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GORDON COLLEGEOLONGAPO CITY

COLLEGE OF NURSING

FAMILY CASE ANALYSIS

SUBMITTED BY:

BALAJADIA, JESSIEFELDE GUZMAN, STEFAN PRAISE

ALVEZ, LUDELLE RENACALIMBAS, MARICELEBALO, GRACE LEE

BSN II-C1B

DATE OF SUBMISSION:

SEPTEMBER 18, 2010





II. FAMILY STRUCTURE AND CHARACTERISTIC

A. GENERAL FAMILY STRUCTURE

NAME AGE SEX CIVILSTATUS

POSITIONIN THE

FAMILY

EDUCATIONALATTAINMENT

OCCUPATION

A 45 Male Married Head Undergraduate(Seaman)

Substitutedriver

B 39 Female Married Wife Highschoolgraduate

None

C 19 Male Single EldestChild

Highschoolgraduate

None

D 18 Male Single 2nd Child Highschoolgraduate

Scavenger

E 15 Female Single 3rd Child Ongoing 3rd year Highschool

Student

F 12 Female Single 4th

Child Ongoing Grade6 student Student

G 10 Female Single 5th Child Ongoing Grade4 student

Student

H 3 Female Single 6th Child - -

I 1 Female Single 7th Child - -

INTERPRETATION:

The Letter family is a nuclear family composing of nine members. Their family life cycleis in stage six which is the Launching Stage family. Letter C, the eldest child was the one who is

separated from the family and began to form a family on his own.

ANALYSIS:

The traditional nuclear family structure is composed of a husband, wife, and children. Anadvantage of a nuclear family is its ability to provide support to family members; people knoweach other well and can feel genuine affection for each other. In a time of crisis, this samecharacteristics may become a challenge to a family as there are few family members to sharethe burden and offer support. As launching stage family, the stage at which children leaves toestablish their own households is the most difficult stage because it appears to represent thebreaking up of the family. Parental roles change from those of the mother or father to onceremoved support people or guideposts. (Maternal and Child Health Nursing; Adelle Pilliteri; 6 th

Edition, Volume 6; Chapter 3, pages 41-47)



B1. GENERAL FAMILY RELATIONSHIP

CRITERIA YES NO

1. Observable conflictsbetween family members

2. Wife/husband beating

3. Frequent quarreling

4. Child abuse

“Madalas kami magtalo lalo na pag patungkol sa pera at kapag walang makain.Napapalo ko din mga anak ko para disiplinahin at hindi na ulitin ung maling ginawa nila.Siyempre hindi umaabot ung palo ko na nagpapasa na, simpleng patapik patapik lang namatututo sila. Kapag nagaaway naman kami ni misis, kinagabihan din noon nagbabati kami”, asverbalized by A.

INTERPRETATION:

There are observable conflicts between family members but it’s not very complicated.They quarrel on simple things like providing food for their daily needs. No husband and wifebeating and no child abuse present within the family.

ANALYSIS:

B2. CHARACTERISTICS OF COMMUNICATION

YES NO

a. Open communication

among family members

b. Swearing or use of insultwhen talking to each other

“Open naman kami dito sa isa’t isa. Pag may problema lahat kami pinaguusapan iyon.Hindi din maiiwasan talaga na minsan nakakapagmura at insultuhan kami”, as verbalized by A.

INTERPRETATION:

There is an open communication within the family and all of then are verbal in showingtheir care towards each other. They sometimes use insult words when talking to each other

especially when they are having fights.

ANALYSIS:

In the eight family tasks by Duvall and Miller (1990), maintenance of order is one ofthem. This task includes opening an effective means of communication among family members,establishing values and enforcing common regulations for all family members. (Maternal andChild Health Nursing; Adelle Pilliteri; 6th Edition, Volume 6; page 45).



The effectiveness of family communication determines the family’s ability to function as acooperative, growth producing unit. The information transmitted influences how members worktogether, fulfill their assigned roles in the family, incorporate family values and develop skills tofunction in society.(Fundamentals of Nursing; Kozier and Erb; 8th Edition, Volume 1;page 434).





III. SOCIO ECONOMIC

EXPENSES AMOUNT ( MONTHLY)

ELECTRIC BILL 700

WATER BILL 500

MEDICATION 40

DAILY SCHOOL ALLOWANCES (3 KIDS) 900

FOODS AND OTHER EXPENSES 4500-6000

Father regular income: 200 per day6000 monthly

The client verbalized that, “Nakadepende sa mga raket ko ang kita ko araw-araw.Regular ko namang kita ay 200 pesos sa pagtritrike, halos sakto lang pampagkain naming.Minsan kapag may gusto magpadrive kumikita din ako ng 400 pesos, minsan sumaside line dinako sa saklaan at kapag may nagpapabenta ng kung anu-anong gamit kapag nakabentabinibigyan ako ng komisyon.”

INTERPRETATION:

The father is eager to provide all the needs of the family. He is accepting part time jobsand sidelines to earn extra income for their other expenses.

ANALYSIS:

According to Duvall and Miller (1990), determining which family needs will be met andtheir order of priority is allocation of resources. In healthy family, there is justification,consistency and fairness in distribution. (Maternal and Child Health Nursing; Adelle Pilliteri; 6 th Edition, Volume 1; page 45)

IV. FAMILY HEALTH STATUS

A. FAMILY HEALTH HISTORY

NAME OF FAMILY MEMBERS HEALTH HISTORY

A Hospitalized for stomachache and diagnoseddyspepsia.

