear to yellowish in
color. (Kozier, 2017)
Reproductive She stated that her first It occurs approximately The onset of her
Status menstruation occurred when every 28 days, with a menarche occurred
she was on her first year in range from every 21 to within the normal age.
high school, around 13 years every 45 days. The Her reproductive
of age. No history of sexually average age of onset of status is considered as
transmitted disease. menarche is 12.4 years normal.
(Lacroix, 2020).
Sleep- Rest Pattern The client usually asleep at Sleep refers to altered The total sleeping
12:00 am and wakes up at 9:00 consciousness with hours of Maxene is
am in the morning. He was general slowing of usually 9 hours each
able to rest some time of the physiological process day which is in the
day while he plays with his while rest refers to normal range of hours
phone. He is awake until relaxation and calmness, of sleep. But the
midnight due to his excessive both mental and sleeping time is not
usage of mobile phone. physical. A typical normal due to
sleeper will pass through excessive use of
7 to 9 hours of sleep and gadgets. adequate
take a rest using some amount of hours for
relaxation activities such rest.
as reading, telling stories
and others (Daniels,
2015).
State of skin As the student nurse assessed Skin surfaces should not The condition of his
appendages and palpate her skin it was be tender, and the skin is skin appendages is
noticed that her skin is fair in dry with a minimum of considered normal.
color, no tenderness and it is perspiration. Skin No abnormalities
smooth, and has no presence temperature should be were found.
of any edema. There are no IV warm and equal
sites on both hands. The bilaterally, hands and
conjunctivae of the client are feet maybe slightly
both pinkish and not dry. cooler than the rest of
Toenails and fingernails the body. Skin should
looked clean and were normally feel smooth.
trimmed. The hair was neat The skin turgor should
and has evenly distributed hair return within 2-3
strands. The scalp has limited seconds and edema

34
 amount of dandruff. should not normally
present. The skin should
be free from lesions and
inflammation (Estes,
2014)

Lexter John P. Pabalan

Age: 18 y/o
Area of assessment Findings Norms Analysis
Social Status Patient is 18 years old resident Social status is the Mr. Lexter has a
of B7 L7 P3, Camella Homes, position one hold's in a good relationship with
Maliwalo, Tarlac City group or community. It his family and friends.
verbalized that he is in 1st year is social support that
college student and he is builds people up during
taking up a Bachelor of times of stress and often
Science and information in gives them the strength
technology,He is currently to carry on and even
living together with his parents thrive (Cherry, 2020).
and two siblings As she stated,
he has an interactive
relationship with her siblings,
they sometime play and have
fun through mobile gaming.
When it comes to her parents,
she is more close to the father
than the mother but they still
able to interact with each other
without hesitation. He has a
lot of friends in their school
but since it is online class he
easily got bored and play
games on his phone
Mental Status The client’s cloth is The patient should He looks
presentable and clean. His hair appear relaxed with the properly groomed at
> General was not trimmed. His teeth are appropriate amount of the time of the visit.
Appearance and not complete and has some concern for the he had no excessive
Behavior dental carries. His fingernails assessment. The patient movement, and no
and toenails were not trimmed should exhibit erect discomfort was felt
properly and there’s a slight posture, smooth gait and during the
presence of dirt in them. He symmetrical body assessment. He
cooperates well with the movement. The patient exhibits erect posture,

