A FAMILY HEALTH ASSESSMENT 

PRESENTED TO THE 

SCHOOL OF NURSING 

In Partial Fulfillment of the Requirements

In

NCM 104 - Community Health Nursing

Submitted by: 

BSN2 C0

( Names of Members)
Baga, Farhana
Cebreros, Felix Diloy
Cruz, Stephanie Anne
Dy, Naomi Cherrie
Gudez, Gwyneth Giselle
Leyba, Alyssa
Luczon, Kristine
Macalalad, Princess Aubrey
Padua, Cathleen Joy
Payad, Jazmin
Ramos, Trisha
Reyes, Lance

Submitted to : 

Dr. Irynne D. Cabanban, RMT, RN, MAN, PhD.

CHN1 Professor 
 INITIAL DATABASE FOR FAMILY NURSING PRACTICE

A. FAMILY STRUCTURE, CHARACTERISTICS, AND DYNAMICS/RELATIONAL

PATTERNS

Family X is a nuclear family composed of Mr. Antonio., who serves as their father. He is

currently 51 years old, working as a police officer everyday and his vacation days depend on their

headquarter’s availability. Out of the 5 family members, he is the only male member and is the head

of their family. Together with his wife, they both make amends to meet and suffice the family needs.

Mrs. Agnes, born July 2, 1971, is the 50 year old mother of Arienne, Anne Stephanie, and Anne

Jillene. She is happily married to husband Mr. Antonio Cruz Jr. for the past 29 years and she is

currently working as a real estate agent in Taguig city. While at home, she mostly takes care of the

children and is responsible for their daily meals, and household chores since Mr. Antonio usually

comes home late in the evening due to his occupation as a Police officer.

Arienne, the family’s eldest daughter, born in January 5, 1995 is a graduate of BS Food Technology

in Technological University of the Philippines and is currently working as a software engineer. She

lives together with her family and visits her boyfriend who resides in Pasay from time to time.

The middle child, Anne Stephanie born on July 3, 2000 is a 21 year old female student currently in

her 2nd year studying BS Nursing at Centro Escolar University in Manila.

Their youngest daughter, Anne Jillene, born on June 23, 2001 is currently 20 years old. She is in her

3rd year studying as Doctor of Dental Medicine at University of the East - Manila.

Their family structure is considered patriarchal as the father acts as the primary authority figure.

Though when it comes to decision making especially on matters of health care, the mom determines

and resolves their matters. Both the parents and the children make efforts to communicate with each

other. The parents join and comprehend what their children like and make this a way for them to

bond, have time for one another, and enjoy their time together.

After interviewing the Cruz family, our group C0 has concluded that their family has a balanced

relationship. Family Cruz maintains a good communication between one another; they tend to

acknowledge each other's feelings and problems whether it's about work, school, or personal

differences that occur within the family. Overall, Family Cruz has a strong foundation and practices

great parenting skills.

B. SOCIO-ECONOMIC AND CULTURAL CHARACTERISTICS

The Cruz family does not belong to any tribe. Mrs. Agnes is a Roman Catholic. She finished

2nd year college, her highest educational attainment. She’s a Real Estate Manager who’s working at

Mckinley, Taguig and has an estimated salary of 40, 000 pesos monthly. Her monthly salary is not

fixed since she’s working as a Real Estate Manager and it’s a commission basis. Mr. Antonio is a

Roman Catholic who is a college graduate and now a Police Officer at Malate, Manila and has an

estimated salary of 60, 000 pesos monthly. Arienne, the eldest daughter of Mr. and Mrs. Cruz, is a

Roman Catholic and a college graduate who’s now working as a Software Engineer at Cubao,
Quezon City and has a monthly salary of 30, 000 pesos. Anne Jelline is the youngest daughter of Mr.

and Mrs. Cruz. She’s a Roman Catholic and a 3 rd year college student who’s studying as a Doctor of

Dental Medicine at UE Manila. Their family has no traditions or practices related to their health and

lifestyle.

According to Mrs. Agnes, their estimated monthly budget is 70, 00 pesos and their family’s

monthly salary is enough to sustain their needs and basic necessities such as food, clothing, shelter,

water and electricity, school stuff, and etc. She’s the one who’s assigned in handling their budget and

where she would allocate those. She stated that she has savings for some purposes but she didn’t

think that it is allocated for emergency matters like accidents etc. Since she’s working as a Real

Estate Manager, sometimes their budget depends on her commission rate and just like other families,

they have also experienced cash shortages but she immediately finds a way to solve it when she gets

a higher salary.

Aside from the members of their family, the Cruz family has a helper or stay out who is

known to be her mother’s cousin. She helps the Cruz family to clean the house and go to the market

to buy some food and other stuff. She’s also the one who took care of Mrs. Agnes Cruz after being

through an operation.