B Obstetric history of G8P7T7P1A0L7 Seven children delivered via normal

spontaneous delivery.

Still birth happened after the 3rd

child andsupposedly their 4th child. It was 35 weeksof AOG and a home delivery.

C NOT MONITORED

D NO HEALTH HISTORY

E NO HEALTH HISTORY

F Cough and cold Had fever for 3 days and given medication



of Paracetamol by her mother.

G Cough and cold Not treated

H Cough and cold Not treated

I NO HEALTH HISTORY

“Lahat ng panganganak ko puro sa bahay lang, pero ung panganay namin saospitaldoon sa eskwelahan niyo ngayon. Walo dapat anak ko, kaso namatay iyong pang-apatpero premature na siya. Nung nilabas ko nga lang patay na siya. Tapos iyong mga anak kohindi pa naman nagkakasakit na naospital sila. Kadalasan puro ubo at sipon, tas kapagnilalagnat sila pinapainom ko lang ng Paracetamol. Halimbawa iyong Tempra o Biogesic napambata, ung syrup”, as verbalized by B.

INTERPRETATION:

The head of the family was hospitalized because of stomachache but only in theEmergency Room and medication was given. The wife delivered only once at the hospital andthe rest was at home. She had one still birth caused by cord compression. None of their childrenwas hospitalized and only cough, cold and fever were experienced by them. The mother wastaking them to the health center but not always, and the past prescriptions for the same illnesswere used again by them. The family is on self-medication like when they experiencing fever.

ANALYSIS:

B. Felt Family Needs

1. Money2. Food3. Clothing4. House

Client A verbalized that, “Mahalaga para sa amin talaga e pera. Kasi diba andoon nalahat. Mabibili mo na lahat kapag may pera. Pagkain din at bagong damit, lalo na para sa mgabata. Gusto ko din ipaayos itong bahay kahit mapapinturahan lang.”

INTERPRETATION:

The family simply believes that money is what they really needed. It was ranked first forthe family’s felt need. They think that they can buy and can fulfill all their needs if they haveenough money. Second is food. They need it for their family survival. Next are new clothes.They want new, comfortable and on the generation clothes especially for the children. Lastly,the family wants to redecorate their house. They want it to be organized simple and clean alsofor their comfort.



ANALYSIS:

All people have the same basic needs; however; each person’s needs and reactions tothose needs are influenced by the culture with which the person identifies. People meet theirown needs relative to their own priorities. Ways of meeting basic needs are considered healthywhen they are not harmful to others or to self, conform to the individual’s sociocultural values

and are within the law. People who satisfy their basic needs appropriately are healthier, happier,and more effective than those whose needs are frustrated. (Fundamentals of Nursing; Kozierand Erb; 8th Edition, Volume 1; pages 274-275).

C. HEALTH BELIEFS AND PRACTICES

FAMILY MEMBERS ILLNESS TREATMENT

A Cough and cold Self medication

B Cough and cold Self medication

C NOT MONITORED NOT MONITORED

D Cough Self medication

E Cough, cold and fever Self medication; consulted atthe health center once

F Cough, cold and fever Self medication

G Cough, cold and fever Self medication

H Cough, cold and fever Self medication

I - -

“Hindi pa kami naoospital, isang beses ko lang din dinala sa health center iyong isanganak ko nung nagkaubo’t sipon saka lagnat siya. Tapos pag nauulit iyong sakit, ginagamitnalang namin iyong dating reseta sa health canter. Pinapainom ko sila ng Carbocestein o kaya

Cephalexin pag may ubo. Paracetamol naman o kaya iyong Tempra ang pinapainom ko kapagnilalagnat sila”, as verbalized by B.

INTERPRETATION:

They don’t consult physicians for their health problem. They only rely on the pastprescriptions that were given at the health center or on the over-the-counter drugs for theirillness.

ANALYSIS:

Culture and social interactions influence how person perceives or experiences and

copes with health and illness. Each culture has ideas about health and is often transmitted fromparents to children. (Fundamentals of Nursing; Kozier and Erb; 8 th Edition, Volume 1; page 302)Older adults often attempt to seek relief from the problems by using over-the-counterpreparations. It is known that over-the-counter medications are used by 75% of older adults torelieve symptoms. Many of these over-the-counter preparations have ingredients that, whenused inappropriately, may cause undesirable side-effects or adverse reactions or may becontraindicated in the client’s condition.



C1. IMMUNIZATION STATUS

MEMBERS OF THE FAMILY IMMUNIZATION

AB (with Tetanus Toxoid Vaccine 1-5)CD Measles VaccineE BCGF OPV (3 dose)G Hepa Vaccine (3 dose)HI

The father verbalized that, “Kumpleto naman ng bakuna mga anak ko kahit ako kahit sabahay lang nanganak asawa ko. Maganda kasing kumpleto sa bakuna para protektado diba.Tsaka sabi samin mahalaga iyon nung nagpupunta kami sa health center”.

INTERPRETATION:

The head of the family is aware that their family needed to complete all the vaccines. Heknew that it could promote health and protect them from any diseases.

ANALYSIS:

Immunization is the process by which vaccines are introduced into the body beforeinfections set in. vaccine are administered to induced immunity thereby causing the recipientsimmune system to react to the vaccine that produces antibodies to fight infections. Vaccinationpromotes health and protects children from disease causing agents. (Public Health Nursing inthe Philippines: Prescilla L. Cuevas RN, MAN; page 142)

C2. FAMILY DAILY ACTIVITIES

FAMILY MEMBERS HOURS OF SLEEP AT NIGHT/NAP

A 10:30pm – 5:30am 8 hours

B 10:30pm – 5:00am/ 2:00pm – 4:00pm 9 hours and 30 mins.