35
 students of all the days of
assessment.
He was very cooperative and
>Level of well-oriented during the
consciousness and interview. He was able to
orientation respond to the questions
correctly regarding on the
information that we need for
this assessment. He knows
what to say if asked for her
name, their address, her line of
work, her children, and other
vital question concerning
herself and most importantly,
her family.
>SPEECH During the interview, he stays
calm while talking. His voice
is not too loud but clear and he
can accurately say the things
he wanted to say. In addition,
he was able to elaborate his
answers to the question
properly.
36
should be clean and and symmetrical body
well- groomed and movement, and
should wear appropriate smooth gait.
clothing for age,
weather, and
socioeconomic status.
Facial expressions
should be appropriate to
the content of the
conversation and should
be symmetrical (Jensen,
2019) He was able to
answer all the
questions that we ask
correctly. He
responds normally
The message's content and appropriately to
should correspond to the topics discussed. In
patient's level of addition, he is well-
education. The patient oriented to time and
should be able to answer place during the
questions accurately and assessment. This
identify all of the objects indicates that his level
as instructed. Denial and of consciousness and
poor eye contact are orientation is normal.
common reactions
during the first
conversation, which may
be attributed to anxiety
over meeting a stranger
or an attempt to screen
or dismiss unwanted
truths by refusing to
acknowledge them. He was able to
(Jensen, 2019) communicate verbally
and clear during the
interview. It is also
consistent and there
The patient should be are only minimal
able to produce pauses in his answers
spontaneous, coherent on the questions. It is
speech (Jensen, 2019) also observed that he
is not nervous and
remained calm during
the interview.
Emotional Status The client stated that if they
have misunderstanding at
home, especially with her
older sisters, they often talk
about it for settlement. He also
said that currently, there are no
kinds of things that is
bothering him except for his
modules that he needs to
accomplish by the end of
every week. The presence of
fear, anxiety, grief, tremors,
uncertainty, irritability, panic,
and tension were all negative.
Sensory Perception
His eyes are brown and
Sense of sight have a normal vision. There
are no lesions or swelling of
the eyes noted. Both eyes
move symmetrically in each 6
cardinal movements. Using a
penlight, the pupils were
observed as dark brown in
color, equally round and
reactive to light.
The client’s nose is in the
midline of the face, and it is
Sense of Taste symmetrical. He was able to
determine and identify
different kinds of odors that
was placed near his nose with
his eyes closed. The presence
of any swelling, lesions,
edema or masses was not
37
During adulthood, here His support
is some support for the system during time of
view that people do stress is his family
undertake a sort of and they were able to
emotional audit, help him to feel at
reevaluate their ease.
priorities, and emerge in addition, he can
with a slightly different control her emotions
orientation to emotional that indicates normal
regulation and personal emotional status.
interaction in this time
period (Lumen, 2017).
Normal vision is
considered 20/20. A He has a
visual acuity of 20/50 normal visual ability.
indicates that the patient The extraocular
can read from 20 ft what muscle movements
a person with normal are normal as well as
acuity (20/20 vision) can the pupillary response
read from 50 ft (Shultz of both eyes.
et.al., 2016).
The client was able to
recognize what
aromatic is being
asked. Therefore, he
has a normal sense of
smell as well as
external appearance
of the nose.
A person usually
identifies the taste of
bitter, sweet, sour, and
salty. By the use of our
sense of taste, we can fix His auditory accuracy
or adjust the taste of our is normal. No signs of
food based on our abnormalities were
capacity (Blue, 2018). observed.
 observed
Sense of hearing The client has a good hearing
ability. There is also no
redness or swelling in his ear
and no tenderness or redness
upon the assessment. Whisper
test was performed in both his
ears, and he was able to repeat
all the words that was said to
him.
Sense of Smell The client has no problem with
regards to his sense of taste.
He was able to determine and
identify the food that was
given to him with his eyes
closed. Whether it is sweet,
salty, bitter or sour kind of
foods.
Sense of Touch The client was asked to hold
various things while his eyes
are close and he was able to
identify the things we gave
him such as paper, pen, and
cellphone. He can easily
respond to pain and touch. In
addition, he can also
differentiate between hot
objects and the cold ones.
Motor Stability Upon assessment, the
client does not have any
38
His taste buds
are functioning well.
Auditory acuity: The No signs of
clarity or clearness of abnormalities were
hearing, a measure of observed.
how well a person hears.
Auditory acuity is
measured in order to
determine a person's
need for a hearing aid
(Stoppler, 2021).
His sense of
touch is also
functioning well. The
sensory signals were
transmitted
immediately along the
sensory pathways.
A person usually
identifies the taste of
bitter, sweet, sour, and
salty. By the use of our
sense of taste, we can fix
or adjust the taste of our
food based on our
capacity (Blue, 2018)
The skin contains
receptors for pain,
pressure, temperature.
Sensory signals are
transmitted along rapid
sensory pathways, and
less distinct signals such
as pressure of localized
touch are sent via slower
sensory pathways.
(Estes, 2014)
Stability skills He has a good
are a type of gross motor and normal motor
 problem when it comes to her
movement such as when
running, jumping, sitting,
walking, and standing. He can
move in her own and shows no
difficulty in doing the things
she is asked to. According to
the patient, he does not
experience any kinds of pain
from moving any part of his
body and his balance is
normal.
Body Temperature 1st day of assessment
T = 37.0 °C
2nd day of assessment
T = 37.2 °C
3rd day of assessment
T = 36.9 °C
Respiratory Status 1st day of assessment
RR = 20 cpm
2nd day of assessment
RR = 18 cpm
3rd day of assessment
RR = 18 cpm
Circulatory Status 1st day of assessment
PR = 90 bpm
BP = 110/70 mmHg
2nd day of assessment
PR = 92 bpm
BP = 120/80 mmHg
39
skill involving balance stability as he is still
and weight transfer. To young. In addition,
master these skills, He completely uses
children must be able to all the parts of his
maintain various body lower extremities
positions, as well as while walking and
adjust them, without sitting while showing
falling. It takes muscle no signs of difficulty.
strength and body
awareness (or
proprioception) to be
able to gain balance and
hold it while moving
around, or even staying
still. (H. Catherine,
2020)
Normal axillary The body
temperature is within temperature is
36.4 to 37.4 degrees considered normal on
Celsius. A single the 1st,2nd, and 3rd day
temperature reading of assessment. No
does not always indicate abnormal conditions
a fever (Potter, et al, were noted.
2021)
Respiration rates The
may increase with respiratory is
exercise, fever, illness, considered normal on
and with other medical the 1st,2nd, and 3rd day
conditions. When of assessment. No
checking respiration, it's abnormal conditions
important to also note were noted.
whether you have any
trouble breathing.
Normal respiration rates
for an adult person at
rest range from 12 to 20
breaths per minute
(URMCR, 2021).
The normal The cardiac
cardiac rate for an adult rate and blood
is 60-100 beats per pressure is considered
minute while for a normal on the 1st,2nd,
normal reading of blood and 3rd day of
pressure, it needs to assessment. No
show a top number abnormal conditions
(systolic pressure) that’s were noted.
 3rd day of assessment
PR = 96 bpm
BP = 120/80 mmHg
Nutritional Status The client stated that
he eats up to 5 times a day
which is 3 meals and 2 set of
snacks. He has no culture or
religious dietary restrictions.
His regular diet consists
mainly meats, which is his
favorite, and usually avoids
vegetable dishes if it is present
in the table. Though he eats
fruits and vegetables, it is only
in minimal amount. In
addition, he drinks
approximately 8 glasses of
water daily.
Elimination Status The client stated that
he had regular bowel
movements which she
defecates once a day and
urinates 4 times daily. He does
not have any difficulty in
eliminating wastes. The color
of her pee ranges from clear to
yellowish. He described her
stool as brown in color and not
watery.
40
between 90 and less than
120 and a bottom
number (diastolic
pressure) that’s between
60 and less than 80.
(Kozier, 2017)
Adequate food The nutritional
intake consists of a status of the client is
balance of nutrients such considered normal
as water, carbohydrates, since he has a balance
proteins, fats, vitamins, diet. She usually eats
and minerals. The meats with
normal eating pattern of vegetables. But it is
a person is a minimum recommended that he
of three times per day should not avoid
depending upon the fruits and vegetables
metabolic demand and as they are vital as
needs of the patient. source of nutrients in
Most of the school-age our body. His
slum children in our nutritional status is
study had a poor not affected by any
nutritional status. vices and bad habits.
Interventions such as
skills-based nutrition
education, fortification
of food items, effective
infection control,
training of public
healthcare workers and
delivery of integrated
programs are
recommended. (Kozier
& Erb's, 2018 and
Potter, et al, 2021)
Normal urinary His
output of a person is 2 elimination status is
liters per day and should normal and there are
typically defecate from no abnormalities. His
once a day to every 3 to stool and urine is
5 days. Feces are considered as normal.
normally brown in color His number of times
and soft but formed. urinating, and
(Kozier & Erb's, 2018) defecating is also
within the normal
range. No problem in
characteristics of the