In their community, the Cruz family are known even though they’re not usually going

outside. They didn’t have the opportunity to join programs in their community like medical missions,

general cleaning, and livelihood programs because they have no time for it. Sometimes, they’re not

informed with the programs that are being implemented within their community because there are

only selected participants. But, in the future, the Cruz family plans to volunteer for community

programs if they have no work and if they will be given much time for it.
 ECOMAP OF X FAMILY

The ecomap represents the relationship of the X family with their community. Each line connected

to the variables describes the level of relationship to the family members. The legend at the bottom of

the ecomap indicates the meaning of each line to serve as a guide. The analysis is based on the

statements of Mrs. Agnes, the mother of the family. Based on the map, Mr. and Mrs. X and one of

their children have a strong relationship with their work. According to Mrs. Agnes, she works as a

Real Estate Manager in McKinley Taguig. However, she now has to work at home because of the

pandemic. Mr. Antonio., a Police Officer in Malate, Manila, usually arrives at home at 11 p.m. Their

first-born daughter is a Software Engineer who works in a BPO company in Cubao, Quezon City.

The other two members of the family are still studying and are currently in college. The 2nd and 3rd

children made good relationships with people in their respective schools. Among the family

members, only Mr. Antonio and Mrs. Agnes are the ones who frequently go outside, which makes

their relationship with their neighbors moderately close. Mrs. Agnes stated that her three daughters
seldom go out of their house but their neighbors know their names. Aside from Mr. and Mrs. Agnes,

their helper runs errands for them and shops in the grocery and the market. The family does not go to

the hospital directly when experiencing health problems. Mrs. Agnes verbalized that they either

consult online or with their neighbor, who is a doctor. She also said that she prefers visiting a private

clinic.

C. HOME AND ENVIRONMENT

The X family owns a lot at Tondo, Manila in which the space is enough for the five of them.

They have their own rooms except for the second child and the youngest where they share the same

room.

There’s no possible space for the insects except on the side of their house because they

maintain the cleanliness of their house by cleaning it every other day. They also hired someone to

help them do household chores. Mrs. Agnes manages to check the electric wirings and fixes it to

prevent any kinds of accidents from happening.

In terms of stocking food, they do groceries twice a month and clean it before putting it to its

designated places inside the refrigerator. They use a gas stove, frying pan, stainless pot, and

stoneware for cooking food. They also have their own water supply from the faucet and they use a

purifier that filters out the water to become alkaline as their drinking water.
 They have their own toilets, one upstairs and the other one is downstairs where they manually

flush their toilets by pouring water. They also clean it every other day by using Mr. Muscle, starting

from the cleanest to dirtiest area-- lavatory, walls, and then the bowl. They have a septic tank as the

drainage system of their house, and sewage outside the house where the wastewater goes.

The family has a lot of trash cans in every part of their house but they are guilty for not

separating the biodegradable from non-biodegradable but for everyone’s safety, they wrap broken

pieces that can cause harm before throwing it to the trash can. The garbage collector collects their

trash everyday.

When it comes to their neighborhood, they have loud neighbors and there are some cases of

wrangle in their street because of the children from the other places who pass by but the moderator in

their community manages to ban them. They have easy access to all of the facilities in their

community as well as communication facilities and transportation because it is just nearby their

house. They also have their own vehicle like four wheels and two motorcycles which they can only

use when Mr. X is around. They prefer to commute rather than riding their own vehicle when they’re

going to run some errands because the traffic jam in their place is not heavy.

D. HEALTH STATUS OF EACH FAMILY MEMBER

I. Nursing Health History (each member of family)

 Mr. Antonio, 51 years old, has a current medical illness which is Hypertension as stated by

his wife. The said lifestyle disease took place back when he was still 29 years old, which is in the

year 1999. The reason for his Hypertension is due to drinking of alcohol, stress, and inadequate

physical activity or exercise. Regarding the current illness Mr. Antonio has, even though his

condition is not that high, he is now taking his medicine named Amlife 50mg for it not to get worse.

Furthermore, in his condition, there was no past history of significant illness mentioned.

Mrs. Agnes, 50 years old, also has a current medical illness which is Hypertension. She

mentioned that the said lifestyle disease took place in the year 2018, back when she was 48 years old.

