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.
.

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

Presented by:

(Name of Students)

Presented to

Mr. Jomer V. Manalang, RN, MAN

Presented on

(Date)
 TABLE OF CONTENTS

I. INTRODUCTION ------------------------------------------------------------ 1
II. OBJECTIVES ----------------------------------------------------------------- 2
III. INITIAL DATA BASE --------------------------------------------------- 3-28
a. Family Structure, Characteristics, and Dynamics ---------------- 3
b. Genogram -------------------------------------------------------------------4
c. Socio – Economic and Cultural Characteristics ---------------------5
d. Home Environment --------------------------------------------------------6
e. Health Status of Each Family Member ------------------------- 8-40
A. Physical Assessment ------------------------------------ 8-16
B. 13 Areas of Assessment -------------------------------- 16-40
f. Nutritional Assessment ------------------------------------------------ 41
g. Values, Habits, Practices on Health Promotion --------------- 42-43
IV. FAMILY COPING INDEX ------------------------------------------- 44-46
V. Typology of Nursing Problems ------------------------------------------- 47
VI. Ranking of Prioritization of Identified Health Problems ------ 48- 51
VII. FAMILY NURSING CARE PLAN --------------------------------- 52-56
VIII. Summary, Evaluation, and Recommendations ------------------- 57-58
IX. DOCUMENTATION -------------------------------------------------- 59-62
X. GROUP PROFILE --------------------------------------------------------- 63
I. INTRODUCTION

Community is a collection of people who interact with one another and whose
common interests or characteristics form the basis for a sense of unity belongings
(Famorca 2006)

Public Health Nursing and Community Health Nursing refers to a service

rendered by a nurse with communities, groups, families, individuals at home, in
health centers, in clinics, in schools, in place of work for the promotion of health
centers, prevention of illness, care of the sick at home and rehabilitation. (Public
Cuervas, RN, MAN 2007)

Family is a basic unit in society, and is shaped by all forces surround it. Values
beliefs and customs of society influence the role and function of the family. (Maglaya
A. 2004)

Tarlac is landlocked province located in the Central Luzon region in the

Philippines. The province comprises three congressional districts and is subdivided
into 17 municipalities and 1 city. The province is situated in the heartland of Luzon,
in what is known as the central Plain covering the provinces of Region III and
pangasinan. Tarlac is also known as “Melting Pot”. The economy of Tarlac is
predominantly agricultural. It is among the biggest producers of rice and sugarcane.
Majority of Tarlaquenos are Roman Catholic which widely influence the strong
family ties within the family. Barangay Batang-batang is one of the barangay in
municipality of Victoria; it composed of 7 puroks with 323 households and has a
population of 1,356. It headed by their Brgy. Captain Hon. Joselito Narne. The place
is full of farm fields, there are some crops which are harvested around the area.
(Wikipedia)

We choose Rigor Family because my group mate’s and I felt that among the other
we visit they are the one who mostly need a nursing care like health promotion, health
maintenance and environmental sanitation, particular presence of vector. They need
to be educated to create awareness in regard to their health.

1
II. OBJECTIVES

General:

At the end of the semester, our group will be able to develop and understand the
family health condition and through that we will be able to formulate appropriate
nursing care plan, effective patient care and implement the proper nursing
intervention to solve the family health and the environment problems.

Specific:

1. To assess current condition of the chosen family.

2. To diagnose proper family nursing problems.
3. To plan possible solution from the identified problems.
4. To implement the planned nursing interventions for the identified health
problems.
5. To evaluate the family members in their health status improvement.

Family based:

1. Participate actively during home visits and assessment interviews.

2. Perform the health teachings taught by the student nurse.

2
 III. INITIAL DATA BASE
A. Family structure, Characteristics, and Dynamics

Family Position in Sex Age Civil Education

Member the family status attainment
Emiliano Father M 64y/o Married Highschool
Rigor Undergraduate
Brioleta Mother F 60y/o Married Highschool
Rigor Undergraduate
Rodriguez Youngest F 28y/o Married Highschool
‘y Rigor Daughter Undergraduate
Lito Son-in-Law M 29y/o Married Highschool
Rodriguez Undergraduate
Leandro Grandson M 10y/o Single Grade 5
Rigor
John Russell Grandson M 9y/o Single Grade 4
Rigor
Dexter Grandson M 6y/o Single Preparatory
Rodriguez
Princess Grand F 9mos Single Not attending
Dianne daughter school

Family Rigor is considered as an extended family. The family is composed of eight

members consisting of the husband and wife, their daughter and son-in-law and the
grandchildren. For 38 years, they have been living in Purok 7, Barangay Batang - Batang,
Victoria, Tarlac. Mr. and Mrs. Rigor are the ones who make major decisions for the family when
it comes to financial and emotional aspects.

Norms:

Family consists of person and their responsibilities within the family. A family structures
of parents and their offspring is known as nuclear family. The relatives of the nuclear families
such as grandparents or aunt and uncles, composed of extended family. In some families,
members are extended family live with the nuclear family may live in different areas, they
maybe in source of emotional or financial support for the family. In family, whose authority was
on the mother it was known as matriarchal and if both parents have authority deciding in their
family it is known as the egalitarian. (Nursing Practice in the Community, Fourth editor, Arceli
S. Maglaya)

Analysis: The Rigor family is considered as an extended family because the grandparents,
the parents, together with the grandchildren lives in one house. Both parents are responsible for
decision makings like in financial and health status which is considered as egalitarian.

3
 B. Genogram

Emiliano Brioleta Grand Father Grand Mother

A&W A&W A&W A&W

First Husband Abel A&W Lito A&W

John Russell Leandro A&W Dexter A&W Princess A&W

A&W

Male
Cardiac
Problem

Female

A&W – Alive and well

4
 C. Socio-Economic and Cultural Characteristics

Family Educational Occupation Ethnic Religion

member Attainment Background
Emiliano Rigor Highschool Farmer/ Brgy. Ilocano Methodist
Undergraduate Health Center
caretaker
Brioleta Rigor Highs chool Housewife Ilocano Methodist
Undergraduate
Abel Rodriguez High school Housewife Ilocano Methodist
‘y Rigor Undergraduate
Lito Rodriguez High school Construction Ilocano Methodist
Undergraduate
Leandro Rigor Grade 5 N/A Ilocano Methodist
John Russell Grade 4 N/A Ilocano Methodist
Rigor
Dexter Preparatory N/A Ilocano Methodist
Rodriguez
Princess Dianne Not attending N/A Ilocano Methodist
school

Mr. Emiliano Rigor together with Mr. Lito is the breadwinner for their family. Mr
Emiliano is a Brgy. Health Center and Part time Farmer while Mr. Lito is a construction worker
they are both under graduate of high school. Mrs. Rodriguez is the one who manage their budget.

Weekly Expenses of the family

Needs Estimated Amount (Monthly)

Foods Php. 1,000.00
Medicines Php. 1,500.00
Supplies Php. 1,000.00
Vices 0
Other expenses (such as electricity, allowance for Php. 1,500.00
school and transportation)
Total: Php. 5,000.00

Norms & Standards:

Filipino families had an annual income of 235 thousand pesos on average. In comparison,
their expenditure for the same year was 193 thousand pesos, on average. These figures translate

5
to an average annual savings of 42 thousand pesos per family (3,500/month). These estimates are
based on the result of the 2012 Family Income Expenditure Survey (FIES), and were computed
at prices in a year 2012. Considering the Valued at 180 thousand pesos at 2006 prices, while the
average annual family expenditure would be valued at 148 thousand pesos. (Nursing Practice in
the Community, Fourth Editor, Arceli S. Maglaya)

Analysis:

Because of the income from being the caretaker of the Brgy. Health Center is not enough
to sustain the needs of medication for they mother, they need to adjust from 2x a week to 3x a
month or sometimes she took medicine when need it most or when the symptoms attack.

D. Home Environment

The family reside near the sugar cane crops, According to Mrs. Rigor they own the land
and they have been living there for 38 years now. Their house is made of mainly light materials
which consists of wood and metal roof. There are some presence of sharp objects around the area
like rusty cans, rusty nails, broken glass from bottles, and the roof for the shelter of animals is
too low. They have two bedrooms, one for the adults and one for the children. There are some
stagnant water around the area, and there is a fish pond located around 10 – 12 meters near their
house. They use mosquito nets for protection. Their water supply is a communal deep well
located 4-5 meters away from the house. They have a gas stove inside the kitchen but they also
have a wood operated stove outside the house. They store their food in the kitchen table and
cover it to prevent flies or any rodents. They have their own toilet system located outside the
house and they also have a separate bathroom for bathing. They dump their wastes by burning it
in their backyard. They have an open drainage system. Their neighborhood is not congested and
it is a very quiet place. They do not have means of communication like cellphones, computers
and the internet available but they do have television for some information like the news. They
do have some medicines and vitamins for health maintenance. Their means of transportations are
tricycle, bus and jeepneys.