Reproductive Client was still
Status uncircumcised and there are
some presences of pubic hair.
The penis has no lesions and
urethral discharge. Testes
normal size without masses or
tenderness. No scrotal masses
and hernia. In addition, there is
no history of sexually
transmitted disease.
Sleep- Rest Pattern The client usually
sleeps at around 2-3 am in the
morning after playing mobile
games, specifically mobile
legends and watching random
videos on social media. He
usually wakes up at around 10
am in the morning. He is able
to sleep for at least 7 hours a
day and reported no difficulty
in sleeping.
State of skin It is observed that the
appendages client’s skin has a fair
complexion and there is no
presence of neither skin
discoloration nor edema.
In addition, there was no
presence of wound, skin
irritation and lesions were
noted. No rashes to be seen
and has normal capillary refill
which goes back 2-3 seconds.
There is no hair loss, and his
nails were short and slightly
pinkish in color. No pallor,
jaundice, or cyanosis. His hairs
are dry, evenly distributed, no
41
stool and urine found.
Puberty is the His
stage during which reproductive status is
people reach full normal based on the
reproductive ability and interview. Since the
develop the adult client is still
features of their sex. In uncircumcised there
boys, puberty usually was a slight presence
occurs between the ages of smegma in the
of 10 and 14 years. penis foreskin.
However, it is not
unusual for puberty to
begin as early as age 9
or to continue until age
16. (Potter, et al, 2021)
Getting enough The amount of
sleep is essential for time the client sleeps
helping a person is 7 hours a day which
maintain optimal health within the normal
and well-being. When it range of hours of
comes to their health, sleep an individual
sleep is as vital as need. Even though the
regular exercise and amount of time is
eating a balanced diet normal, the time of
(Fletcher, 2019). the day he sleeps is
not normal, which is
around 2-3 am due to
the consistent usage
of his gadget in
playing online games.
The skin appendages are The state of
epidermal and dermal- her skin appendages
derived components of is normal based on the
the skin that include observation during
hair, nails, sweat glands, interview. No
and sebaceous glands. significant
Each component has a abnormalities
unique structure, were found.
function, and histology.
This article describes the
unique characteristics of
each of these
components and
provides insight into
tissue preparation for
microscopic evaluation
 parasite infestations, and and the clinical
well-trimmed. significance of these
structures (Yousef,
Miao, et al. 2021).