The said reason for her Hypertension is due to stress, lack of exercise or physical activity, and that it

might also be because of her age. Beyond that, she also mentioned her past history of significant

illness where she had undergone an operation which is TAH BSO or Total Abdominal Hysterectomy

with Bilateral Salpingo-Oophorectomy, a surgery that will remove the organs such as uterus, cervix,

ovaries, and fallopian tubes. The operation had to be done due to the enlargement of her Myoma also

called Fibroids, which happened January 18,2021. After the surgery, the healing stage lasted for

about 2 to 3 months where she experienced difficulty in walking, and her movements were limited

since there were a lot of organs removed inside her body, resulting in having more scars. The

medications that she is currently taking are Amlife 50mg , Calcitect, Remifemine, Vitamin c,

Sangobion.

Ms. Arienne, 26 years old, does not have any current illnesses. However, she has mentioned that

she had an irregular menstruation cycle before, but it is now being taken care of since she already

consulted a doctor, which means she presently has a regular menstrual cycle.
 Ms. Anne Stephanie, 21 years old, has Allergic Rhinitis according to her mother. Mrs. Agnes

also stated that Ms. Anne Stephanie sometimes gets attacked by her allergy during the morning. And

the reason for what triggers her allergy is mostly because of the smoke and dust in the surroundings.

Moreover, she personally mentioned that, currently she has an irregular menstrual cycle and she did

not consult a doctor regarding this.

II. GENOGRAM OF FAMILY X- Z

Paternal Grandparents Maternal Grandparents

(Grandfather) (Grandmother)
(Grandfather) (Grandmother)

(Mother) (Uncle) (Aunt)

(Father)

Legend:

Male

(Eldest Child) (Second Child) (Third Child) (Youngest Child)

(Sister-In-Law)

Female

(Son) Male
(Deceased)

Narrative discussion of Genogram:

The grandfather on the paternal side, deceased due to diabetes. The grandmother on the paternal side, is still

alive and is known to have colon cancer. They have only one child and his name is Antonio Jr. with

Hypertension. On the maternal side, the grandfather is also deceased due to lung cancer. The grandmother on

the maternal side, is still alive and is known to have mild hypertension and diabetes. , they were blessed with

3 children. The eldest with no health problems, the 2nd child having a hypertension and history of Myoma.

The 3rd child with no health problems.

The X family has 4 children. Anjon who is married to Manilyn and has only one child who is Andrue, and

they all have no health problems. Next is the second child who is Arienne and has no health problems. The

3rd child is Anne Stephanie, same as with the second child who is also having no health problems. Lastly, the

4th child, Anne Jillene and is known to have a history of Dengue.

III. NUTRITIONAL ASSESSMENT

Mr. Antonio, based on his 24-hour-dietary recall, he ate 2 strips of bacon, a piece of fried egg,

a cup of fried rice, 2 glasses of water, and a cup of coffee in the morning. After that, he had bangus,

mung-bean rice cake, a cup of rice, and 2 glasses of water in the afternoon. Lastly, he had 2 pieces of

fried chicken, a cup of fast food rice, and 3 glasses of water in the evening. He also drinks his

vitamins and medicine for his illness which is hypertension.

Mrs. Agnes, 24-hour-dietary recall, had the same meal with her husband which is for her

breakfast she had 2 strips of bacon, a piece of fried egg, a cup of fried rice, 2 glasses of water, and a

cup of coffee. For her lunch, she had bangus, mung-bean rice cake, a cup of rice, and 2 glasses of

water in the afternoon. And for her dinner, she had 2 pieces of fried chicken, a cup of fast food rice,

and 3 glasses of water. Since she also has an illness which is hypertension, therefore she is also

taking up her medicines.

 Ms. Arienne, regarding her 24-hour-dietary recall, she also had the same meal together with

her father and mother since they all lived in the same house. She had 2 strips of bacon, a piece of

fried egg, a cup of fried rice, and 2 glasses of water taken for breakfast. She had bangus, mung-bean

rice cake, a cup of rice, and 2 glasses of water taken for lunch. She had 2 pieces of fried chicken, a

cup of fast food rice, and 3 glasses of water taken for dinner. She is also taking up her vitamins.

Ms. Anne Stephanie also had the same meal, where for her breakfast, she had 2 strips of

bacon, a piece of fried egg, a cup of fried rice, and 2 glasses of water. For her lunch, she had bangus,

mung-bean rice cake, a cup of rice, and 2 glasses of water. Lastly for her dinner, she had 2 pieces of

fried chicken, a cup of fast food rice, 3 glasses of water and a glass of orange juice.

III. PHYSICAL ASSESSMENT (per member of family )

Client: Antonio

General Appearance: The client has a large body frame, posture is upright, smooth and maintains a

balanced gait, appropriately dressed and groomed, no obvious deformity nor odor.