C NOT MONITORED

D 11:00pm – 8:30am 9 hours and 30 mins.

E 10:00pm – 6:00am 8 hours

F 10:00pm – 6:00am 8 hours

G 10:00pm – 6:00am 8 hoursH 10:00pm – 7:00am/

2:30pm – 3:30 pm 10 hours

I 10:00pm – 6:30am/ 2:00 – 3:30pm 10 hours

“Natutulog iyong mga anak kong nag-aaral, mga alas-dies ng gabi kasi papasok pakinabukasan. Gumigising naman sila mga ala-sais para makaligo at makakain pa. Ung iba



naman mga alas-onse siguro, kasi nanunuod pa kami mga drama sa t.v. Kami mag-asawa mgaala-singko gumigising, sina D, H at ung bunso mga alas-otso na siguro”, as verbalized by B.

INTERPRETATION:

Each family member had an adequate sleeping pattern. They consume normal hours ofsleep and it’s good for them that they have no difficulty in their sleeping pattern.

ANALYSIS:

Normal sleep pattern and requirements is used to believe that maintaining a regularsleep-wake rhythm is more important than the number of hours actually slept. (Fundamentals ofNursing; Kozier and Erb; 8th Edition, Volume 2; page 1166) Sleep is widely believe thateveryone needs eight hours of sleep at night, some need more and others can adjust toconsiderably less. Many attempt to get by with too little sleep, because they are constantly busyand because staying up late is a symbol of the adult status they long for. Frequent lack of sleepcan lead to chronic fatigue or depression, however. (Maternal and Child Health Nursing; Adele

Pilliteri; 6th Edition, Volume 2; page 925)

C3. STRESS MANAGEMENT

FAMILY MEMBER STRESS MANAGEMENT

A “Kapag may problema ako, dinadaan ko sapaninigarilyo”.

B “Naglilinis lang ako ng bahay o kaya nanunuodng t.v”.

C NOT MONITORED

D “Gumagala lang ako, kasama mga tropa kokung saan saan o kaya umiinom kami atnaninigarilyo nalang”.

E “Minsan gusto ko lang mapag-isa, ayoko langmay naggugulo pag may iniisip ako”.

F “Nanunuod akong t.v. o kaya nakikinig ng mgakanta sa radyo”.

G “Nakikipaglaro ako sa mga kaibigan ko o kayananunuod minsan”.

H “Nanunuod lang yan o kaya nakikipaglaro samga kapatid niya”, as verbalized by B.

I “Binibigyan namin ng laruan para malibang okaya pagkain”, as verbalized by B.

INTERPRETATION:

All the members of the family have their own stress management. But in their case, theother members of the family are not coping with their stresses in a healthy manner. Some ofthem spend their time drinking alcohols and smoking cigarettes.



ANALYSIS:

Family coping mechanisms are the behaviors family use to deal with stress or changesimposed from either within or without. Coping mechanisms can be viewed as an active methodof problem solving developed to meet life’s challenges. The coping mechanisms families andindividuals develop reflect their individual resourcefulness. Family may use coping pattern rather

consistently over fine or may change their coping strategies when new demands are made onthe family.

C4. FAMILY PLANNING METHOD

“Pills lang ang ginamit ko simula nung nakadalawang anak na kami hanggang ngayon.Pero nabubuntis pa din ako kasi nakakalimutan ko uminom minsan eh”, as verbalized by themother.

INTERPRETATION:

Oral contraception is the family planning method they are using. It became ineffectivebecause the mother sometimes misses taking it, the reason why pregnancy occurs.

ANALYSIS:

Oral contraceptives, commonly known as the pill or OCs, are composed of varyingamounts of synthetic estrogen combined with a small amount of synthetic progesterone. Pillsmust be prescribed by a physician, a nurse practitioner, or nurse-midwife following a pelvicexamination and a Papanicolaou (Pap) smear. When used correctly, they are 99.5% effective inpreventing conception. Because women occasionally forget to take them and there areindividual differences in women’s physiology, the typical failure rate is around 3%. (Maternal and

Child Health Nursing; Adele Pillitteri; 4th

Edition, Volume 1; page 106)

HEAD TO TOE PHYSICAL ASSESSMENT:

NAME: A AGE: 45 YEARS OLD

GENDER: MALE

A. MEASUREMENTS FINDINGS NORMAL FINDINGS INTERPRETATION

Weight 53 kg.

Height 162 cm

BMI 20.38 <16 malnutrition16-19 underweight20-25 normal26-30 overweight31-40 moderately toseverely obese>40 morbidly obese(Fundamentals ofNursing; 7th edition;

Normal



Barbara Kozier; pg.1175)

B. VITAL SIGNS

Blood pressure 110/70 mmHg 120/80 mmHg

Temperature 36.4 C 36.5-370C

Pulse rate 81 bpm 60-100 bpm NormalRespiratory Rate 17 cpm 16-20 cpm

Body parts Actual Findings Normal Findings Interpretation

SKIN Dark brown color,rough and dry skintexture, turgor:pinched up skinimmediately return(-) edema

(-) swellingWarm to touch(-) nodule

-Generally uniform exceptin the areas exposed tothe sun: areas of lighterpigmentation(palms,lips,nail beds) in dark skinpeople

-no edema-no nodule- when pinched skinspring back to previousstate

Normal

HAIR Thick HairBlack in color(+) for dandruffHair is evenlydistributed(-)for lice