Patient is a 32 years old resident of 56 Bayan Park Aurora Hill, Baguio City. Patient
verbalized that he currently provides his basic needs by working as a radio technician.
His wife and relatives are always around helping him in doing his activities of daily
living. Patient is practicing Catholic. He believes that his current condition is due to the
effects of alcohol and believes that he could overcome it.
Patient is a 32 years old resident of 56 Bayan Park Aurora Hill, Baguio City. Patient
verbalized that he currently provides his basic needs by working as a radio technician.
His wife and relatives are always around helping him in doing his activities of daily
living. Patient is practicing Catholic. He believes that his current condition is due to the
effects of alcohol and believes that he could overcome it.
Patient is a 32 years old resident of 56 Bayan Park Aurora Hill, Baguio City. Patient
verbalized that he currently provides his basic needs by working as a radio technician.
His wife and relatives are always around helping him in doing his activities of daily
living. Patient is practicing Catholic. He believes that his current condition is due to the
effects of alcohol and believes that he could overcome it.
Patient is a 32 years old resident of 56 Bayan Park Aurora Hill, Baguio City. Patient
verbalized that he currently provides his basic needs by working as a radio technician.
His wife and relatives are always around helping him in doing his activities of daily
living. Patient is practicing Catholic. He believes that his current condition is due to the
effects of alcohol and believes that he could overcome it.
Patient is a 32 years old resident of 56 Bayan Park Aurora Hill, Baguio City. Patient
verbalized that he currently provides his basic needs by working as a radio technician.
His wife and relatives are always around helping him in doing his activities of daily
living. Patient is practicing Catholic. He believes that his current condition is due to the
effects of alcohol and believes that he could overcome it

42
 Alexa Sophia P. Pabalan
Age: 6 y/o
Area of assessment Findings Norms Analysis
Social Status The Client is very talkative at Social status is the The client is very jolly
the age of six Ms. Alexa can position one hold's in a she is the stress
state her age and where she group or community. It reliever in their family
lived and what are the names is social support that and she can socialize
of her family. She is currently builds people up during with anyone
starting her grade school times of stress and often
which she is now a grade one gives them the strength
student. Since she is the to carry on and even
youngest her mother is very thrive (Cherry, 2020).
strict to her when using
gadgets and cellphones
particularly she have many
friends on their neighbors As
the client stated she always
play with her Sister and
brother after she sleep in the
afternoon she stated that her
favorite playmate is her father

43
 since it is pandemic she is not
allowed to go outside to play
with her friends. Also she is
not a shy type person and can
entertain the visitors by
singing and dancing
Mental status
> General During the visitation Alexa
Appearance and Sophia took a bath already and
Behavior she have a neat clothes and
hair. Also her nails are been
trimmed. The client can count,
write and read. Since She is
still a kid when the student
nurse are interviewing her
she’s easily distracted but the
client could cooperate with the
student nurse with respect
The Client is very cooperative
>Level of and coherent in the whole
consciousness and interview. She is very
orientation responsive into the question
that being ask and aware on
can state her age and where
she lived and what are the
names of her family. Since she
was a kid she have so many
clarification when we are
asking a few question she is
very curious about anything
but she is very well cooperated
and playful all though out the
assessment
44
Appearance is described On the client status
as the client is on the
wellgroomed/disheveled normal state. Even
, how they are dressed, though she is still
demeanor in interview, young and starting
level of eye contact. In school she could
males - shaving. As cooperate very easy
appropriate, physical and understand the
behavior such as things the being ask.
restlessness, motor She is very
Activity presentable and neat
(retardation/over during the assessment.
activation) Level of co-
operation, any evidence
of aggression or
hostility.
Overfamiliarity, for
instance touching
interviewer
inappropriately (MSE,
n.d)
She is well oriented to
The normal state of time and place that
consciousness comprises she is in. She was able
either the state of to answer well during
wakefulness, awareness, each assessment and
or alertness in which cooperates well with
most human beings the student nurse.
function (Tindall, 1990).
Being oriented to place
and time means that you
know who you are,
where you are, where
you live, and what time
it is. When
consciousness is