Vital signs : Tempt: 34.6 BP: 130/82

RR: 18 PR:82

b. Mental Status - The client is cooperative, conscious and he uses technical words.

c. Skin - The client has a uniform and normal skin color, warm temperature, no lesions and skin

hair is evenly distributed

d. Nails - the client nail is convex curved, smooth texture, pink in color and the capillary refill is

within 3 seconds.
e. Head and Face - The client skull is proportionate to the body size, smooth contour, no

tenderness, no lesions and infestation. The hair is evenly distributed. The face is symmetrical in

shape and movement.

f. Eyes - The eye condition is straight normal, thick eyebrows, eyelids there were no presence of

discharges, no discoloration, and lids close symmetrically with involuntary and frequent blinks.

The bulbar conjunctiva appeared transparent, the sclera color is white, and the palpebral

conjunctiva was shiny, smooth and pink. There is no edema in the lacrimal gland. Pupils are

equal ( 3mm R, 3mm L ) The reaction to light accommodation left and right is both brisk, the

visual acuity near vision 12-14 inches away the patient is able to recognize the object.

g. Ears - The client auricles color is uniform to the skin and face color, both auricles are

symmetrical in position and shape. The pinna recoils when folded and there is some external

cerumen. The client can respond to a normal voice.

h. Nose - The client nose is similar to the face skin color, the septum is in midline position,

mucosa’s color is pink, and both are patent. There is no tenderness in the sinus and the nasal

cavity is moist.

i. Mouth - the client mouth is pink in color, symmetrical and has no lesions. The mucosa is pink,

tongue is in midline position, the patient has dentures and no discoloration. The gums are pink.

j. Pharynx - the client pharynx appeared normal, the position of uvula is in midline, mucosa is

pink, tonsils are not inflamed and gag reflex is present.

k. Neck - The client neck muscles are equal in size, lymph nodes are palpable, but no tenderness

or masses. The trachea is midline and the thyroid gland is palpable.

l. Breast and Axilla - the client breast and axilla is symmetrical and the contour is flat. Skin

characteristics are smooth and have no other remarkable features.

 j. Chest and lungs - The client shape of chest and lungs is AP to lateral ratio 1:2, symmetrical

movement and quiet, rhythmic and effortless respiration. Anterior and exterior expansion is

symmetrical. Breathing patterns are regular, breath sounds are bronchovesicular, resonant sounds

are heard.

i. Heart - The client heart sounds 82, rhythm is normal sinus.

k. Abdomen - The client abdomen appears uniform in color, symmetric contour and abdominal

movement caused by respirations. Bowel sounds are normal. Palpation is muscle guarding, the

bladder is not distended, and the liver is not palpable.

l. Upper Extremities - The client peripheral pulses are normal. appeared without scars and

lesions on both extremities, muscle strength is 5 normal strength and has normal muscle tone.

lymph nodes are not palpable.

m. Lower Extremities - The client peripheral pulses are normal. appeared without scars and

lesions on both extremities, muscle strength is 5 normal strength and has normal muscle tone.

lymph nodes are not palpable.

n. Genitalia - The client is circumcised, normal hair distribution, Urinary Meatus is lateral

opening, scrotum is asymmetrical, testes are descended, inguinal hernia is absent and no other

remarks.

o. Rectum and Anus - The client perineum and saccrogeal, Coccygeal appears smooth, no

tenderness nor lesions. Anal muscosa is moist, no hair, lesions, and inflammations.

III. PHYSICAL ASSESSMENT (per member of family )

Client: Agnes

General Appearance: The client has upright posture and steady gait with opposing arm swing and

unaided, Large Frame and maintaining balance.

 Vital signs : Tempt: 34.2 BP:120/80

RR: 16 PR:74

b. Mental Status - The client can express herself using simple words, she is oriented to cooperate

as evidence by answering the questions appropriately.

c. Skin - The client skin is uniform in color, unblemished and no presence of any foul odor. She

has a good skin turgor and skin’s temperature is warm.

d. Nails - The client nail shape is convex curve, it is smooth and intact with the epidermis. When

the nail is pressed between the fingers, the nail returns to its usual color within 3 seconds.

e. Head and Face - The face of the client appears smooth and has uniform consistency and no

presence of nodules or masses. The head of the client is rounded and symmetrical. The skull has

no nodules or masses and depression when palpated.

f. Eyes- The client eyebrows hair is evenly distributed, symmetrically aligned and showed equal

movement when asked to raise and lower eyebrows. Eyelashes appear to be equally distributed

and curled slightly outward. Eyelids there were no presence of discharges, no discoloration, and

lids close symmetrically with involuntary blinks. The bulbar conjunctiva appeared transparent,

the sclera color is white, and the palpebral conjunctiva was shiny, smooth and pink. There is no

edema in the lacrimal gland. Pupils is equal ( 4mm R, 4mm L ) The reaction to light

accommodation left and right is both brisk, the visual acuity near vision 12-14 inches away the

patient is able to recognize the object

g. Ears- the client’s auricles are symmetrical and have the same color with her facial skin. The

auricles are aligned with the outer canthus of the eye. When palpating for the texture, the auricles

are elastic. The pinna recoils when folded. External ear canal has some cerumen.
h. Nose - The client’s nose appeared symmetric, straight and uniform in color. There was no

presence of discharge or flaring. When lightly palpated, there was no tenderness in the sinus.