- evenly distributed hair- thick hair- silky and resilient hair- no infection or infestation

Presence of dandruffis due to poorhygiene

NAILS intact epidermisDirty nailsBlanch test capillaryrefillAngle of nails are160 degrees

- convex curvature; angleof nail plate about 160degree- smooth texture- highly vascular and pinkin light skinned clients:dark skinned clients mayhave brown or blackpigmentation inlongitudinal streaks- intact epidermis- prompt return of pink or

usual color(generally lessthan 4 sec)

Dirty nails is due topoor hygiene

HEAD Rounded skull(-)nodules ormassesSymmetric facial inmovement

- rounded( normocephalicand symmetrical, withfrontal, parietal andoccipitalprominence):smooth skullcontour

Normal



- smooth, uniformConsistency; absence of

nodules and masses- symmetric facialmovement

EYES EyebrowssymmetricallyEqual movement(-) edema and tearyeyesPupil is round andequalBlinking issymmetricallyRedness ofconjunctiva

eyebrow symmetricallyaligned; equal movement- skin intact; no discharge;no discoloration- no edema or tearing- clients blinks when thecornea is touched,indicating that thetrigeminal nerve is inintact

Normal

EARS Color is same asfacial skin, auriclesis aligned in outercantus of the eye,no discharged

- color is same as facialskin- auricles is aligned inouter cantus of the eye- no discharge- symmetrically- no tender- firm

Normal

NOSE No lesion, skin coloris same as face,nasal septum intact

and in midline.Client breaths freelyNo discharge

symmetric and straight- no discharge or flaring- uniform color

- not tender; no lesion-air moves freely as theclient breaths through thenares

Normal

MOUTH ANDTHROAT

Lips is pink(-) nodules, notendernessAbility to purse thelipsMoves freelyno tenderness

- pink gums(bluish or darkpatches in dark skinnedclients)- moves freely; notenderness- smooth with no palpablenodules- ability to purse the lips

- no discharge

Normal

NECK Movement with nodiscomfort(-)masses andnodules

- coordinated, smoothmovements with nodiscomfort-masses and nodules arenot palpable

Normal



CHEST No nodules ormassesSpinal column isstraightLeft and rightshoulder and hips

are at the sameheight, equal chestsymmetry

- chest symmetry- spine vertically aligned- chest wall intact; notenderness; no masses- Spinal column is straightLeft and right shoulder

and hips are at the sameheight

Normal

NAME: B AGE: 39 YEARS OLD

GENDER: MALE


Weight 110 lbs.

Height 165 cm

BMI 18.5 <16 malnutrition16-19 underweight20-25 normal26-30 overweight31-40 moderately toseverely obese>40 morbidly obese(Fundamentals ofNursing; 7th edition;Barbara Kozier; pg.1175)

Underweight

B. VITAL SIGNS

Blood pressure 110/70 mmHg 120/80 mmHgTemperature 36.7 C 36.5-370C

Pulse rate 83 bpm 60-100 bpm Normal

Respiratory Rate 19 cpm 16-20 cpm


SKIN Light brown color,pinched up skinimmediately return(-) edema(-) swellingWarm to touch(-) noduleDry skin(+) scars in legs

-Generally uniform exceptin the areas exposed tothe sun: areas of lighterpigmentation(palms,lips,nail beds) in dark skinpeople-no edema-no nodule- when pinched skinspring back to previousstate

Normal



HAIR Thick HairBlack in color(+) for dandruffHair is evenlydistributed(-)for lice



NAILS intact epidermisClean nailsBlanch test capillaryrefill=2 sec.Angle of nails are160 degrees

- convex curvature; angleof nail plate about 160degree- smooth texture- highly vascular and pinkin light skinned clients:dark skinned clients mayhave brown or blackpigmentation inlongitudinal streaks- intact epidermis- prompt return of pink or

usual color(generally lessthan 4 sec)

Normal


- rounded( normocephalicand symmetrical, withfrontal, parietal andoccipitalprominence):smooth skullcontour- smooth, uniformConsistency; absence of

nodules and masses

- symmetric facialmovement

Normal

EYES EyebrowssymmetricallyEqual movement(-) edema and tearyeyesPupil is round andequalBlinking issymmetrically

eyebrow symmetricallyaligned; equal movement- skin intact; no discharge;no discoloration- no edema or tearing- clients blinks when thecornea is touched,indicating that thetrigeminal nerve is in

intact

Normal


- color is same as facialskin- auricles is aligned inouter cantus of the eye- no discharge- symmetrically

Normal



- no tender- firm

NOSE No lesion, skin coloris same as face,nasal septum intact

and in midline.Client breaths freelyNo discharge

symmetric and straight- no discharge or flaring- uniform color

- not tender; no lesion-air moves freely as theclient breaths through thenares

Normal

MOUTH ANDTHROAT


- pink gums(bluish or darkpatches in dark skinnedclients)- moves freely; notenderness- smooth with no palpablenodules

- ability to purse the lips- no discharge

Normal



Normal

CHEST No nodules ormassesSpinal column isstraightLeft and rightshoulder and hipsare at the sameheight, equal chestsymmetry

- chest symmetry- spine vertically aligned- chest wall intact; notenderness; no masses- Spinal column is straightLeft and right shoulderand hips are at the sameheight

Normal

NAME: D AGE:18 YEARS OLD

GENDER: MALE


Weight 98 lbs.Height 5’4’’

BMI 16.54 kg/m2 <16 malnutrition16-19 underweight20-25 normal26-30 overweight31-40 moderately toseverely obese>40 morbidly obese