TOTAL WINDOW OPENING

W1 = 0.61 x 0.91 = 0.56

TWO = 0.56 sq. m

TOTAL FLOOR AREA (TFA)

TFA= L X H

8.96 x 2.29 = 20.52 sq. m

6
 TOTAL SPACE REQUIREMENT (TSR)

LEGEND:

TSR>TFA=not overcrowded

TFA>TSR=Overcrowded

3 adults x 2.5 = 7.5

4 children x 1.26 = 5.04

TSR: 12.54 – OVERCROWDED

VENTILATION (V)

Above 20% - Satisfactory

18%-19% - Fair

Below 17% - Poor

(Nursing Care in the community 4th edition by Arceli S. Maglaya)

𝑇𝐹𝐴
Ventilation : 𝑇𝑆𝑅 x 100

2.5
x 100 = 20 SATISFACTORY
12.5

NORMS:

According to Maglaya book 4th edition typical normal family living in a proper housing is
not over crowded 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 Maglaya)

ANALYSIS:
As a conclusion, both assessment have a sufficient ventilation and enough living space.
They also have certain presence of health threat and some health deficiency.

7
A. Health Status of each family member
a. Physical Assessment

Leandro Rigor
10 y/o

Area of assessment Findings Norms Analysis

>Skin His skin has a presence Must be smooth and soft, oily/ Based on the findings
of small scars and no moist and no lesion. although he have a scars
- Inspection presence of lesion. The (Maternity and Pediatric the skin is normal
-Palpation over-all texture of his Nursing by Scott and Susan)
skin is smooth. When
pinched, it goes back
immediately. The color
is brown.
>Hair & Nails His hair are evenly Must be evenly distributed, Based on the findings he
distributed, smooth and smooth and soft, course and has a normal condition
-Inspection color black there no fine and no lice. hair and nails
presence of dandruff The nails must be transparent,
Nails are pinkish in pinkish, firm, smooth, and no
color, intact and there is convex with surrounding
no presence of smooth cuticle, intact and
inflammation. without inflammation & has
Analysis: good hygiene. (Maternity &
. Pediatric Nursing by Scott and
Susan)

>Head His head and face are The scalp must be oily or Based on the assessment
-Inspection symmetrical, there is no moist, smooth and no of head he has normal
-Palpation presence of lesion in his dandruff, no lesion (Maternity findings because there no
scalp and there is no lice & Pediatric Nursing by Scott presence of lesion, lice

8
 and dandruff. and Susan) and dandruff.

>Eyes Findings: They must be parallel to each Based on the findings

-Inspection There is ocular other, can raise and lower both eyes are normal
movement on his eyes eyebrows symmetrically the because he can see
they constrict and dilate,pupil is equally round and normally and clearly
sclera is pinkish, his reactive to light and
eyelashes and eyebrows accommodation. (Maternity &
are evenly distributed. Pediatric Nursing by Scott and
Susan)
>Ears Findings: The ears must be the same Based on the finding the
-Inspection His ears are not color as the face, and the color of his ears are
-Palpation symmetrical the color is auricles are equal size and normal but there is a
the same as the face. But level to each other, no presence of earwax so we
there is a presence of presence of discharge or any need to do to health
earwax on his ears. foul odor. (Maternity & teaching about that.
Pediatric Nursing by Scott and
Susan)
>Nose Findings: The nose must be patient, has Based on findings his
-Inspection His nose is patent and the same color as the face, nose is normal.
-Palpation has the same color as the smooth, symmetric, nasal
face, there is no structure is firm stable, and no
tenderness. discharge. (Maternity &
Pediatric Nursing by Scott and
Susan)
>Mouth Findings: It should be pink, moist, Based on the assessment
-Inspection His lips is pinkish, symmetrical, smooth, and soft the findings are normal
smooth and and no lesions. Gums should even though there is
symmetrical, there is no be pinkish in color, moist and cavity on his teeth.
presence of lesion in his hard, intact, no lesion. Must
mouth. The tongue is be red in color, slightly rough
pinkish. His teeth has a on the top surface at the
cavity. midline and can move freely.

9
 (Maternity & Pediatric
Nursing by Scott and Susan)
>Thorax, Lungs, and Abdomen Findings: The chest well must be intact Findings:
-Inspection The chest wall is intact. with no tenderness and His chest wall is intact.
-Auscultation No tenderness and masses. There’s a full and No masses and
-Palpation masses. And has quiet, symmetric expansion and the tenderness. The
-Percussion rhythmic and effortless thumbs separate 2-3 cm breathing pattern is
breathing. The abdomen during deep, has quiet, normal. During palpation
has no lesion and no rhythmic and effortless there is no pain stated by
pain during palpation. respirations. Dexter, and has no
The abdomen has an lesions.
Analysis: unblemished skin and is
The findings during uniform in color. The Analysis:
assessment is normal. abdomen has a symmetric The findings is normal.
contour, there were symmetric
movement. (Maternity &
Pediatric Nursing by Scott and
Susan)
>Extremities Findings: The extremities should be Based on the assessment
-Inspection The extremities were complete, symmetrical in size the findings are normal
-Palpation complete and equal in and length. No clubbing of
size and length and there fingers and nails should have
is no presence of scars. a presence of cyanosis, palms
must be normal in color and
texture. (Maternity &
Pediatric Nursing by Scott and
Susan)

10
John Russell Rigor
9 y/o
Area of assessment Findings
>Skin There are presence of
lesions and there is
- Inspection increased in size. The
-Palpation temperature is even.
>Hair & Nails The hair is smooth and
there is no presence of
-Inspection lice and dandruff and
evenly distributed. Nails
are pinkish in color and
intact the capillary refill
comes back after 3
seconds.
>Head The head has no mass
-Inspection and no presence of lice
-Palpation and dandruff. His is
symmetrical to his face.
>Eyes The movement of his
-Inspection eyes are normal, and has
ocular movement.
Eyelashes and eyebrows
are evenly distributed.
The pupil is equally
11
Norms Analysis
Must be smooth and soft, oily/ The skin of John Russell
moist and no lesion. is not normal but there
(Maternity and Pediatric are presence of lesions
Nursing by Scott and Susan) that is increasing in size.
Must be evenly distributed, Based on findings the
smooth and soft, course and hair and nails of John
fine and no lice. Russell is normal.
The nails must be transparent,
pinkish, firm, smooth, and no
convex with surrounding
smooth cuticle, intact and
without inflammation & has
good hygiene. (Maternity &
Pediatric Nursing by Scott and
Susan)
The scalp must be oily or Based on the assessment
moist, smooth and no the findings are normal
dandruff, no lesion (Maternity
& Pediatric Nursing by Scott
and Susan)
They must be parallel to each Based on findings, both
other, can raise and lower eyes are normal.
eyebrows symmetrically the
pupil is equally round and
reactive to light and
accommodation. (Maternity &
 round and reactive to Pediatric Nursing by Scott and
round. Susan)
>Ears The ears are The ears must be the same Based on finding both
-Inspection symmetrical to the face color as the face, and the ears are normal but there
-Palpation and they are equal in auricles are equal size and is earwax noted.
size. There is a presence level to each other, no
of earwax. presence of discharge or any
foul odor. (Maternity &
Pediatric Nursing by Scott and
Susan)
>Nose His nose is patent and The nose must be patient, has Based on our assessment,
-Inspection has the same color as the the same color as the face, the findings are normal.
-Palpation face and symmetrical to smooth, symmetric, nasal
the face. There is no structure is firm stable, and no
presence of discharge. discharge. (Maternity &
Pediatric Nursing by Scott and
Susan)
>Mouth The lips and tongue are It should be pink, moist, Based on our
-Inspection pinkish, smooth and symmetrical, smooth, and soft assessments, the findings
there is no presence of and no lesions. Gums should are normal and there are
lesions. Gums are be pinkish in color, moist and poor alignment of teeth
pinkish and clean. There hard, intact, no lesion. Must noted.
is dental carries. be red in color, slightly rough
on the top surface at the
midline and can move freely.
(Maternity & Pediatric
Nursing by Scott and Susan)
>Thorax, Lungs, and Abdomen His chest wall is intact. The chest well must be intact Findings are normal.
-Inspection There is no presence of with no tenderness and .
-Auscultation mass and edema. There masses. There’s a full and
-Palpation is no difficulty of symmetric expansion and the
-Percussion breathing. During thumbs separate 2-3 cm
palpation, the abdomen during deep, has quiet,

12
 is soft and not tender. rhythmic and effortless
respirations.
The abdomen has an
unblemished skin and is
uniform in color. The
abdomen has a symmetric
contour, there were symmetric
movement. (Maternity &
Pediatric Nursing by Scott and
Susan)
>Extremities The extremeties are The extremities should be Based on the findings, he
-Inspection symmetrical and equal complete, symmetrical in size is considered normal..
-Palpation in size and length. There and length. No clubbing of
is no presence of edema. fingers and nails should have
She can ambulate freely. a presence of cyanosis, palms
. must be normal in color and
texture. (Maternity &
Pediatric Nursing by Scott and
Susan)

Dexter Rigor

6 y/o

Area of assessment Findings Norms Analysis

>Skin His skin has a presence Must be smooth and soft, oily/ The skin has presence of
of lesions. The over-all moist and no lesion. lesions.
- Inspection texture of his skin is (Maternity and Pediatric
-Palpation smooth. The color is Nursing by Scott and Susan)
brown.