The mucosa is pink, the patency of the nose is both patent and Nasal Cavity is moist.

i. Mouth - The lips of the client are uniformly pink, moist, symmetric and have smooth texture.

The teeth and gums of the client have no discoloration of the enamels, no retraction of gums,

pinkish in color of gums.

j. Pharynx - The client’s position of the uvula is in midline, mucosa is pink, tonsils are not

inflamed and gag reflex is present.

k. Neck - the neck muscles are equal in size. The client showed coordinated, smooth head

movement with no discomfort. The lymph nodes are palpable, the trachea's position is midline,

and the thyroid gland is palpable.

l. Breast and Axilla - the client has symmetric breast and axilla, the contour is sagging and skin

characteristics are smooth.

j. Chest and lungs - The client shape of chest and lungs is AP to lateral ratio 1:2, symmetrical

movement and quiet, rhythmic and effortless respiration. Normal breath sounds without dyspnea.

i. Heart - The client heart sounds rate 74, rhythm is normal sinus.

k. Abdomen - The client abdomen appears smooth skin, uniform in color, symmetric contour

and abdominal movement caused by respirations. She has an operation scar about 14 cm long.

Bowel sounds are normal. Palpation is muscle guarding, the bladder is not distended, and the

liver is not palpable.

l. Upper Extremities - The client’s upper extremities of the patient appeared no scars and

lesions on both extremities, muscle strength is 5 normal strength and has normal muscle tone.

lymph nodes are not palpable.

 m. Lower Extremities - The client’s lower extremities of the patient appeared no scars and

lesions on both extremities, muscle strength is 5 normal strength and has normal muscle tone.

lymph nodes are not palpable. Presence of varicosities.

n. Genitalia - The client pubic hair is evenly distributed, Labia majora is symmetrical in size and

shape, Urethral Meatus is in midline position, Labium is soft and Clitoris has no lesions.

o. Rectum and Anus - The client perineum and saccrogeal, Coccygeal appears smooth, no

tenderness nor lesions. Anal muscosa is moist, no hair, lesions, and inflammations.

III. PHYSICAL ASSESSMENT (per member of family ) ( highlight the abnormal findings )

Client:Arienne

General Appearance: The client appears appropriately dressed and groomed, medium frame,

posture is stooped and smooth rhythmic gait. There is no obvious deformity nor odor.

Vital signs : Tempt: 34.1 BP: 128/75

RR: 93 PR: 93

b. Mental Status - The client is conscious as evidence by appropriately answering the questions

using simple words.

c. Skin - The client skin color is uniform in color, dry skin and smooth skin texture. She has a

good skin turgor and skin’s temperature is warm.

d. Nails - The client nail shape is convex curve, it is smooth and intact with the first layer of the

skin. When the nail is pressed between the fingers, the nail returns to its usual color within 3

seconds.

e. Head and Face -The client skull is proportionate to the body size, no tenderness and lesions in

the scalp. The hair is evenly distributed and the face appears symmetric left and right and has

symmetrical movement.
f. Eyes - The client eye condition is straight normal, has thick eyebrows, eyelids there were no

presence of discharges, no discoloration, and lids close symmetrically with involuntary blinks.

The bulbar conjunctiva appeared transparent, the sclera color is white, and the palpebral

conjunctiva was shiny, smooth and pink. There is no edema in the lacrimal gland. Pupils are

equal ( 4mm R, 4mm L ) The reaction to light accommodation left and right is both brisk, the

visual acuity near vision 12-14 inches away the patient is able to recognize the object.

g. Ears - the client’s auricles are symmetrical and have the same color with her facial skin.

When palpating for the texture, the auricles are elastic. The pinna recoils when folded. External

ear canal has some cerumen.

h. Nose - The client’s nose appeared symmetric, straight and uniform in color. There was no

presence of discharge. When lightly palpated, there was no tenderness in the sinus. The mucosa

is pink, the patency of the nose is both patent and Nasal Cavity is moist.

i. Mouth - The lips of the client are uniformly pink, moist, symmetric and have smooth texture.