>SPEECH
She is very articulate and she
doesn't exert too much effort
in talking and explaining
things. Her way of talking was
loud and clear and
understandable.
Emotional Status  After asking for her condition, During adulthood, here
she said that she is feeling
well. The student nurse asked
if there is something that
bothers her like fear of
something, anxiety, or grief.
And she stated that there is
nothing specifically that
bothers her. Her support
system in case of stress is
mainly her husband. She also
stated that she is an optimistic period (Lumen, n.d).
type of person
Sensory Perception
Sense of sight Her eyes are brown and have a
normal vision. There are no
lesions or swelling of the eyes
noted. Both eyes move
symmetrically in each 6
cardinal movements. Using a
penlight, the pupils were
observed as dark brown in
decreased, your ability
to remain awake, aware,
and oriented is impaired
(Lights, 2019). Her way of
communication
Rate ranges from through verbal
"poverty of speech" with manner is normal and
few utterances to can easily be
"pressure of speech", understood.
spontaneity with little or
no spontaneous
utterances to
circumstantiality with
overinclusion of detail,
volume: from low to
high, rhythm:
monotonous, without
variation or inflection;
staccato, with frequent
pauses between fluent
speech, and normal.,
tone: ranges from low to
high (MSE, n.d)
Her emotional status
is some support for the is normal since there
view that people do is nothing that bothers
undertake a sort of her. She has a good
emotional audit, support system to help
reevaluate their her cope up during
priorities, and emerge stress.
with a slightly different
orientation to emotional
regulation and personal
interaction in this time
She has a normal
Normal vision is visual ability. The
considered 20/20. A extraocular muscle
visual acuity of 20/50 movements are
indicates that the patient normal as well as the
can read from 20 ft what pupillary response of
a person with normal both eyes.
acuity (20/20 vision) can
read from 50 ft (Shultz
45
 color, equally round and et.al., 2016)
reactive to light.
The client has no problem with
Sense of Taste regards to his sense of taste.
He was able to determine and
identify the food that was
given to her with eyes closed.
Whether it is sweet, salty,
bitter or sour kind of foods.
Sense of hearing The client has a good hearing
ability. There is also no
redness or swelling in his ear
and no tenderness or redness
upon the assessment. Whisper
test was performed in both his
ears, and he was able to repeat
all the words that was said to
her
Sense of Smell The client’s nose is in the
midline of the face, and it is
symmetrical. He was able to
determine and identify
different kinds of odors that
was placed near his nose with
his eyes closed. The presence
of any swelling, lesions,
edema or masses was not
observed
46
A person usually Her taste buds are
identifies the taste of functioning well. No
bitter, sweet, sour, and signs of abnormalities
salty. By the use of our were observed.
sense of taste, we can fix
or adjust the taste of our
food based on our
capacity (Blue, 2018)
To determine the
presence of smell, have Her auditory accuracy
the patient close both is normal. No signs of
eyes and describe or abnormalities were
identify a particular observed.
scent that you wave
under the nose. The
scent should be one that
the patient is familiar
with and able to identify
under normal
circumstances (Shultz
et.al., 2016). Nose must
be symmetrical and
along of the face.
To determine the The client was able to
presence of smell, have recognize what
the patient close both aromatic is being
eyes and describe or asked. Therefore, he
identify a particular has a normal sense of
scent that you wave smell as well as
under the nose. The external appearance of
scent should be one that the nose.
the patient is familiar
with and able to identify
under normal
circumstances (Shultz

Motor Stability Upon assessment, the
client can move in her own
and shows no difficulty in
doing the things she is asked
to. She does not have any
problem when it comes to her
movement such as when
sitting, walking, and standing.
According to the patient, she
does not experience any kinds
of pain from moving any part
of his body and her balance is
normal.
Body Temperature 1st day of assessment
T = 36.5 °C
2nd day of assessment
T = 36.7 °C
3rd day of assessment
T = 36.6 °C
Respiratory Status 1st day of assessment
RR = 18
2nd day of assessment
RR = 17
3rd day of assessment
RR = 18
47
et.al., 2016). Nose must
be symmetrical and
along of the face. Each
nostril must be patent
and recognize the smell
of an object (Estes,
2014)
Balance is not only Her motor stability is
important for relatively good and normal. In
stationary positions such addition, she
as sitting and standing, completely uses all
but also it provides the the parts of her lower
necessary stable base to extremities while
support movements of walking and sitting
the head, torso, or limbs while showing no
(Adolph, 2003). There signs of difficulty.
should be absence of
discomfort during range
of motion exercise.
(Estes, 2006)
Normal body The body temperature
temperature varies by is considered normal
person, age, activity, and on the 1st,2nd, and 3rd
time of day. The average day of assessment. No
normal body abnormal conditions
temperature is generally were noted.
accepted as 98.6°F
(37°C). Some studies
have shown that the
"normal" body
temperature can have a
wide range, from 97°F
(36.1°C) to 99°F
(37.2°C). (MedlinePlus,
2021)
Respiration rates may The respiratory rate is
increase with exercise, considered normal on
fever, illness, and with the 1st,2nd, and 3rd day
other medical of assessment. No
conditions. When abnormal conditions
checking respiration, it's were noted.
important to also note
whether you have any
trouble breathing.