Underweight



(Fundamentals ofNursing; 7th edition;Barbara Kozier; pg.1175)

B. VITAL SIGNS


Temperature 36.60C 36.5-370C




SKIN Dark brown color,rough and dry skintexture, turgor:pinched up skin

immediately returnwithin 2-3 sec.(-) edema(-) swellingWarm to touch(-) nodule

-Generally uniform exceptin the areas exposed tothe sun: areas of lighterpigmentation(palms,lips,

nail beds) in dark skinpeople-no edema-no nodule- when pinched skinspring back to previousstate

Normal

HAIR Thick HairBlack in color(+) for dandruffHair is evenly

distributed(+)for lice


Presence of dandruffand lice are due topoor hygiene

NAILS intact epidermisClean nailsBlanch test capillaryrefill=2 sec.Angle of nails are160 degrees

- convex curvature; angleof nail plate about 160degree- smooth texture- highly vascular and pinkin light skinned clients:dark skinned clients mayhave brown or blackpigmentation inlongitudinal streaks

- intact epidermis- prompt return of pink orusual color(generally lessthan 4 sec)

Normal

HEAD Rounded skull(-)nodules ormassesSymmetric facial in

- rounded( normocephalicand symmetrical, withfrontal, parietal andoccipital

Normal



movement prominence):smooth skullcontour- smooth, uniformConsistency; absence of

nodules and masses- symmetric facial

movement

EYES EyebrowssymmetricallyEqual movement(-) edema and tearyeyesPupil is round andequalBlinking issymmetricallyRedness of

conjunctiva


Normal



Normal

NOSE No lesion, skin color

is same as face,nasal septum intactand in midline.Client breaths freelyNo discharge

symmetric and straight

- no discharge or flaring- uniform color- not tender; no lesion-air moves freely as theclient breaths through thenares

Normal

MOUTH ANDTHROAT

Lips is pink(-) nodules, notendernessAbility to purse thelips

Moves freelyno tenderness

- pink gums(bluish or darkpatches in dark skinnedclients)- moves freely; notenderness

- smooth with no palpablenodules- ability to purse the lips- no discharge

Normal

NECK Movement with nodiscomfort(-)masses and

- coordinated, smoothmovements with nodiscomfort

Normal



nodules -masses and nodules arenot palpable

CHEST No nodules ormassesSpinal column is

straightLeft and rightshoulder and hipsare at the sameheight, equal chestsymmetry

- chest symmetry- spine vertically aligned- chest wall intact; no

tenderness; no masses- Spinal column is straightLeft and right shoulderand hips are at the sameheight

Normal

NAME: E AGE: 15 YEARS OLD

GENDER: MALE

A. MEASUREMENTS FINDINGS NORMAL FINDINGS INTERPRETATIONWeight 98 lbs.

Height 135 cm

BMI 23.33 <16 malnutrition16-19 underweight20-25 normal26-30 overweight31-40 moderately toseverely obese>40 morbidly obese(Fundamentals ofNursing; 7th edition;

Barbara Kozier; pg.1175)

Normal

B. VITAL SIGNS


Temperature 36.70C 36.5-370C




SKIN Dark brown color,rough and dry skintexture, turgor:pinched up skinimmediately returnwithin 2-3 sec.(-) edema(-) swellingWarm to touch

-Generally uniform exceptin the areas exposed tothe sun: areas of lighterpigmentation(palms,lips,nail beds) in dark skinpeople-no edema-no nodule- when pinched skin

Normal



(-) nodule spring back to previousstate

HAIR Thick HairBlack in color(+) for dandruff

Hair is evenlydistributed

- evenly distributed hair- thick hair- silky and resilient hair

- no infection or infestation


NAILS intact epidermisDirty nailsBlanch test capillaryrefill=2 sec.Angle of nails are160 degrees

- convex curvature; angleof nail plate about 160degree- smooth texture- highly vascular and pinkin light skinned clients:dark skinned clients mayhave brown or blackpigmentation in

longitudinal streaks- intact epidermis- prompt return of pink orusual color(generally lessthan 4 sec)






Normal

EYES EyebrowssymmetricallyEqual movement(-) edema and tearyeyesPupil is round and

equalBlinking issymmetricallyRedness ofconjunctiva

eyebrow symmetricallyaligned; equal movement- skin intact; no discharge;no discoloration- no edema or tearing- clients blinks when the

cornea is touched,indicating that thetrigeminal nerve is inintact

Normal





- no tender- firm

Normal

NOSE No lesion, skin coloris same as face,nasal septum intactand in midline.Client breaths freelyNo discharge

symmetric and straight- no discharge or flaring- uniform color- not tender; no lesion-air moves freely as theclient breaths through thenares

Normal

MOUTH AND

THROAT

Lips is pink

(-) nodules, notendernessAbility to purse thelipsMoves freelyno tenderness

- pink gums(bluish or dark

patches in dark skinnedclients)- moves freely; notenderness- smooth with no palpablenodules- ability to purse the lips- no discharge

Normal

NECK Movement with nodiscomfort(-)masses and

nodules

- coordinated, smoothmovements with nodiscomfort

-masses and nodules arenot palpable

Normal



Normal

NAME: F AGE: 12 YEARS OLD

GENDER: FEMALE


Weight 18 kg.

Height 129 cm.