13
>Hair & Nails His hair is smooth and Must be evenly distributed, :Based on the findings
color black. There is no smooth and soft, course and the hair and nails of
-Inspection presence of lice and fine and no lice. Dexter is normal.
dandruff. Nails are The nails must be transparent,
pinkish in color and pinkish, firm, smooth, and no
intact the capillary refill
convex with surrounding
comes back after 3 smooth cuticle, intact and
seconds. without inflammation & has
good hygiene. (Maternity &
Pediatric Nursing by Scott and
Susan)
>Head His head is symmetrical, The scalp must be oily or Based on the findings the
-Inspection and there is no presence moist, smooth and no head of Dexter is normal
-Palpation of lice and dandruff. dandruff, no lesion (Maternity because there is no
There is no lesions. & Pediatric Nursing by Scott lesions, lice and dandruff
and Susan) also.
>Eyes The movement of his They must be parallel to each Based on the findings
-Inspection eyes are normal, they other, can raise and lower both eyes are normal
constrict together and eyebrows symmetrically the because they are
dilate, eyelashes and pupil is equally round and constricting together.
eyebrows are evenly reactive to light and
distributed. accommodation. (Maternity &
Pediatric Nursing by Scott and
Susan)
>Ears His ears are not The ears must be the same Based on the findings the
-Inspection symmetrical and the color as the face, and the both ears are normal.
-Palpation color is the same is his auricles are equal size and
face. There is no level to each other, no
earwax. presence of discharge or any
foul odor. (Maternity &
Pediatric Nursing by Scott and
Susan)
>Nose His nose is patent and The nose must be patient, has Based on the findings his

14
-Inspection has the same color as the the same color as the face, nose is normal.
-Palpation face. There is no smooth, symmetric, nasal
presence of discharge structure is firm stable, and no
and tenderness. discharge. (Maternity &
Pediatric Nursing by Scott and
Susan)
>Mouth His lips is dark in color, It should be pink, moist, Based on the
-Inspection tounge and gums are symmetrical, smooth, and soft assessments, the findings
pinkish and clean. There and no lesions. Gums should are normal.
is no presence of be pinkish in color, moist and
lesions. The teeth are hard, intact, no lesion. Must
complete and no cavity. be red in color, slightly rough
on the top surface at the
midline and can move freely.
(Maternity & Pediatric
Nursing by Scott and Susan)
>Thorax, Lungs, and Abdomen His chest wall is intact. The chest well must be intact The findings is normal.
-Inspection No masses and with no tenderness and
-Auscultation tenderness. The masses. There’s a full and
-Palpation breathing pattern is symmetric expansion and the
-Percussion normal. During thumbs separate 2-3 cm
palpation there is no during deep, has quiet,
pain stated by Dexter, rhythmic and effortless
and has no lesions. respirations.
The abdomen has an
unblemished skin and is
uniform in color. The
abdomen has a symmetric
contour, there were symmetric
movement. (Maternity &
Pediatric Nursing by Scott and
Susan)
>Extremities The extremities are The extremities should be Based on the findings it

15
-Inspection complete and equal in
-Palpation sizes and length. There
is no presence of edema.
And there is no lesions.
a. 13 Areas of Assessment
Emiliano N. Rigor
64y/o
Area of assessment Findings
Social Status As he stated, when they
have a misunderstanding
they settle it by talking to
each other. Because of
his work, he get more
socialized, not only with
their neighbor, but with
some people with other
puroks. Because he’s
working, he spent less
time with his family but
he said that as much as
possible, he guides his
grandchildren in their
life. His hobby is to plant
different plants. He also
16
complete, symmetrical in size is normal.
and length. No clubbing of
fingers and nails should have
a presence of cyanosis, palms
must be normal in color and
texture. (Maternity &
Pediatric Nursing by Scott and
Susan)
Norms Analysis
Social status includes He has harmonious
family relationship with their
relationships/friendships neighbors and her family.
.
that state the patient’s
support system in time of
stress and in time of need. It
meets a fundament human
need for social ties, making
life less stressful and social
support buffers the negative
effects of stress, thus
indicating indirectly
contributing to good health
outcomes. (Friedman and

Mental Status
> General Appearance and Behavior
>Level of consciousness and orientation
Norms:
The level of consciousness and orientation
determine whether a person is aware of
things that are happening (Kozier 2004)
go to church of The Smith 1988)
United Methodist every
Sunday
His clothes is not clean The content of the patient’s He has a good education
because he has been to background based on
message should make sense.
work. And his fingernails normal state. His unclean
and toe nails looks dirty, The ability to read and write because of the cloth his
he has a dry skin and a should match the patient’s wearing as well as his
dirty hair, he’s able to educational level. The finger nails and toe nails
write and read and patient should be able to and he doesn’t have a
cooperate during the correctly respond to normal state of skin and
interview. He doesn’t questions and to identify all appendages
look tired even he is
the objects as requested.
from work and was able
to accompany us when The patient should be able
we do some assessment to evaluate and act
to their surroundings. appropriately in situations
requiring judgment. (Health
Assessment and Physical
Examination 3rd Edition by
Mary Ellen Zator Estes)
He was cooperative The level of consciousness He was able to answer our
during interview; he also and orientation determine questions correctly. These
respond to our question whether a person is aware are major determinants
correctly, such as what is that indicate his mental
of things that are happening
his name, where does he capabilities are functioning
reside from, where he (Kozier 2004) well
works and other
17
 questions regarding the
data we needed from
their family.

>SPEECH He was able to

As per assessing him his Patient’s speech is communicate with us
way of talking is clear understandable, in moderate clearly(we didn’t had a
loud enough and pace and in clear tone. hard time understanding
understandable what he was saying)
Thoughts are logical
(Kozier 2004)
Emotional Status He said whenever they The old adult is in the stage He has a good control of
have misunderstandings where an issue of ego his emotion or feelings
at home they usually talk integrity vs. despair arises. with the help of his
with each other about it family( as a source of his
Integrity manifests with
to settle things out. He strength)
also stated things out that wisdom and feelings of
when his stressed he satisfaction with one’s life
watch television shows while despair arises from
or find things to do. remorse about what could
have been. The presence of
despair causes life to be
viewed as meaningless.
(Nursing CEU.com: The
process of human
development)
Sensory Perception

Sense of sight His eyes is brown T he client who has a visual He has a normal visual

18
 without swelling or acuity of 20/20 is test: was able to read what
lesions. His sclera is considered to have normal we asked him to read. His
white when light is being visual acuity. The eyes must eyes are symmetrical no
directed to his eyes his lesion or swelling
be symmetrical during the
pupil constrict and accessed, papillary
dilated when the light has six cardinal gazes test. The response is normal
been taken away. His sclera should be white with
visual acuity has been some small blood vessels.
accessed by performing Papillary constrictions
near visual test but should occur when struck
letting him read words by light. (Health
and phrases being
Assessment and Physical
pointed from a book
which is 14 inches away Examination, Mary Ellen
from him and was able to Zator Estes)
read it right. Both eyes
moves symmetrically in
each 6 cardinal
movements.
Conjunctivas aren’t pale.

We let him taste a little Taste is intact in the

Sense of Taste bit of sugar and coffee posterior one third of the His taste buds are
while his eyes are close tongue. (Health Assessment functioning well.
for him to know the
and Physical Examination,
difference and he was
able to taste it. Mary Ellen Zator Estes)

19

His ear are symmetrical
Sense of hearing in shape and has the
same color with the skin.
There’s no redness or
swelling on his ear.
There was no complain
of pain upon the
assessment of his ear. No
tenderness and redness
noted. During whisper
test at a distance of 2 feet
he was able to repeat the
words. There was a small
amount of ear wax seen
in both ear
Sense of Smell His nose is located in the
midline of the face and
hasn’t noted any swelling
or masses. Both of his
nostrils are patted and
cilia project into the
cavity of his internal
mucosa is little pale
without swelling and he
was to identify the
different odor of alcohol
20
For auditory acuity, the
patient should be able to
repeat the words whispered
from a distance of two feet.
(Health Assessment and
Physical Examination, Mary
Ellen Zator Estes)
Nose must be symmetrical
and along of the face. Each
nostril must be patent and
recognize the smell of an
object. (Health Assessment
and Physical Examination,
Mary Ellen Zator Estes)
Based on norms his
auditory accuracy is
normal. No signs of ear
infection
Analysis:
Her taste buds are
functioning well.
He has a good olfactory
function since he was able
to recognize everything we
let his nose sniff while his
eyes were close. He also
has no sign of infection
 cologne and coffee.