The teeth and gums of the client have no discoloration of the teeth, no retraction of gums, pinkish

in color of gums.

j. Pharynx - The client’s position of the uvula is in midline, mucosa is pink, tonsils are not

inflamed, the posterior pharynx is not inflamed nor congested and gag reflex is present.

k. Neck - The neck muscles are equal in size. The client showed coordinated, smooth head

movement with no discomfort. The lymph nodes are palpable, the trachea's position is midline,

and the thyroid gland is palpable.

l. Breast and Axilla - The client has symmetric breast and axilla, the contour is flat and skin

characteristics are smooth. No masses and lesions in the breast.

 j. Chest and lungs - The client shape of chest and lungs is AP to lateral ratio, symmetrical

movement and quiet, rhythmic and effortless respiration. Breathing patterns are regular, breath

sounds are bronchovesicular, resonant sounds are heard.

i. Heart - The client heart sounds rate 93, rhythm is normal sinus.

k. Abdomen - The client abdomen appears unblemished skin, uniform in color, symmetric and

flat contour and abdominal movement caused by respirations. Bowel sounds are normal.

Palpation is muscle guarding, the bladder is not distended, and the liver is not palpable.

l. Upper Extremities - The client’s upper extremities appeared no scars and lesions on both

extremities, muscle strength is 5 normal strength and has normal muscle tone. lymph nodes are

not palpable.

m. Lower Extremities - The client’s lower extremities appeared no scars and lesions on both

extremities, muscle strength is 5 normal strength and has normal muscle tone. lymph nodes are

not palpable.

n. Genitalia - The client pubic hair is evenly distributed, Labia majora is symmetrical in size and

shape, Urethral Meatus is in midline position, Labium is soft and Clitoris has no lesions.

o. Rectum and Anus - The client perineum and saccrogeal, Coccygeal appears smooth, no

tenderness nor lesions. Anal muscosa is moist, no hair, lesions, and inflammations.

III. PHYSICAL ASSESSMENT (per member of family ) ( highlight the abnormal findings )

Client: Anne Stephanie

a. General Appearance: The client looks properly dressed and groomed, large frame, posture

is upright and smooth rhythmic gait. There is no obvious deformity nor odor.

Vital signs : Tempt: 34.3 BP:110/90

 RR:17 PR:88

b. Mental Status The client is conscious and cooperative as evidenced by appropriately

answering the questions using technical words.

c. Skin The client skin color is normal racial tone, sweaty skin and smooth skin texture. She has

a good skin turgor and is warm.

d. Nails the client nail shape is convex curve, it is smooth and intact with the first layer of the

skin. When the nail is pressed between the fingers, the nail returns to its usual color within 3

seconds.

e. Head and Face - The client skull is proportionate to the body size, smooth contour, no

tenderness and lesions in the scalp. The hair is evenly distributed and the face appears symmetric

left and right and has symmetrical movement. No present of infestation.

f. Eyes - The client eye condition is straight normal, has thin eyebrows, eyelids there were no

presence of discharges, no discoloration, and lids close symmetrically with involuntary blinks.

The bulbar conjunctiva appeared transparent, the sclera color is white, and the palpebral

conjunctiva was shiny, smooth and pink. There is no edema in the lacrimal gland. Pupils are

equal ( 3mm R, 3mm L ) The reaction to light accommodation left and right is both brisk, the

visual acuity near vision 12-14 inches away the patient is able to recognize the object.

g. Ears - the client’s auricles are symmetrical and have the same color with her facial skin. The

auricles are aligned with the outer canthus of the eye. When palpating for the texture, the auricles

are elastic. The pinna recoils when folded. External ear canal has some cerumen.

h. Nose - The client’s nose appeared symmetric, straight and uniform in color of the face. There

was no presence of discharge or flaring. When lightly palpated, there was no tenderness in the

sinus
i. Mouth - The lips of the client are uniformly pink, moist, symmetric and have smooth texture.

The teeth and gums of the client have no discoloration of the teeth, no retraction of gums, pinkish

in color of gums.

j. Pharynx - The client's position of the uvula is in midline, mucosa is pink, tonsils are not

inflamed, the posterior pharynx is not inflamed nor congested and gag reflex is present.

k. Neck - The neck muscles are equal in size. The client showed coordinated, smooth head

movement with no discomfort. The lymph nodes are palpable, the trachea's position is midline,

and the thyroid gland is palpable.

l. Breast and Axilla - The client has symmetric breast and axilla, the contour is round and skin

characteristics are smooth

j. Chest and lungs -The client shape of chest and lungs is AP to lateral ratio 1:2, symmetrical

movement and quiet, rhythmic and effortless respiration. Breathing patterns are regular, breath

sounds are bronchovesicular, resonant sounds are heard.