Circulatory Status 1st day of assessment
PR = 76 bpm
BP = 110/70 mmHg
2nd day of assessment
PR = 79 bpm
BP = 100/70 mmHg
3rd day of assessment
PR = 83 bpm
BP = 110/80 mmHg
Nutritional Status The client stated that
she eats up to 7 times a day
which is 3 meals and 4 set of
snacks. She has no culture or
religious dietary restrictions.
Her regular diet consists
mainly of balanced meals such
as healthy foods such as fruits
and vegetables together with
high protein foods. She
observes her diet regularly and
drinks approximately 8 glasses
of water daily.
Elimination Status The client stated that
she has regular bowel
movements which she
defecates once in 2 day and
usually urinates at least 3
times daily. She does not have
any difficulty in eliminating
wastes. The color of her void
48
Normal respiration rates
for an adult person at
rest range from 12 to 20
breaths
The normal cardiac rate The cardiac rate and
for an adult is 60-100 blood pressure is
beats per minute while considered normal on
for a normal reading of the 1st,2nd, and 3rd day
blood pressure, it needs of assessment. No
to show a top number abnormal conditions
(systolic pressure) that’s were noted.
between 90 and less than
120 and a bottom
number (diastolic
pressure) that’s between
60 and less than 80.
(Kozier, 2017)
Nutritional status is a The nutritional status
requirement of health of of the client is
a person convinced by considered normal
the diet, the levels of since she has a
nutrients containing in balance diet. She
the body and normal usually eats healthy
metabolic integrity. foods high in nutrients
Normal nutritional status and avoids unhealthy
is managed by balance foods. Her nutritional
food consumption and status is not affected
normal utilization of by any vices and bad
nutrients (NSRA, 2021). habits.
Normal eating pattern is
considered to be at least
three times a day
depending on the
metabolic demands and
needs of the patient.
Fluid intake should be 8-
10 glasses per day
(Monahan, 2017)
Normal bowel Her stool and urine
movement of a person are considered as
must be 1 to 2 times a normal. Her number
day and voiding in 3 to 4 of times urinating, and
times a day with an defecating is also
output of 1200 to within the normal
1500mL a day. A range. No problem in
normal stool is brown in characteristics of the
 ranges from clear to yellowish. color and well formed, stool and urine found.
She described her stool as urine is clear to
brown in color and soft but not yellowish in color.
formed. (Kozier, 2017)
Reproductive The patient is stil 6 years old It occurs approximately Not yet with a
Status and she didn’t hit puberty yet every 28 days, with a puberty
range from every 21 to
every 45 days. The
average age of onset of
menarche is 12.4 years
(Lacroix, 2020).
Sleep- Rest Pattern The client usually sleeps at Sleep refers to altered She has a normal
around 12 am in the midnight consciousness with sleeping pattern based
after doing school related tasks general slowing of on the norms and able
and activities. She usually physiological process to sleep and rest for at
wakes up at around 7 am in the while rest refers to least 7 hours per day
morning for her online class relaxation and calmness, based on the findings.
which starts around that time. both mental and
In addition, she reported no physical. A typical
difficulty in sleeping and is sleeper will pass through
able to sleep for at least 7 7 to 9 hours of sleep and
hours a day. take a rest using some
relaxation activities such
as reading, telling stories
and others (Daniels,
2015).
State of skin It is observed that the Skin surfaces should not The state of her skin
appendages client’s skin has a fair be tender, and the skin is appendages is normal
complexion and there is no dry with a minimum of based on the
presence of neither skin perspiration. Skin observation during
discoloration nor edema. No temperature should be interview. No
rashes to be seen and has warm and equal significant
normal capillary refill which bilaterally, hands and abnormalities
goes back 2-3 seconds. In feet maybe slightly were found.
addition, there was no cooler than the rest of
presence of wound, skin the body. Skin should
irritation and lesions were normally feel smooth.
noted. No pallor, jaundice, or The skin turgor should
cyanosis. Her hairs are dry, return within 2-3
evenly distributed, no parasite seconds and edema
infestations, and color black. should not normally
There is no hair loss, and her present. The skin should
nails were short and slightly be free from lesions and
pinkish in color. inflammation (Estes,
2014)

49
B. Nutritional Assessment

All the members of the family have no disease that needs an intake of maintenance
medicine, they are only taking medications if needed. No supplements are being taken by anyone
in the family and they mostly based the nutrient intakes in their diet. The family are able to eat 3
times a day and has sufficient source of clean water for drinking. The food that usually prepared
by Mrs. Romano are Filipino dishes. In their overall diet, they are able to eat variety of foods
such as meat like pork, beef, chicken and fish, green and leafy vegetables, variety of dairy
products, fruits, and their main source of carbohydrates is rice. They also have supplies of
biscuits, crackers and candies in their home which they consume whenever they want. No signs
of malnutrition noted within the family.

Family Member Height Weight BMI

Marlon V. Pabalan 160 cm 71 kg 28.6
Zoraida P. Pabalan 170 cm 75 kg 26.7
Maxene Dhale P. 166 cm 56 kg 20.5
Pabalan
Lexter John P. 154 cm 49 kg 20.4
Pabalan
Alexa Sophia P. 140 cm 40 kg 20.5

50
 Pabalan

Table 5: Body Mass Index (BMI) of each member of the Family

NORMS:

A healthy body is maintained by good nutrition, regular exercise, avoiding harmful

habits, making informed and responsible decisions about health, and seeking medical assistance
when necessary. (Mankato 2016)

ANALYSIS:

The nutritional intake of the family is considered normal since they are able to eat
wide variety of foods. No medications are altering their body systems. Their lifestyle
when it comes in the diet is normal. Based on the taken height and weight, the BMI was
able to compute. The computed BMI of Mr. and Mrs.Pabalan are both above the normal
range for healthy weight and considered as overweight. All of their children’s BMI are
within the normal range which means that they have healthy weight.