The skin contains receptors

Tactile He was able to identify Based on the norms and
for pain, touch, pressure and findings that assessed, her
things we let her hold
while her eyes were close temperature. These sense of touch is
(such as pen, phone, and receptors originate in the functioning well.
notebook). dermis and terminate as
either free nerve endings
throughout the skin’s
surface or as special touch
receptors that are
encapsulated and found
predominantly in the
fingertips and lips. Sensory
signals that help determine
precise locations on the skin
are transmitted along rapid
sensory pathways, and less
distinct signals such as
pressure or poorly localized
touch are sent via slower
sensory pathways. ( Health
Assessment and Physical
Examination, Estes 2006)
Motor Stability The patient remains erect His has normal motor
During assessment, he and balanced during all stability. No signs of
was standing in upright stages of gait. The patient kyphosis, lordosis, or
position. When walking scoliosis. Has a complete
should be able to transfer
there is no staggering and set of extremities and was
21
 he walks straight; using easily to various positions. able to do ROM..
his all extremities and There should be absence of
was able to do active discomfort during range of
range motion(ROM)
motion exercise. (Health
Assessment and Physical
Examination, Mary Ellen
Zator Estes)
st
Body Temperature 1 Visit: 36.7 ⁰C Normal axillary temperature His temperature is within
nd
2 visit: 37.0 ⁰C is within 36.4⁰C to 37.4⁰C. the normal range during
3rd visit: N/A (Health Assessment and the assessments based on
the findings and norms
Physical Examination 3rd
stated
edition by Mary Ellen Zator
Estes
Respiratory Status Findings: Normal respiratory rate for Respiratory rate is within
His respiratory rate is 23 adults is 12-20cpm. the above normal range.
cpm. Her shoulders are at Average is 18. In terms of No signs of difficulty of
the same level. No breathing.
pattern, normal respirations
superficial veins visible.
he is also not using must be regular and even in
accessory muscles while rhythm. The normal depth
breathing. Breathing is of respirations is non-
not exaggerated, and exaggerated and effortless.
respirations are regular (Health Assessment and
and even in rhythm. Physical Examination 3rd
edition by Mary Ellen Zator
Estes)
Circulatory Status His pulse rate is 98 bpm The normal cardiac rate for His cardiac rate is in the
and has a blood pressure an adult is 60-100 beats per normal range. The patient
of 150/90mmHg. His minute while the normal is hypertensive. And
capillary refill time is 3 blood pressure is normal capillary refill.

22
 seconds. 120/800mmHg. (Kozier,
Fundamentals of Nurisng
2nd visit: 135/90mmHg 7th Edition)
Nutritional Status He said that he usually According to Health Asian normal range of 20-25,
drinks 8 glasses of water Diet Pyramid, there should indicating that she’s
a day. He eats 3 times a be a daily intake of rice, healthy, especially without
day that usually consist vices.
grains, bread, fruits and
of rice, vegetables and
sometimes fish, meat and vegetables; optional daily
cassava. He also said that for fish, shellfish and dairy
he doesn’t smoke and products; weekly for
drink alcohol. He is sweets, eggs and poultry,
weighin 140lbs and and monthly for meat.
standin 5’6 feet tall. She There should be an
has BMI of: 22.6
increased intake of a wide
variety of fruits and
vegetables. Include in the
diet foods higher in
Vitamins C and E, and
Omega-3 fatty acid rich
foods. (www.webmd.com)
Elimination Status Findings: Normal bowel movement of His elimination status is
He said that he usually a person must be 1 to 2 normal. No abnormalities
pees 3 times a day. With times a day and voiding in 3 of the urine or stool.
regards with his bowel to 4 times a day with an
movement he defecates output of 1200 to 1500mL a
once a day and said day. A normal stool is
that’s it’s not a brown in color and well
loose/watery. Urine color formed, urine is clear to
assessed was yellowish yellowish in color.
as per Mr. Rigor and (Fundamentals of Nursing,
doesn’t have a foul odor. Kozier, 2007)

23
 Analysis:

Reproductive Status Findings: Based on the interview/

He has stated that he had assessment he has normal
his circumcision when he reproductive status and he
was 11 years old. As per has no sexually
him, he has no history of transmitted disease noted.
sexually transmitted .
infections/disease.

Sleep-rest Pattern He Usually sleeps Sleep refers to altered He has a normal sleeping
9:00Pm and wakes consciousness with general pattern based on the norms
5:00Am and eat slowing of physiological as stated and the number
breakfast before going to process while rest refers to of hours of sleep that she
farm. Whenever he have relaxation and calmness, stated she’s taking.
leisure time, he both mental and physical. A
sometimes usually typical sleeper will pass
spends it with his family through 7 to 9 hours of
especially in night. sleep and take a rest using
some relaxation activities
such as reading, telling
stories and others. (Nursing
Fundamentals by Rick
Daniels)
State of Skin Appendages He has fair complexion The palpebral conjunctiva Based on norms he doesn’t
and warm to touch skin. should appear pink and moist. meet the standard on his
He have so many callus Normally, the skin is a uniform skin and nails
in the both toe and also whitish pink or brown color,
dirty. Have tiny wounds. depending on the patient’s
His hair is black in color race. Normally, the nails
and not oily. Fingernails have apink cast in light-
and toenails are skinned individuals and

24
 untrimmed and unclean. are brown in dark-skinned
individuals.
(Healthassessment and physical
examination 3rd edition by
Mary Ellen Zator Estes)

Brioleta Rigor
Age: 60
Area of assessment Findings
Social Status As she stated when they have a
misunderstanding they settle it
by talking with each other.
Because of her current
condition, she’s less socialize
with their neighbors. She
spends more time in resting
than to doing some work. But
she’s able to be with their
grandchildren when their
mother is not around.
Mental Status
Norms Analysis
Social status includes family She has harmonious
relationships/friendships that relationship with their
state the patient’s support neighbor and her family
system in time of stress and in
time of need. It meets a
fundament human need for
social ties, making life less
stressful and social support
buffers the negative effects of
stress, thus indicating indirectly
contributing to good health
outcomes. (Friedman and
Smith 1988)

> General Appearance and Her clothes is clean but looks The content of the patient’s She has a good education
Behavior dirty because she wearing an message should make sense. background based on normal

25
 old clothes. She has a neat
finger nails and toe nails but a
dirty hair and she doesn’t have
a dry skin. She’s able to write
and read and cooperate during
the interview. She doesn’t look
>Level of consciousness and She was cooperative during
orientation interview; she also respond to
our question correctly, such as
what is her name, what day it
is, where she’s from, where
does she live and other
question regarding our data
that we need from our family
case study.
>SPEECH As per assessing her, her way Patient’s
of talking is clear and loud understandable, in moderate
The ability to read and write state. She looks dirty because
should match the patient’s of the old cloth she’s wearing.
educational level. The patient She has a normal state of skin
should be able to correctly and appendages based on
respond to questions and to norms stated. She has a dirty
identify all the objects as hair
requested. The patient should
be able to evaluate and act
appropriately in situations
requiring judgment. (Health
Assessment and Physical
rd
Examination 3 Edition by
Mary Ellen Zator Estes)
The level of consciousness and She was able to answer all our
orientation determine whether a questions correctly. This are
person is aware of things that major determinants that
are happening (Kozier 2004) indicate her mental capabilities
are functioning well
speech is She was able to communicate
with us clearly( we didn’t had
a hard time understanding
26
 enough and understandable
Emotional Status As the mother in the houses
she usually settles things out
by talking about their problem
together. She said when she’s
being scolded by her husband
she usually goes out to his
friends and plays with them as
her diversion.
Sensory Perception
Sense of sight His eyes is brown without
swelling or lesions. His sclera
is white when light is being
directed to his eyes his pupil
constrict and dilated when the
light has been taken away. His
visual acuity has been accessed
by performing near visual test
but letting him read words and
phrases being pointed from a
book which is 14 inches away
from him and was able to read
pace and in clear tone. what she was doing)
Thoughts are logical (Kozier
2004)
The old adult is in the stage She has a good control over
where an issue of ego integrity her emotions and also has a
vs. despair arises. Integrity good coping mechanisms since
manifests with wisdom and they settles their problem
feelings of satisfaction with
one’s life while despair arises
from remorse about what could
have been. The presence of
despair causes life to be viewed
as meaningless. (Nursing
CEU.com: The process of
human development)
The client who has a visual She has a normal visual test:
acuity of 20/20 is considered to was able to read what we
have normal visual acuity. The asked her to read, her eyes
eyes must be symmetrical are symmetrical no lesion or
during the six cardinal gazes swelling accessed, papillary
test. The sclera should be white response is normal
with some small blood vessels.
Papillary constrictions should
occur when struck by light.
(Health Assessment and
Physical Examination, Mary
Ellen Zator Estes)
27
 it right. Both eyes moves
symmetrically in each 6
cardinal movements.
Conjunctivas aren’t pale