i. Heart - The client heart sounds rate 93, rhythm is normal sinus.

k. Abdomen - The client abdomen appears unblemished skin, uniform in color, symmetric

contour and abdominal movement caused by respirations. Bowel sounds are normal. Palpation is

muscle guarding, the bladder is not distended, and the liver is not palpable.

l. Upper Extremities - The client peripheral pulses are normal. appeared without scars and

lesions on both extremities, muscle strength is 5 normal strength and has normal muscle tone.

lymph nodes are not palpable.

m. Lower Extremities - The client peripheral pulses are normal. appeared without scars and

lesions on both extremities, muscle strength is 5 normal strength and has normal muscle tone.

lymph nodes are not palpable.

 n. Genitalia - The client pubic hair is evenly distributed, Labia majora is symmetrical in size and

shape, Urethral Meatus is in midline position, Labium is soft and Clitoris has no lesions.

o. Rectum and Anus - The client perineum and saccrogeal, Coccygeal appears smooth, no

tenderness nor lesions. Anal muscosa is moist, no hair, lesions, and inflammations.

III. PHYSICAL ASSESSMENT (per member of family ) ( highlight the abnormal findings )

Client: Anne Jillene

General Appearance: The client appears properly dressed and groomed, medium frame, posture is

upright, smooth rhythmic gait and maintained balanced . There is no obvious deformity nor odor.

Vital signs : Tempt:34.2 BP: 105/57

RR:16 PR: 83

b. Mental Status - The client is conscious as evidenced by her answering the questions using

technical words.

c. Skin - The client skin color is uniform in color, sweaty, smooth skin texture. She has a good

skin turgor and skin’s temperature is warm. Even the distribution of hair.

d. Nails - The client nail shape is convex curve, it is smooth and intact with the epidermis. When

a blanch test is done to Finger nail the finger nail returns to its usual color within 3 seconds.

e. Head and Face - The client skull is proportionate to the body size, smooth contour, no

tenderness, and lesions in the scalp. The hair is evenly distributed and the face appears symmetric

left and right and has symmetrical movement.

f. Eyes - The client eye condition is straight normal, has thin eyebrows, eyelids were no presence

of discharges, no discoloration, and lids close symmetrically with involuntary blinks. The bulbar

conjunctiva appeared transparent, the sclera color is white, and the palpebral conjunctiva was
shiny, smooth and pink. There is no edema in the lacrimal gland. Pupils are equal ( 3mm R, 3mm

L ) The reaction to light accommodation left and right is both brisk, the visual acuity near vision

12-14 inches away the patient is able to recognize the object.

g. Ears - the client’s auricles are symmetrical and have the same color with her facial skin. The

auricles are aligned with the outer canthus of the eye. When palpating for the texture, the auricles

are elastic. The pinna recoils when folded. External ear canal has some cerumen.

h. Nose - the client’s nose appeared symmetric, straight and the same color as the face. There

was no presence of discharge. When lightly palpated, there was no tenderness in the sinus. The

mucosa is pink, the patency of the nose is both patent and Nasal Cavity is moist.

i. Mouth - The lips of the client are uniformly pink, moist, symmetric and have smooth texture.

The teeth and gums of the client have no discoloration of the teeth, no retraction of gums, pinkish

in color of gums.

j. Pharynx - The client’s position of the uvula is in midline, mucosa is pink, tonsils are not

inflamed, the posterior pharynx is not inflamed nor congested and gag reflex is present.

k. Neck - The neck muscles are equal in size. The client showed coordinated, smooth and easy

head movement. The lymph nodes are palpable, the trachea's position is midline, and the thyroid

gland is palpable.

l. Breast and Axilla - The client has symmetric breast and axilla, the contour is flat and skin

characteristics are smooth.

j. Chest and lungs - The client shape of chest and lungs is symmetrical AP to lateral ratio 1:2,

symmetrical movement and quiet, rhythmic and effortless respiration. Breathing patterns are

regular, breath sounds are bronchovesicular, resonant sounds are heard.

i. Heart - The client heart sounds rate 83, rhythm is normal sinus.
 k. Abdomen - The client abdomen appears unblemished skin, uniform in color, symmetric

contour and abdominal movement caused by respirations. Bowel sounds are normal and have no

lesions or scars.

l. Upper Extremities - The client’s show no scars and lesions on both extremities, muscle

strength is 5 normal strength and has normal muscle tone. lymph nodes are not palpable.

m. Lower Extremities - The client’s show no scars and lesions on both extremities, muscle

strength is 5 normal strength and has normal muscle tone. lymph nodes are not palpable.

n. Genitalia - The client pubic hair is evenly distributed, Labia majora is symmetrical in size and

shape, Urethral Meatus is in midline position, Labium is soft and Clitoris has no lesions.

o. Rectum and Anus - The client perineum and saccrogeal, Coccygeal appears smooth, no

tenderness nor lesions. Anal muscosa is moist, no hair, lesions, and inflammations

IV. Results of laboratory/diagnostic and other screening procedures supportive of assessment

findings ( if there is any).