WATER INTAKE EVERYDAY

4-6 glasses a
day
20% 10 glasses
7-9 glasses
4-6 glasses
7-9 glasses a
day
40%

Graph 1 : Water intake of each member of the family in a day

Interpretation
Graph 1 shows the water intake of the family members each day. As you can notice on
the above pie graph, 40% of the family members drink 10 glasses of water and above each day as

51
well as 7-9 glasses. If you will notice on the above graph, there’s 20% or 1 member of the family
that usually drink 4-6 glasses and that is their youngest

Norms:
In May 2018, the Health Assembly approved the 13th General Programme of Work
(GPW13), which will guide the work of WHO in 2019–2023 (19). Reduction of salt/sodium
intake and elimination of industrially-produced trans-fats from the food supply are identified in
GPW13 as part of WHO’s priority actions to achieve the aims of ensuring healthy lives and
promote well-being for all at all ages. To support Member States in taking necessary actions to
eliminate industrially-produced trans-fats, WHO has developed a roadmap for countries (the
REPLACE action package) to help accelerate actions (6).

Analysis:
In comparison to the standards, each family members have adequate water intake each day even
though one of the family member drinks 4-6 glasses, it is still considered normal especially If an
individual is not easily get thirsty since you will still get water in the regular diet. There’s a need for
increase fluid intake if you need to replace fluid loss specially to replenish the lost fluid from sweat.

C.Values, Habits, Practices on health promotion, Maintenance and Disease Prevention

The family still use some herbal plants for medication. These plants include oregano for
cough and calamansi for vitamin C. They also have supply of over-the-counter drugs which
include Paracetamol, Ibuprofen for pain, Loperamide for diarrhea, and Neozep for colds. When it
comes to vaccinations, all of the family members were able to be vaccinated.

Each family member has enough rest and sleep. The members of the family usually have
about 7 to 9 hours of sleep every day. They are all able to have rest during their respective free
time. They usually watch television, listen to music, play with their phones, or asleep during
their resting hours. When it comes to exercising, they usually do not have proper routine of
exercise and the only exercise they stated is walking. The family usually have their respective
scheduled time for cleaning the house.

The parents are both striving to give all the needs of the family. They are also helping and
encouraging their children to strive harder in studies

NORMS:

Personal hygiene is an act of caring your body. This practice includes such as bathing, brushing
teeth, washing your hands, and more. (Kimberly Holland 2018)

52
 Immunization programs gives a set of services that provide immunity to vaccine-
preventable diseases, administering immunizations, re-immunizations, documenting evidence of
immunity, and record-keeping (for future purposes) and reporting to state or local immunization
information systems (IIS). (CDC 2019)

Sleep is a vital component of human health and the amount of sleep changes with their
age. A typical sleep is 8 hours. (Lori Smith 2017)

ANALYSIS:

All the members of Pabalan family were able to have complete vaccination except for their
6 years child named Alexa because she is still six year old and the required age in DPT is 7 years
old above . They do not have any member with health problem that is why they do not have any
maintenance medications. They are still able to use traditional medicine like different herbal
plants and they also have adequate supply of over-the-counter drugs which they can use during
ailments. The family understand the importance of health, they usually eat healthy foods also
they used herbal medicine or over the counter medication.

Family Measles (2 BCG (1 dose at DPT (1 dose at OPV (4 doses) HEPA B (3-4
Member dose first at birth) 7 years old) doses)
12-15 moths
then 6 years)
Marlon Complete Complete Complete Complete Complete
Pabalan
Zoraida Complete Complete Complete Complete Complete
Pabalan
Maxene Complete Complete Complete Complete Complete
Pabalan
Lexter Complete Complete Complete Complete Complete
Pabalan
Alexa Sophia Complete Complete N/A Complete Complete
Pabalan
Table 6: Immunizations of each member of the family

ANALYSIS:
In view to the table above, it clearly shows that all the family members have complete
vaccinations except for their 6 years old child name Sophia she’s not yet in the right age to have
DPT vaccine. As claimed by Mrs. Pabalan, since she and her husband have a complete
vaccination, they want to guarantee their children’s early protection from diseases

53
Norms:
Filipino children should grow up healthy and protected from preventable diseases. Health
workers, national and local government officials, civil society, mothers, fathers, and community
members have a role to play to ensure that Filipinos receive the right information on
immunization, families are supported in overcoming barriers, and that children complete their
vaccines (UNICEF, 2018).
Analysis:
The member of the family are able to perform physical activities to improve their health
however, they were able to recognize the importance of health disease prevention as they were
all have a complete vaccination.