Sense of Taste We let her taste a little bit of Taste is intact in the posterior Her taste buds are functioning
sugar and coffee while her eyes one third of the tongue. (Health well.
are close for her to know the Assessment and Physical
difference and she was able to Examination, Mary Ellen Zator
taste it. Estes)

Sense of hearing Her ears are symmetrical in For auditory acuity, the patient Based on norms her auditory
shape and has the same color should be able to repeat the accuracy is normal. No signs
with the skin. There was no words whispered from a of ear infection.
redness swelling on her ear. distance of two feet. (Health
There was no complain of pain Assessment and Physical
upon the assessment of Examination, Mary Ellen Zator
hearing. No tenderness and Estes)
redness noted. During whisper
test at a distance of 2 feet she
was able to repeat the words.
There was a small amount of
ear wax seen in both ear

Sense of Smell Her nose is located in the mid Nose must be symmetrical and She has a good olfactory

28
 line of the face and hasn’t
noted any swelling or masses.
Both of her nostrils are patted
and cilia project into the cavity
of her internal mucosa is little
pale without swelling and she
was to identify the different
odor of alcohol cologne and
coffee.
along of the face. Each nostril
must be patent and recognize
the smell of an object. (Health
Assessment and Physical
Examination, Mary Ellen Zator
Estes)
function since she was able to
recognize everything we let
his nose sniff while her eyes
were close. also she has no
sign of infection

Tactile She was able to identify things
we let her hold while her eyes
were close (such as pen,
phone, and notebook).
The skin contains receptors for Based on the norms and
pain, touch, pressure and findings that assessed, her
temperature. These receptors sense of touch is functioning
originate in the dermis and well.
terminate as either free nerve
endings throughout the skin’s
surface or as special touch
receptors that are encapsulated
and found predominantly in the
fingertips and lips. Sensory
signals that help determine
precise locations on the skin
are transmitted along rapid
sensory pathways, and less
distinct signals such as pressure
or poorly localized touch are
sent via slower sensory
pathways. ( Health Assessment

29

Motor Stability During the assessment, she
was standing upright by their
balcony, the shoulders are
symmetrical in height. When
walking there is no also
staggering and walks straight;
with complete extremities and
was able to do active range of
motion (ROM)
Body Temperature 1st Visit: 36.5 ⁰C.
2nd Visit: 37.1 ⁰C
Respiratory Status Her respiratory rate is 29 cpm.
Above normal Her shoulders
are at the same level. No
superficial veins visible. he is
also not using accessory
muscles while breathing.
Breathing is not exaggerated,
and respirations are regular and
even in rhythm.
and Physical Examination,
Estes 2006)
The patient remains erect and She has normal motor
balanced during all stages of stability. No signs of kyphosis,
gait. The patient should be able lordosis, or scoliosis. Has a
to transfer easily to various complete set of extremities
positions. There should be and was able to do ROM.
absence of discomfort during
range of motion exercise.
(Health Assessment and
Physical Examination, Mary
Ellen Zator Estes)
Normal axillary temperature is Her temperature is within the
within 36.4⁰C to 37.4⁰C. normal range during the
(Health Assessment and assessments based on the
Physical Examination 3rd findings and norms stated
edition by Mary Ellen Zator
Estes
Normal respiratory rate for Respiratory rate is within the
adults is 12-20cpm. Average is above normal range. No signs
18. In terms of pattern, normal of difficulty of breathing.
respirations must be regular
and even in rhythm. The
normal depth of respirations is
non-exaggerated and effortless.
(Health Assessment and
Physical Examination 3rd
edition by Mary Ellen Zator
Estes)
30
Circulatory Status Her pulse rate is 83 bpm and
has a blood pressure of 90/70.
Her capillary refill time is 3
seconds
2nd Visit: 100/70 Bpm
Nutritional Status She said that he usually drinks
8-10 glasses of water a day.
She eats 3 times a day that
usually consist of rice,
vegetables and sometimes fish,
meat and cassava. she also said
that she doesn’t smoke and
drink alcohol. She is weighing
105lbs and standing 5’0 feet
tall. She has BMI of 20.5
Elimination Status She said that he usually pees 3
times a day. With regards with
her bowel movement she
defecates once a day and said
that’s it’s not a loose/watery.
Urine color assessed was
yellowish as per Mrs. Rigor
and doesn’t have a foul odor.
The normal cardiac rate for an Her cardiac rate is in normal
adult is 60-100 beats per range and the blood pressure is
minute while the normal blood normal. The capillary refill is
pressure is 120/800mmHg. normal.
(Kozier, Fundamentals of
th
Nurisng 7 Edition)
According to Health Asian Diet Her BMI is within the normal
Pyramid, there should be a range of 20-25, indicating that
daily intake of rice, grains, she’s healthy, especially
bread, fruits and vegetables; without vices.
optional daily for fish, shellfish
and dairy products; weekly for
sweets, eggs and poultry, and
monthly for meat. There should
be an increased intake of a
wide variety of fruits and
vegetables. Include in the diet
foods higher in Vitamins C and
E, and Omega-3 fatty acid rich
foods. (www.webmd.com)
Normal bowel movement of a Her elimination status is
person must be 1 to 2 times a normal. No abnormalities of
day and voiding in 3 to 4 times the urine or stool.
a day with an output of 1200 to
1500mL a day. A normal stool
is brown in color and well
formed, urine is clear to
yellowish in color.
(Fundamentals of Nursing,
Kozier, 2007)
31
Reproductive Status She has stated that her first
menstruation is at the age of 13
and her last menstruation/ she
menopaused at the age of 48.
She got pregnant when she’s
17 years old. And she has no
history of sexually transmitted
infection/disease.
Sleep-rest Pattern She usually sleeps 9:00Pm and
wakes 5:00Am to cook for her
husband and for other member
also. Whenever she have
leisure time, she sometimes
usually spends it playing with
her grandchildren, and
sometimes tale a nap.
State of Skin Appendages She has fair complexion and
warm to touch skin. No signs
of infection such as redness or
swelling, no rashes and even
open wounds. Her hair is black
in color and not oily.
Fingernails and toenails are
untrimmed and unclean.
Menarche, which is the first Based on the interview/
menstruation occur at assessment she has a normal
an average age of onset between reproductive status. And has
9 to 17 years old. Pregnancy may
no sexually transmitted disease
occur from stage of menarche up
to cessation of menstrual noted.
period.
Menopause occurs with age
range of 40 to 55.
(Maternal and Child Health
nursing fourthEdition by
Pilliterri)
Sleep refers to altered She has a normal sleeping
consciousness with general pattern based on the norms as
slowing of physiological stated and the number of hours
process while rest refers to
of sleep that she stated she’s
relaxation and calmness, both
mental and physical. A typical taking.
sleeper will pass through 7 to 9
hours of sleep and take a rest
using some relaxation activities
such as reading, telling stories
and others. (Nursing
Fundamentals by Rick Daniels)
Obvious changes occur in the Has a normal state of skin and
integumentary system (skin, appendages, no open wounds,
hair, nails) with age. The skin rashes.
become drier and more fragile,
the hair loses color, the finger
nails and toe nails become
thickened and brittle, and in
32

Abel Rodriguez ‘y Rigor
28 y/o
Area of assessment Findings
Social Status As she stated when they have a
misunderstanding they settle it
by talking each other. She
socializes with their neighbors.
She’s the one who spend more
time with their child than to
her husband she’s the one who
do the house chores. Same as
usual life of Filipino family
they watch Television when
she finishes the house chores
and whatever she’s doing.
When they have a free time
they will have bonding and
quality time by going to malls
or some time they have
women over 60, facial hair
increases. These integumentary
system changes accompany
progressive losses of
subcutaneous fat and muscle
tissue, muscle atrophy, and loss
of elastic fibers. (Fundamental
of Nursing 7th Edition by
Barbara Kozier)
Norms Analysis
Social status includes family She has harmonious
relationships/friendships that relationship with their
state the patient’s support neighbors and her family.
system in time of stress and in
time of need. It meets a
fundament human need for
social ties, making life less
stressful and social support
buffers the negative effects of
stress, thus indicating indirectly
contributing to good health
outcomes. (Friedman and
Smith 1988)
33
 bonding by going to church. .
Mental Status

> General Appearance and Her clothes look neat, her
Behavior fingernails and toe nails looks
neat, her skin is not dry, her
hair is neat and she’s able to
read and write and also
cooperate during the interview.
She’s doesn’t look tired even
she carrying her 9 months old
daughter.
The content of the patient’s She has a good education
message should make sense. background based on normal
The ability to read and write state. She has a clean cloth and
a clean finger nails and toe
should match the patient’s
nails though untrimmed. She
educational level. The patient has a normal state of skin and
should be able to correctly appendages based on norms
respond to questions and to stated.
identify all the objects as
requested. The patient should
be able to evaluate and act
appropriately in situations
requiring judgment. (Health
Assessment and Physical
rd
Examination 3 Edition by
Mary Ellen Zator Estes)

>Level of consciousness and
She was cooperative during
orientation interview; she also respond to
our question correctly such as
how many children she has,
where she’s from, what day it
is and other questions
regarding the data needed
from our family case study.
The level of consciousness and
orientation determine whether a
person is aware of things that
are happening (Kozier 2004)
She was able to answer all the
questions correctly. These are
major determinant that
indicate his mental capabilities
are functioning well.