Provide discussion of the test results

- There were no results of the laboratory or diagnostic and other screening procedures, as the

family did not undergo examinations such as X-rays in the past six months, blood, urine or

stool tests in the past 2 weeks, and any other type of “diagnostic procedures”. However, it

was mentioned that the Mother underwent a surgery which is TAH BSO for her Myoma, but

it took place in the month of January.

24 Hr Dietary Recall ( Per member )

Time Food Amount Biochemical Appraisal

BREAKFAST (August 23)

Bacon 2 Stripes
 CHO = 23 g

Fried Egg CHON = 10 g

1 Piece
Fried Rice FAT= 20 g
1 Cup
Water Total kcal = 312 kcal
2 Glasses

Bangus
1 Serving
CHO = 42 g
Rice
LUNCH (August 23) 1 Cup
CHON = 12 g
Mung-bean rice
1 Serving
cake FAT= 8 g
2 Glasses
Water Total kcal = 291 kcal

PM SNACKS N/A N/A

CHO = 23 g
Fried Chicken 2 Pieces
DINNER (August 23) CHON = 10 g
Rice (fast food) 1 Cup
FAT= 6 g
Water 3 Glasses
Total kcal = 272 kcal

CHO = 41 g
Hotdog 2 Pieces
CHON = 16 g
Breakfast (August 24)
Fried Rice 1 Cup FAT= 32 g

Total kcal = 502 kcal

Water 2 Glasses
( Did not provide a Narrative discussion )

E. VALUES, HABITS, PRACTICES ON HEALTH PROMOTION, MAINTENANCE, AND

DISEASE PREVENTION

The X family has completed their vaccine immunization: BCG, DPT, Polio, AMV (Anti-

Measles vaccine), MMR (Measles, Mumps, Rubella), Flu vaccine, Pneumococcal and including

Covid-19 vaccine in each member of the family.

The X family eats nutritious foods, just like different kinds of vegetables, fish, juices, milk,

and fruits. But, according to Mrs. Agnes, they don't eat breakfast at the same time. It only depends on

what time each of the family members will wake up. If there are classes or work, they eat at a proper

time for each meal, but if there are no classes or work, there is no exact meal time. The Cruz family

also takes up vitamins or food supplements to have sufficient immunization, namely: Vitamin C and

Iron for the children; Mrs. Agnes takes up Calcium, Iron, and Vitamin C, whereas Mr. Cruz also

takes up Vitamin C, Iron, and Glucosamine as his food supplement.

No one in the family drinks alcoholic beverages frequently. Mr. Antonio drinks alcoholic

beverages only once a month and can only finish a minimal bottle or glass of alcoholic beverages

because Mr. Antonio drinks only by himself. Whereas Mrs. Agnes' children only drink alcoholic

liquors in a family gathering and prefer to drink lady's drink just like Smirnoff.
 In terms of sleep, the Xfamily doesn't have enough sleep. Since Mr. Cruz goes home late at

night because of his work, he only has 6 hours of sleep and then wakes up early in the morning to go

to his work. Mrs. X only has 6-7 hours of sleep and can sometimes have 8 hours of sleep due to her

age. Whereas for the children, it only depends if there are classes or not. Also, in the family, only Mr.

Antonio exercises regularly, whereas Mrs. Agnes only occasionally exercises because she

experiences pain while doing Zumba, which is why she stopped exercising.

According to Mrs. Agnes, they use slippers as their foot protection but don't use a mosquito

net and insect repellant. Only their middle child uses it because mosquitos frequently bite her.

The coping mechanism of the stress of the X family is stress eating, binge-watching Netflix

series, and sleeping all day. Mr. Antonio eats chocolate and nuts if he is experiencing stress. Whereas

the children tend to listen to Korean Pop music, watch Korean dramas, and sleep all day.

Mrs. Agnes did not share any activities in boosting her self-confidence because it is

confidential for her part. But, according to her, there will be a chance she is shy in showing herself,

but she is sure that her children are confident enough to show themselves.

As stated by Mrs. Agnes, they go to the health center near their home for a medical consultation. She

also remembers going there to obtain her children's weight when they were young. She doesn't

participate in their barangay's health teaching program. She also chooses not to join lifestyle-related

services such as Zumba because of her reluctance. Mrs. Agnes also said that she and her family don't

participate in the feeding programs.