BMI 11.25 <16 malnutrition Underweight



16-19 underweight20-25 normal26-30 overweight31-40 moderately toseverely obese>40 morbidly obese

(Fundamentals ofNursing; 7th edition;Barbara Kozier; pg.1175)

B. VITAL SIGNS

Blood pressure





SKIN brown color, pinchedup skin immediatelyreturn within 2-3sec.(-) edema(-) swellingWarm to touch(-) nodule


Normal

HAIR Thin HairBlack in colorHair is evenlydistributed(+)for lice


Presence of lice isdue to poor hygiene

NAILS intact epidermisDirty nails(-)Blanch testcapillary refillAngle of nails are160 degrees

- convex curvature; angleof nail plate about 160degree- smooth texture- highly vascular and pinkin light skinned clients:

dark skinned clients mayhave brown or blackpigmentation inlongitudinal streaks- intact epidermis- prompt return of pink orusual color(generally lessthan 4 sec)








Normal

EYES EyebrowssymmetricallyEqual movement(-) edema and tearyeyesPupil is round and

equalBlinking issymmetricallyRedness ofconjunctiva

eyebrow symmetricallyaligned; equal movement- skin intact; no discharge;no discoloration- no edema or tearing- clients blinks when the

cornea is touched,indicating that thetrigeminal nerve is inintact

Normal

EARS Color is same asfacial skin, auriclesis aligned in outercantus of the eye,(+) discharged


- no tender- firm

Normal

NOSE No lesion, skin coloris same as face,nasal serum intactand in midline.Client breaths freely(+) discharge


Normal

MOUTH ANDTHROAT

Lips is pink(-) nodules, no

tendernessAbility to purse thelipsMoves freelyno tendernessincomplete teeth

- pink gums(bluish or darkpatches in dark skinned

clients)- moves freely; notenderness- smooth with no palpablenodules- ability to purse the lips- no discharge

Normal





Normal



Normal

NAME: G AGE: 10 YEARS OLD

GENDER: FEMALE


Weight 16 kg.

Height 124 cm

BMI 10.66 <16 malnutrition16-19 underweight20-25 normal26-30 overweight31-40 moderately toseverely obese

>40 morbidly obese(Fundamentals ofNursing; 7th edition;Barbara Kozier; pg.1175)

Malnutrition

B. VITAL SIGNS

Blood pressure 120/80 mmHg





SKIN Light brown color,rough and dry skintexture, turgor:pinched up skinimmediately returnwithin 2-3 sec.

-Generally uniform exceptin the areas exposed tothe sun: areas of lighterpigmentation(palms,lips,nail beds) in dark skinpeople

Normal



(-) edema(-) swellingWarm to touch(-) noduleScars

-no edema-no nodule- when pinched skinspring back to previousstate

HAIR Thin HairBlack in colorHair is evenlydistributed(+)for lice



NAILS intact epidermisDirty nailsBlanch test capillaryrefillAngle of nails are160 degrees

- convex curvature; angleof nail plate about 160degree- smooth texture- highly vascular and pinkin light skinned clients:dark skinned clients may

have brown or blackpigmentation inlongitudinal streaks- intact epidermis- prompt return of pink orusual color(generally lessthan 4 sec)


HEAD Rounded skull(-)nodules ormassesSymmetric facial in

movement

- rounded( normocephalicand symmetrical, withfrontal, parietal andoccipital

prominence):smooth skullcontour- smooth, uniformConsistency; absence of


Normal

EYES EyebrowssymmetricallyEqual movement(-) edema and teary

eyesPupil is round andequalBlinking issymmetricallyRedness ofconjunctiva

eyebrow symmetricallyaligned; equal movement- skin intact; no discharge;no discoloration

- no edema or tearing- clients blinks when thecornea is touched,indicating that thetrigeminal nerve is inintact

Normal



EARS Color is same asfacial skin, auriclesis aligned in outercantus of the eye,(+) discharged


- no tender- firm

Normal

NOSE No lesion, skin coloris same as face,nasal septum intactand in midline.Client breaths freely(+) discharge


Normal

NECK Movement with no

discomfort(-)masses andnodules

- coordinated, smooth

movements with nodiscomfort-masses and nodules arenot palpable

Normal

CHEST No nodules ormassesSpinal column isstraightLeft and rightshoulder and hipsare at the same

height, equal chestsymmetry

- chest symmetry- spine vertically aligned- chest wall intact; notenderness; no masses- Spinal column is straightLeft and right shoulderand hips are at the same

height

Normal

NAME: H AGE: 3 YEARS OLD

GENDER: FEMALE


Weight 10 kg.

Height 85 cm

BMI 13.88 kg/m2 <16 malnutrition

16-19 underweight20-25 normal26-30 overweight31-40 moderately toseverely obese>40 morbidly obese(Fundamentals ofNursing; 7th edition;Barbara Kozier; pg.

Malnutrition



1175)

B. VITAL SIGNS






SKIN Dark brown color,rough and dry skintexture, turgor:pinched up skinimmediately returnwithin 2-3 sec.(-) edema

(-) swellingWarm to touch(-) nodule

-Generally uniform exceptin the areas exposed tothe sun: areas of lighterpigmentation(palms,lips,nail beds) in dark skinpeople-no edema

-no nodule- when pinched skinspring back to previousstate

Normal

HAIR Thick HairBlack in colorHair is evenlydistributed(+)for lice



NAILS intact epidermisDirty nails

Blanch test capillaryrefill=2 sec.Angle of nails are160 degrees

- convex curvature; angleof nail plate about 160

degree- smooth texture- highly vascular and pinkin light skinned clients:dark skinned clients mayhave brown or blackpigmentation inlongitudinal streaks- intact epidermis- prompt return of pink orusual color(generally lessthan 4 sec)