34
>SPEECH Patient’s speech is She was able to communicate
As per assessing her, her way with us clearly( we didn’t had
of talking is clear loud enough understandable, in moderate
pace and in clear tone. a hard time understanding
and understandable
Thoughts are logical (Kozier what she was saying)
2004)

Emotional Status She said whenever they have
misunderstanding at home they
usually settles things out by
talking about their problems
together. She goes out with her
kids to play with her friends
whenever she’s emotionally
down.
Sensory Perception
The old adult is in the stage She has a good control over
where an issue of ego integrity her emotion or feelings with
vs. despair arises. Integrity the help of her family
manifests with wisdom and
feelings of satisfaction with
one’s life while despair arises
from remorse about what could
have been. The presence of
despair causes life to be viewed
as meaningless. (Nursing
CEU.com: The process of
human development)

Sense of sight She has a normal visual test:
was able to read what we asked
her to read, her eyes are
symmetrical no lesion or
swelling accessed, papillary
response is normal
The client who has a visual
acuity of 20/20 is considered to
have normal visual acuity. The
eyes must be symmetrical
during the six cardinal gazes
test. The sclera should be white
She has a normal visual test:
was able to read what we
asked her to read, her eyes are
symmetrical no lesion or
swelling accessed, papillary
response is normal

35

Sense of Taste We let her taste a little bit of
sugar and coffee while her eyes
are close for her to know the
difference and she was able to
taste it.
Sense of hearing Her ears are symmetrical in
shape and has the same color
with the skin. There was no
redness and swelling on her
ear. There was no complain of
pain upon the assessment f
hearing. No tenderness and
redness noted. During whisper
test at a distance of 2 feet she
was able to repeat the words.
There was a small amount of
ear wax seen in both ear
Sense of Smell Her nose is located in the mid Nose must be symmetrical and She has a good olfactory
line of the face and hasn’t along of the face. Each nostril function since she was able to
noted any swelling or masses. must be patent and recognize recognize everything we let
with some small blood vessels.
Papillary constrictions should
occur when struck by light.
(Health Assessment and
Physical Examination, Mary
Ellen Zator Estes)
Taste is intact in the posterior Her taste buds are functioning
one third of the tongue. (Health well.
Assessment and Physical
Examination, Mary Ellen Zator
Estes)
For auditory acuity, the patient Based on norms her auditory
should be able to repeat the accuracy is normal. No signs
words whispered from a of ear infection.
distance of two feet. (Health
Assessment and Physical
Examination, Mary Ellen Zator
Estes)
36
 Both of her nostrils are patted the smell of an object. (Health his nose sniff while her eyes
and cilia project into the cavity Assessment and Physical were close. also she has no
of her internal mucosa is little Examination, Mary Ellen Zator sign of infection
pale without swelling and she
Estes)
was to identify the different
odor of alcohol cologne and
coffee.

Tactile
She was able to identify things The skin contains receptors for
we let her hold while her eyes
were close (such as pen,
phone, and notebook).
Based on the norms and
pain, touch, pressure and findings that assessed, her
temperature. These receptors sense of touch is functioning
originate in the dermis and well.
terminate as either free nerve
endings throughout the skin’s
surface or as special touch
receptors that are encapsulated
and found predominantly in the
fingertips and lips. Sensory
signals that help determine
precise locations on the skin
are transmitted along rapid
sensory pathways, and less
distinct signals such as pressure
or poorly localized touch are
sent via slower sensory
pathways. ( Health Assessment
and Physical Examination,
Estes 2006)

37
Motor Stability During the assessment, she
was sitting upright, through a
little slouchy. When she walks,
there is no also staggering and
walks straight; with complete
extremities and was able to do
active range of motion (ROM)
. Ellen Zator Estes)
Body Temperature 1st visit: 37.1 ⁰C.
2nd visit: 36.8 ⁰C
3rd visit: N/A
Respiratory Status Her respiratory rate is 17 cpm.
Her shoulders are at the same
level. No superficial veins
visible. She is also not using
accessory muscles while
breathing. Breathing is not
exaggerated, and respirations
are regular and even in rhythm.
Circulatory Status Her pulse rate is 76 bpm and
has blood pressure of 100/60.
The patient remains erect and She has normal motor
balanced during all stages of stability. No signs of kyphosis,
gait. The patient should be able lordosis, or scoliosis. Has a
to transfer easily to various complete set of extremities
positions. There should be and was able to do ROM
absence of discomfort during
range of motion exercise.
(Health Assessment and
Physical Examination, Mary
Normal axillary temperature is Her temperature is within the
within 36.4⁰C to 37.4⁰C. normal range during the
(Health Assessment and assessments based on the
Physical Examination 3rd findings and norms stated
edition by Mary Ellen Zator
Estes
Normal respiratory rate for Respiratory rate is within the
adults is 12-20cpm. Average is normal range. No signs of
18. In terms of pattern, normal difficulty of breathing.
respirations must be regular
and even in rhythm. The
normal depth of respirations is
non-exaggerated and effortless.
(Health Assessment and
Physical Examination 3rd
edition by Mary Ellen Zator
Estes)
The normal cardiac rate for an Her cardiac rate is in normal
adult is 60-100 beats per range and the blood pressure is
38
 Her capillary refill time is 3 minute while the normal blood normal and the capillary refill
seconds pressure is 120/800mmHg. is normal.
(Kozier, Fundamentals of
th
Nurisng 7 Edition)
Nutritional Status She said that he usually drinks According to Health Asian Diet normal range, indicating that
6-8 glasses of water a day. She Pyramid, there should be a she’s healthy, especially
eats 3 times a day that usually daily intake of rice, grains, without vices.
consist of rice, vegetables and
bread, fruits and vegetables;
sometimes fish, meat and
cassava. she also said that he optional daily for fish, shellfish
doesn’t smoke and drink and dairy products; weekly for
alcohol. She is weighing sweets, eggs and poultry, and
115lbs and standing 5’2 feet monthly for meat. There should
tall. She has BMI of 20.5 be an increased intake of a
wide variety of fruits and
vegetables. Include in the diet
foods higher in Vitamins C and
E, and Omega-3 fatty acid rich
foods. (www.webmd.com)
Elimination Status She said that he usually pees 3 Normal bowel movement of a Her elimination status is
times a day. With regards with person must be 1 to 2 times a normal. No abnormalities of
her bowel movement she day and voiding in 3 to 4 times urine or stool.
defecates once a day and said a day with an output of 1200 to
that’s it’s not a loose/watery. 1500mL a day. A normal stool
Urine color assessed was is brown in color and well
yellowish as per Mrs. Rodrigez formed, urine is clear to
and doesn’t have a foul odor. yellowish in color.
(Fundamentals of Nursing,
Kozier, 2007)
Reproductive Status She stated that she had her first Menarche, which is the first Her reproductive status is
menstruation when she’s 13 menstruation occur at normal. No history of
years old and started to be an average age of onset between transmitted disease noted

39
 sexually active when she was
16 years old. She has an OB
scoring G3T3P0A0L3. She got
pregnant when she’s 17 years
old. And according to her she
has no history of sexually
transmitted infections/disease..
Sleep-rest Pattern She usually sleeps 9:00Pm and
wakes 6:00Am to cook for her
children and for other member
also. Whenever she have
leisure time, she sometimes
usually spends it playing with
her siblings or friends, and
sometimes take a nap.
State of Skin Appendages She has fair complexion and
warm to touch skin. No signs
of infection such as redness or
swelling, no rashes and even
open wounds. Her hair is black
in color and not oily.
Fingernails and toenails are
untrimmed and unclean.
9 to 17 years old. Pregnancy may
occur from stage of menarche up
to cessation of menstrual
period.
Menopause occurs with age
range of 40 to 55.
(Maternal and Child Health
nursing fourthEdition by
Pilliterri)
Sleep refers to altered She has a normal sleeping
consciousness with general pattern based on the norms as
slowing of physiological stated and the number of hours
process while rest refers to
of sleep that she stated she’s
relaxation and calmness, both
mental and physical. A typical taking.
sleeper will pass through 7 to 9
hours of sleep and take a rest
using some relaxation activities
such as reading, telling stories
and others. (Nursing
Fundamentals by Rick Daniels)
Obvious changes occur in the Has a normal state of skin and
integumentary system (skin, appendages, no open wounds,
hair, nails) with age. The skin rashes
become drier and more fragile,
the hair loses color, the finger
nails and toe nails become
thickened and brittle, and in
women over 60, facial hair
increases. These integumentary
system changes accompany
40
progressive losses of
subcutaneous fat and muscle
tissue, muscle atrophy, and loss
of elastic fibers. (Fundamental
of Nursing 7th Edition by
Barbara Kozier)

41
B. Nutritional Assessment

The grandmother of the family takes maintenance medicines for her heart disease, while
the other members do not take any medications or food supplements. They eat three times a day
and their diet is composed of rice, vegetables, picked fruits and sometimes they combine it with
meat and fish. The children are fond of eating sweets. Mrs. Abel Rodriguez is the one who
usually prepare their food. The children eats healthy food but they are also fond of eating sweets
and it is not healthy for them to take large amount of sugar in their body.