IV. FAMILY COPING INDEX

Legend:
1- No Competence
2- Moderate Competence
3- Complete Competence
Categories 1 2 3 Justification

54
1)PHYSICAL INDEPENDENCE
This category is concerned with the
ability to move about to get out of the bed, to
take care daily grooming, walking and other
things which involves the daily activities.
2) THERAPEUTIC COMPONENT
This category includes all the
procedures or treatment prescribed for the care
of ill, such as giving medication, dressings,
exercise and relaxation, special diets.
55
1st Visit: During the first visit, The
student Nurse (NS) observed that
the Pabalan Family are able to
perform their daily activities and to
maintain the cleanliness of the
house. They also perform a daily
fitness in their house every 7:00 am
the family had a Zumba fitness in
their house. For the grooming the
SN observe that they are properly
groomed.
2nd Visit: The day after the initial
visit, The family are well manage
and the SN accurately observed the
bonding of the family activities.
After they went to sleep they ensure
that the bed are clean. The SN
asked the family if they did follow
his health teachings or not, and the
family gladly said that they did.
3rd Visit: On the third day, the SN
asked them again about the
information that he gave about the
proper hygiene and guidance in
their daily activities. The family
was able to restate most of the
teachings that the SN said on the
previous days. They are also able to
demonstrate proper hygiene like
hand washing.
1st Visit: During the first visi
the student nurse ask if the cl
they are taking up medicatio
they said they are always
Vitamin C and every year they
a over-all check up to detec
problem that may occur to
Also during the first day the
eating vegetable with meat.
2nd Visit: On the next visit, aft

3) KNOWLEDGE OF HEALTH
CONDITION
This system is concerned with the
particular health condition that is the occasion
of care.
4) APPLICATION OF THE PRINCIPLES
OF THE GENERAL HYGIENE
This is concerned with the family action
in relation to maintaining family nutrition,
securing adequate rest and relaxation for
family members, carrying out accepted
preventive measures, such as immunization.
56
giving health teachings on
preventing major diseases, the
able to cope up with the topic
said that they will be vigilant w
it comes to health problems. T
are able to maintain their healt
diet and some basic exercises
able to demonstrate to them.
3rd Visit: The family member
always prioritize their health.
1st visit: The family was ask
what are the disease that the
encountering or have
encountered. Based on
statement that they told tha
encountered COVID-19 the
family was been quarantine
statement said that it first
with the father who is in
Arabia and went home in
Philippines to have a vacatio
was been a positive
2nd Visit: On the next day, the
able to understand and verbali
health teachings of the SN wh
about other symptoms and gen
knowledge about this disease.
are also able to understand the
importance of hand washing to
prevent COVID-19
3rd Visit: On the third day Stu
Nurse observe that the implica
of hand washing is being appl
1st Visit: The family’s meals a
well selected. Most of the fam
members are able to have adeq
sleep and rest. They are able to
cope up and adapt new preven
measure particularly for COV
pandemic. They are able to
complete all the needed vaccin
for immunization from differe
deadly diseases.
2nd Visit: They are able to mai
their routines when it comes to

5) HEALTH ATTITUDES
This category is concerned with the
way the family feels about health care in
general, including preventive services, care
of illness and public health measures
6) FAMILY LIVING
This category is concerned with the
interpersonal or group aspects of the
family get along with one another, the
ways in which they take decisions
affecting the family as a whole.
57
meal, sleep and rest. However
there are still one family mem
with inadequate amount of sle
and rest, but he said that he wi
to improve his sleeping pattern
3rd Visit: The family is able to
maintain and improve their
appropriate hygiene. They wer
also able to restate the teachin
SN.
1st Visit: The family said they
a savings for Health Finance a
also they have a Social Securi
Service (SSS) and PHILHEAL
if there is any presence of illne
that may occur they have a mo
to pay the bills.
2nd Visit:Upon teaching the
importance of having a regula
consultation with a doctor, the
said that they will look into th
they will be more vigilant in
observing each of their health
condition
3rd visit: Through the last day
are realizing that saving more
money for Health status is a
investmet.
1st Visit: On the initial visit, t
SN noticed that each member
family are respecting each oth
and communicate along with t
They are able to interact
accordingly. When it comes to
decision making, they are able
share their thoughts with the h
of the family
2nd Visit: hey are able to main
that routine and additional
information are given to them.
Before the end of the visit, the
able to verbalize the informati
they have learned this day.
3rd Visit:They are able to verb
 the teachings of the SN on the
previous days.
7) PHYSICAL ENVIRONMENT
This is concern with the home, the
community and the work environment as it
affects family health.

V. TYPOLOGY OF NURSING PROBLEM

This Chapter discusses about the problem that were identified during the assessment and interview with
the family. It includes the cues/data, the family nursing problem and the nursing diagnosis. The problems
identified are categorized into presence of wellness state, health deficits, health threats, and foreseeable
crisis and stress points.

58
59