Normal




EYES Eyebrowssymmetrically

Equal movement(-) edema and tearyeyesPupil is round andequalBlinking issymmetricallyRedness ofconjunctiva

eyebrow symmetricallyaligned; equal movement

- skin intact; no discharge;no discoloration- no edema or tearing- clients blinks when thecornea is touched,indicating that thetrigeminal nerve is inintact

Normal

EARS Color is same asfacial skin, auricles

is aligned in outercantus of the eye,no discharged

- color is same as facialskin

- auricles is aligned inouter cantus of the eye- no discharge- symmetrically- no tender- firm

Normal

NOSE No lesion, skin coloris same as face,nasal septum intactand in midline.Client breaths freely

No discharge

symmetric and straight- no discharge or flaring- uniform color- not tender; no lesion-air moves freely as the

client breaths through thenares

Normal

MOUTH ANDTHROAT


- pink gums(bluish or darkpatches in dark skinnedclients)- moves freely; notenderness- smooth with no palpablenodules- ability to purse the lips- no discharge

Normal



Normal

CHEST No nodules ormasses

- chest symmetry- spine vertically aligned

Normal



Spinal column isstraightLeft and rightshoulder and hipsare at the sameheight, equal chest

symmetry

- chest wall intact; notenderness; no masses- Spinal column is straightLeft and right shoulderand hips are at the sameheight

NAME: I AGE: 1 YEAR OLD

GENDER: MALE


Weight 7 kg.

Height 63 cm.

BMI 17.5 <16 malnutrition16-19 underweight

20-25 normal26-30 overweight31-40 moderately toseverely obese>40 morbidly obese(Fundamentals ofNursing; 7th edition;Barbara Kozier; pg.1175)

Underweight

B. VITAL SIGNS


Temperature 36.5-370C

Pulse rate 60-100 bpmRespiratory Rate 16-20 cpm


SKIN Light brown color,pinched up skinimmediately return(-) edema(-) swellingWarm to touch(-) nodule


Normal

HAIR Thin HairBlack in color

- evenly distributed hair- thick hair

Normal



(-) for dandruffHair is evenlydistributed(-)for lice

- silky and resilient hair- no infection or infestation

NAILS intact epidermisClean nails

Blanch test capillaryrefillAngle of nails are160 degrees

- convex curvature; angleof nail plate about 160

degree- smooth texture- highly vascular and pinkin light skinned clients:dark skinned clients mayhave brown or blackpigmentation inlongitudinal streaks- intact epidermis- prompt return of pink orusual color(generally lessthan 4 sec)

Normal




Normal

EYES EyebrowssymmetricallyEqual movement(-) edema and tearyeyesPupil is round andequalBlinking issymmetrically


Normal



Normal



NOSE No lesion, skin coloris same as face,nasal septum intactand in midline.Client breaths freelyNo discharge

symmetric and straight- no discharge or flaring- uniform color- not tender; no lesion-air moves freely as theclient breaths through the

nares

Normal

MOUTH ANDTHROAT


- pink gums(bluish or darkpatches in dark skinnedclients)- moves freely; notenderness- smooth with no palpablenodules- ability to purse the lips- no discharge

Normal



Normal

CHEST No nodules ormassesSpinal column isstraightLeft and rightshoulder and hips

are at the sameheight, equal chestsymmetry

- chest symmetry- spine vertically aligned- chest wall intact; notenderness; no masses- Spinal column is straightLeft and right shoulder

and hips are at the sameheight

Normal

V. HOME AND ENVIRONMENT

They live on their own house and it is enough for them to live in. It is made from woodand cement. The house is not yet finish and further development like painting is needed. Theclient verbalized that “Tatapusin nalang namin ang bahay, tapos pipinturahan pa namin kapagmay sapat na kaming pera para dito.” Every Tuesday and Thursday, the garbage collector

collects the garbage in their barangay. They have their own water supply and electricity. Theclient verbalized that “ Kumukuha kami ng tubig sa poso sa tabi ng bahay namin para sa panginom at panligo na rin.” They use plastic container for their drinking storage and it is placebeside the kitchen. They use charcoal for their cooking. The client verbalized that “Masnakakamura kasi kami pag uling ang ginagamit kesa sa gas.”

“Maraming insekto, ipis at daga dito sa bahay, hindi naman kasi naiiwasan yang mgaiyan dito sa lugar namen.’ As verbalized by the client. They have no presence of hazardaccident in the house. The family has no pet.



INTERPRETATION:

The family was lucky for having a house of their own. They don’t have to pay any rentalfees. They have garbage collecting unit assigned to their area that’s why there is a propergarbage disposal. But the areas of the house are prone to infection causing agent becausepests and breeding sites of vectors are present. They have good water supply but drinking there

is not a safe action because the water are not ideal for drinking. Having no pet helps the familyto reduce the risk of infection caused by pets inside or even outside the house.

ANALYSIS:

A few environmental factors that can influence growth and development include livingconditions of the child; socio-economic status (e.g. poor versus financial stability), climate andcommunity (e.g. provide developmental support versus exposes the child to hazards). In theMan- Disease Agent-Environment link man by manipulating his environment is able to preventcontracting disease by blocking disease agent from entering his body. If the community fails toclean its environment and the breeding sites for Aedes mosquitoes are found everywhere thenthe community will have a higher risk for contracting dengue fever, since the mosquito vector

will be prevalent in the area.(Fundamentals of Nursing; Barbara Kozier; 8th edition; page 309)

VI. FAMILY ENVIRONMENT

The head of the family verbalized that, “Dito samin magkakasundo naman ang mga tao.Marunong naman makisama lahat ng kapitbahay. Ginagawa naman ng mga namumuno ditomga tungkulin nila. Madali silang lapitan kapag kailangan namin ng tulong”.