NORMS:

A nutrition assessment is an in-depth evaluation of both objective and subjective

data related to an individual's food and nutrient intake, lifestyle, and medical history.
Once the data on an individual is collected and organized, the practitioner can assess and
evaluate the nutritional status of that person. The assessment leads to a plan of care, or
intervention, designed to help the individual either maintain the assessed status or attain a
healthier status.

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

One member of the family does not have any vaccines or immunizations at all, but all of
them had their vaccines and immunizations.

The family has good rest and sleep. They usually sleep early, they sleep at around 8-9pm
and wake up early in the morning at around 6-7 am to prepare for school and for work. The
adults in the family does the house chores and do the farming.

The mother has her maintenance medicine for her heart problems but does not have
enough supplies of maintenance medicines because of financial problems. She limited her taking
of medicines only 2-3 times a week or if the heart problem attacks, but the prescribed dose of the
drug must be taken daily.

They have lack of knowledge about the importance of immunizations because one
member did not have any immunizations or vaccines at all.

NORMS:

42
 The expanded program of immunization objective is to reduce infant
mortality and morbidity through decreasing the prevalence of six immunizable
diseases (TB, Diphteriasis, Pertusis, Tetanus, Polio, and Measles)

Children need to receive complete and timely immunization. Children who

are not fully immunized are more susceptible to common childhood diseases.

To have protection to the disease like: TB, Diphtheriasis, Pertussis,

Tetanus, Polio and Measles, we must fully vaccinated with BCG 1 dose after
birth, OPV 3 doses after 6 weeks, DPT 3 doses after 6 weeks HEPA B 3 doses
after birth and measles 1 dose after 9 months. (Maglaya book)

ANALYSIS:

They do have normal sleep pattern and exercise but the family doesn’t recognize the
maintenance of health disease prevention. One of the children doesn’t have any of the
immunizations and vaccines while the others have completed their vaccines.

Family Measles (2 BCG DPT OPV HEPA B

member dose first at 12- (1 dose (1 dose (4 doses) (3-4 doses)
15 moths then at birth) at 7
6 years) years
old)
Emiliano Complete Complete Complete Complete Complete
Rigor
Brioleta Complete Complete Complete Complete Complete
Rigor
Abel Complete Complete Complete Complete Complete
Rodriguez
‘y Rigor
Lito Complete Complete Complete Complete Complete
Rodriguez
Leandro Complete Complete Complete Complete Complete
Rigor
John N/A N/A N/A N/A N/A
Russell
Rigor
Dexter Complete Complete Complete Complete Complete
Rodriguez
Princess Complete Complete Complete Complete Complete
Dianne

43
IV. FAMILY COPING INDEX
Categories
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.
Legend:
1 - No competence
2 - Moderate Competence
3 - Complete Competence
1 2 3 Justification
1stVisit: During our first visit we observe and notice that
the family is capable of doing their activities of daily living
(bathing, dressing, etc) independently
2nd Visit: On this visit we observe that there’s a little bit
difference
3rd Visit: We evaluate their hygiene and according to our
re- assessment there is an improvement, they do what we
advised them.
1st Visit: During our visit we notice that the family is
unable to monitor their health. They just have a
consultation in the health center when they are really ill or
ask medicines from the BHW.
2nd Visit: on our second visit, we notice that there was still
no improvement when it comes to their health
management,
3rd Visit: On this visit we provide a health teaching
44

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
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.
45
especially to a parent in the family and explain to her on
how important it is and just complied that they’ll go to the
health center not just when they’re really ill.
1st Visit: The family doesn’t know the underlying
principles and information about the illness or disease that
they have in the family.
2nd Visit: The family has some general knowledge of the
health condition, but has not grasped the underlying
principles or partial information.
3rd Visit: We provide health teachings about their specific
condition and on this visit we observe an improvement and
they implement what we advised to them.
1st Visit: The family die is adequate and good, necessary
immunization were completed by the children; house in not
really dirty and organized, food handled in unsanitary way
but children and adults have an adequate sleep and rest.
2nd Visit: During this visit, we noticed that there’s
improvement.
3rd Visit: On this visit we provide health teaching and we
observed that they are willing to do it.
1st Visit: During our visit the family stated that they prefer
to go the Health Centers when the member of the family is
in sick or needs a medical attention.
2nd Visit: On our second visit they are interested to the
health teaching that we imparted for their health and
illnesses.
3rd Visit: We provide health teachings on the family.
 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.
7.) Physical Environment
This is concern with the home, the community
and the work environment as it affects family
health
46
1st Visit: During our visit we noticed that they respect
every individual’s decision and their relationship to each
member of the family; when it comes to decision-making
and problem solving it is shared among the members of the
family except young members. Each member has his or her
own part or role in the family, which is well respected.
2nd Visit: On this visit they still give importance and
respect each and everyone’s decision.
3rd Visit: On this visit they still give importance and
respect each and everyone’s decision.
1st Visit: During our visit we noticed that there’s an
adequate living space for the family but disordered things
in the house. There is presence of accident hazards,
breeding or resting site, presence of sharp object, and
unclean animal’s shelter.
2nd Visit: We provide a health teachings and also
encouraged them regarding on how important the
cleanliness of their house and their environment.
3rd Visit: We implement some of our intervention and
family members help and cooperate with us.
 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.

Scoring:

1. Decide on a score for each of the criteria Score Weight

A. Nature of the problem Weight
a. Wellness state 3
b. Health deficit 3 1
c. Health Threat 2
d. Foreseeable Crisis 1

B. Modifiability of the problem

a. Easily Modifiable 2
b. Partially Modifiable 1 2
c. Not Modifiable 0

C. Preventive potential
a. High 3
b. Moderate 2 1
c. Low 1

D. Salience scale
a. A condition needing immediate attention 2
b. A condition needing immediate attention 1 1
c. Not perceive as problem 0

2. Divide the score by the highest possible score and multiply by the weight
3. Sum of the scores for all the criteria. The highest score is 5, equivalent to the total
weight
Source: (Nursing Practice in the community Fourth Edition by Arceli S. Maglaya)

47
 VI. RANKING OF PRIORITIZATION OF IDENTIFIED HEALTH PROBLEMS

Problems Score
1. Presence of Sharp object as health threat 4.17
2. Presence of breeding sites as a health threat 4.17
3. Lack of knowledge about proper hygiene as health 4.17
threat
4. Lack of knowledge in segregation as health threat 3.84
5. Incomplete immunization & vaccines as health 2.67
deficiency

This table shows the priorities of family health problems that were identified. The
computation on how priorities were shown with their corresponding justification. These are the
top 5 problems in the family:

Presence of Sharp object as health threat

CRITERIA COMPUTATION ACTUAL JUSTIFICATION

SCORE
1.) Nature of the 2/3*1 0.67 It is a health threat
problem that requires an
intervention
because this can
cause harm to the
family members
2.) Modifiability of 2/2*2 2 It is easily
the problem modifiable with the
help of student
nurse by identifying
and having health
teaching for having
a sharp object in the
environment.
3.) Preventive 3/3*1 1 It is highly
potential preventable
because immediate
and easy action &
intervention can be
done.
4.) Salience of the 1/2*1 0.5 A condition
problem needing immediate
attention
Total: 4.17

48
 Presence of breeding sites as a health threat

CRITERIA COMPUTATION ACTUAL JUSTIFICATION

SCORE
1.) Nature of the 2/3*1 0.67 It is a health threat
problem that requires an
intervention because
it can lead to an
illness or disease to
a family members
2.) Modifiability of 2/2*2 2 It is easily
the problem modifiable with the
help of student nurse
by identifying and
having health
teaching regarding
about the cause and
effect of having
breeding sites
3.) Preventive 3/3*1 1 It is highly
potential preventable because
immediate and easy
action &
intervention can be
done.
4.) Salience of the 1/2*1 0.5 A condition needing
problem immediate attention
Total:4.17

Lack of knowledge about proper hygiene as health threat

CRITERIA COMPUTATION ACTUAL JUSTIFICATION

SCORE
1.) Nature of the 2/3*1 0.67 It is a health threat
problem that requires an
intervention because
this can lead to an
illness or disease to
a family members
2.) Modifiability of 2/2*2 2 It is easily
the problem modifiable with the
help of student nurse
by identifying and
having health
teaching regarding
the proper hygiene

49
 3.) Preventive 3/3*1 1 It is highly
potential preventable because
immediate and easy
action &
intervention can be
done.
4.) Salience of the 1/2*1 0.5 A condition needing
problem immediate attention
Total:4.17

Lack of knowledge in segregation as health threat

CRITERIA COMPUTATION ACTUAL JUSTIFICATION

SCORE
1.) Nature of the 2/3*1 0.67 The problem is
problem health threat that
requires immediate
attention and
management by a
family member
2.) Modifiability of 2/2*2 2 It is easily
the problem modifiable with the
help of student nurse
by identifying and
having health
teaching regarding
about the benefits of
having a knowledge
about segregation
3.) Preventive 2/3*1 0.67 It is moderately
potential preventable because
immediate and easy
action &
intervention can be
done.
4.) Salience of the 1/2*1 0.5 A condition needing
problem immediate attention
Total:3.84

Incomplete immunization & vaccines as health deficiency

CRITERIA COMPUTATION ACTUAL JUSTIFICATION

SCORE
1.) Nature of the 3/3*1 1 The problem is
problem health deficiency

50
 that requires
immediate attention
and management by
a family member
2.) Modifiability of 1/2*2 0.5 It is partially
the problem modifiable with the
help of student nurse
by having health
teaching regarding
the importance of
having a complete
vaccine
3.) Preventive 2/3*1 0.67 It is moderately
potential preventable because
the action can be
done by the mother
4.) Salience of the 1/2*1 0.5 A condition needing
problem immediate attention
Total: 2.67

51
VII. FAMILY NURSING CARE PLAN

Presence of Sharp object as health threat

Health Family Goal of care Objectives of Nursing Methods of Resources

Problems nursing care intervention nurse family required
problem contact
Presence of Inability to After three After three Discussed with Nursing home Human
sharp objects locate and days of days of nursing the family the visit Resource:
as a health properly place nursing home home visit, the risks of having
threat for the the sharp visits, the selected family sharp objects Health Time and effort
entire objects that are family will be : around the teachings of both student
population of surrounded able to identify house nurse and the
the family. around the the presence of -Will be able to family.
house. sharp objects identify where Discussed with
and how to the sharp the family
properly objects are where to put the
manage it. located sharp objects
and see to it
-Will be able to that it won’t
properly place cause harm.
the sharp
objects in the
correct are
where it should
be located.

52
Presence of breeding sites as a health threat

Health Family Goal of care Objectives of Nursing Methods of Resources

Problems nursing care intervention nurse family required
problem contact
Presence of Inability to After 3 days of After 3 days of Gave health Nursing home Shovels, this
breeding sites have an nursing home nursing home teachings visit can be used to
as a health environment visits, the visits, they will regarding the empty stagnant
threat. that is family will be be able to show problem and Health water.
conducive to able to acquire us how to emphasized to teachings
health knowledge properly them the risks Time and
maintenance about the risks manage the of breeding effort of both
due to lack of of having problem and be sites like the student
knowledge breeding sites able to mosquitoes are nurse and the
about this around the area understand the most likely to family.
problems. and how to risks of having live in these
manage the breeding sites breeding sites
specific around the that will affect
problem. area. their health
because these
mosquitoes can
carry different
viruses such as
dengue and
malaria.

53
Lack of knowledge about proper hygiene as health threat

Health Family Goal of care Objectives of Nursing Methods of Resources

Problems nursing care intervention nurse family required
problem contact
Lack of Inability of the After 3 days of After 3 days of Performed Nursing home Time and
knowledge family to nursing home nursing home health teachings visit effort of both
about proper recognize visits the visits the family about proper the student
hygiene as a problems family will be will be able to hygiene like Health nurse and the
health threat. because of lack able to know recognize the brushing their teachings. family
of knowledge the problems problem and teeth three
on the and be able to will be able to times a day
importance of do hygienic show after meals,
proper hygiene practices. understanding cutting of
like hand regarding the fingernails
washing before importance of when they are
and after proper hygiene. already long,
meals, changing of
brushing of untidy clothes,
teeth, taking a taking a bath at
bath, changing least 2-3 times
of dirty daily. And
clothes, cutting washing hands
of long with soap and
fingernails. water before
and after meals.

54
Lack of knowledge in proper segregation as health threat

Health Family Goal of care Objectives of Nursing Methods of Resources

Problems nursing care intervention nurse family required
problem contact
Lack of Inability of the After 3 days of After 3 days of Gave health Nursing home Time and
knowledge in family to have nursing home nursing home teachings about visit effort of both
proper an adequate visits, the visits, the segregation like the student
segregation as knowledge family will be family would the Health nurse and the
a health threat. about the able to have be able to biodegradable teachings family.
health hazards adequate properly wastes must be
of not having a knowledge segregate separated from
proper regarding wastes and the non-
segregations of proper how to dispose biodegradable
waste. segregation of it. and hazardous
wastes like wastes, and
what are the how to dispose
wastes that them.
should be
together, the
biodegradable
wastes should
be separated
from the non-
biodegradable
and hazardous
wastes.

55
Incomplete immunization & vaccines as health deficiency

Health Family Goal of care Objectives of Nursing Methods of Resources

Problems nursing care intervention nurse family required
problem contact
Incomplete Lack of After 3 days of After 3 days of Discussed with Nursing Transportation
immunizations knowledge nursing home nursing home the family the home visit from their
and vaccines as regarding the visits, the visits the family importance of house to the
a health potential risks family will be should immunizations Health health facilities
deficiency. of not having able to gain recognize the and vaccines in teachings
any knowledge problem and order for them Time and effort
immunizations about the will be able to to prevent of both the
and vaccines as potential risks understand the diseases which student nurse
a result of of not having importance of will cause and the family.
health any immunizations harm.
deficiency. immunizations and vaccines.
and vaccines. Advised the
family
especially those
who does not
have any
immunization
and vaccines to
go to the
nearest rural
health unit or
any health
facilities to
have their
immunization
and vaccines.

56
 VIII. SUMMARY AND EVALUATION

At the end of the rotation the A2 Group was able to develop and understand the health
condition of the Rigor Family and through that we were able to formulate the necessary nursing
care plan, effective patient care and we implement the proper nursing interventions to solve the
family health problems and environmental problems, health teaching and related knowledge and
different skills to the family. We implement the planned nursing interventions for the identified
problems and help the family members to improve their health management for their house and
surroundings. They became aware to the present condition within their home and environment
that can affect their health condition. Perceived the presence of problem that immediate action
and realize the importance of maintaining health by promoting a healthy environment lifestyle
and improve their health as well as their lives. Our exposure in the community strengthened and
gives more meaning to us in being a student nurse. It opens certain opportunities and challenges
for us to handle real situations in the community and allow us to deal and interact with different
types of families, and also apply nursing knowledge and skills.

RECOMMENDATION

The student nurse have identified and prioritized the problems and need with the family. The
student nurse have created care plan on how to deliver the best nursing care for the family to
address their needs.

The following are propositions and recommendations recognized by both the student nurse and
family.

- The family should also maintain the proper hygiene, such as taking a bath every day
and brush their teeth 2 to 3 times a day.
- The family must identify the presence of sharp objects and how to properly manage
it.
- The family will acquire knowledge about the risk of having breeding sites around the
area and how to manage specific problems.
- The family should know and should perform properly how to segregate wastes.
- The family should be aware about the potential risk of having incomplete
immunization and vaccines.

To the Barangay Health Official:

57
- Encourage the Barangay Health Officials to have monthly home visit to the families
that they have health problems.
- Conduct a seminar workshop to help the community in preventing disease.
- Provide a proper garbage disposal like trashcan in all the puroks in the barangay

58
 IX. DOCUMENTATION

Before

59
During Assessment

60
During Intervention

61
After

62
X. GROUP PROFILE

Name: Tomilola Blessing

Name: Vincent Luis M. Rojo
Akitanyo
Age: 20
Age: 18
Address: Paraiso Tarlac City
Address: Nigeria
Religion: Roman Catholic
Religion: Roman Catholic

Name: Merlene S. Salunga Name: Faith Onu

Age: 18 Age: 23
Address: Porac, Pampanga Address: Nigeria
Religion: Roman Catholic Religion: Roman Catholic

Name: Anthony Elijah P. Agustin Name: Mark Neil C. Guitterez

Age: 18 Age: 21
Address: Maligaya, Tarlac City Address: Matatalaib, Tarlac City
Religion: I.N.C Religion: Roman Catholic

63