INTERPRETATION:

They have a good relationship with their neighborhood. The health center, social worker,private doctors and official are present in their place.

ANALYSIS:

A client environment includes all of the many psychosocial factors that influence or affectthe life and survival of the client. This broad definition of environment crosses the continuum ofcare for setting in which the nurse and client interact. Safety in health care setting reduces theincidence of illness and injury, shortens the length of treatment and hospitalization, improves ormaintains a client’s functional status, and increases the client’s sense of well-being.

(Fundamentals of Nursing; Potter - Perry; 6th

Edition, Volume 2; page 960-961)

VII. AWARENESS OF COMMUNITY ORGANIZATION

“May mga alam din akong community organization, tulad nung mga aktibidad sa healthcenter pati yung mga kagawad, may kakilala din naman kami hindi lang namin alam iyong mga



pangalan nila. Minsan nakikita namin pag may mga programa sila tulad ng libreng pagkain attuli”, as verbalized by A.

INTERPRETATION:

The family is aware of the community organizations within the area but their participationis not active. They believe that it is not that important and will not help in their daily living.

ANALYSIS:

It is important to be aware of community organization because it can help improve thelifestyle and socialization among family member and the community. Community organizationrefers to various methods of interventions whereby a professional change agent helps ascommunity system composed of individuals, group or organization to engage to plan collectedaction in order to deal with social problems within a democratic system of values. It is concernedwith programs aimed at social changed with primary reference to environmental conditions andsocial institution. It involves to major and interrelated concern; the process of working with an

action system, which includes planning and organizing, indentifying problem areas; diagnosingcauses and formulating solution; and developing the strategies and mobilizing the resources toeffect action. (Community Health Nursing in the Philippines; Elisa V. Dizon)



PRIORITIZATION:

A. WALKING BAREFOOTED

CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION

1. Nature of theproblem

2/3 x 1 2/3 The problem is healththreat since walkingbarefooted can makethe children acquireinfection.

2. Modifiability ofthe problem

2/2 x 2 2 The problem is easilymodifiable since thefamily has theirfootwear already. Butthe problem is theyare not wearingespecially the childrenwhen going outsidethe house, the nursecan encourage thefamily to use footwearand discuss the effectof not using it.

3. Preventivepotential

3/3 x 1 1 Since the family hastheir footwear already,they can preventwalking barefooted ifthe effect of doing socan be well explain tothem. They can avoidit if they can teachproper grooming.

4. Salience of theproblem

0/2 x 1 0 The family does notrecognize theexistence of theproblem.

TOTAL 3 2/3

B. SELF MEDICATION



2/3 x1 2/3 It is a health threatsince not allmedicines over thecounter drug have thesame effect to everyindividual.




2/2 x2 2 It is easily modifiablesince the resourcesand facilities areavailable in thecommunity like healthcenter for the

consultation of thefamily illnesses.


2/3 x 1 2/3 It is moderatelypreventive since it isnot in the nature ofthe family to visit thehealth center forconsultation. Theyrather self medicatethat to spend timegoing in health center.

4. Salience of the

problem

½ x 1 ½ They consider it as a

problem but notneeding immediateattention because themedication they areusing don’t causeallergic reaction to thefamily.

TOTAL 3 5/6

C. PRESCENCE OF BREEDING OR PESTING SITE OF VECTORS OF DISEASES



2/3 x 1 2/3 It is a health threatbecause it can spreadinfection and cancause diseases.


½ x 2 1 The problem ispartially modifiablebecause the familydoes not have theresources and budget

to renovate or fix theeare to prevent vectorsfrom multiplying.


2/3 x 1 2/3 It has a moderatelypreventive potentialbecause it is timeconsuming ineliminating thepesting site of vectors



and family resourcesare unavailable.


2/2 x 1 1 The family recognizedit as a problemneeding immediateattention to prevent

avoid illness anddisease caused bythese vectors.

TOTAL 3 1/3

D. INADEQUATE FOOD INTAKE BOTH IN QUALITY AND QUANTITY


1. Nature of the

problem

2/3 x 1 2/3 The problem is a

health threat since thefamily cannot provideproperly for the family.


½ x 2 1 The problem ispartially modifiablebecause the familydoes not have enoughmoney to sustain thedesirable foodrequirement for all theremaining membersof the family.

3. Preventivepotential 1/3 x 1 1/3 The problem is low inpreventive potentialbecause of the natureof work by the head ofthe family which isunstable, meaning hecannot supply theneeded nutrient toprevent malnutrition inthe family.


2/2 x 1 1 It is a problem thatneeds immediate

attention sinceinadequate foodintake can lead tomalnutrition.

TOTAL 3



E. CIGARETTE OR TOBACCO SMOKING



2/3 x 1 2/3 The problem is ahealth threat becauseit may result todisease caused bythe chemicalsacquired whilesmoking.


3/3/ x 1 1 The problem is highlypreventive since it isby choice of the headof the family, who wassmoking if he will stopit when the afterproblem will explainedand the effects are tobe known.


½ x 1 1 The problem ispartially modifiablesince the head of thefamily was smokingfor quite years nowand it had become hishabit and stressmanagement action.He will not easilyprevent from doing itand will take quitesometimes to totallyquit it.


0/2 x 1 0 The family does notperceived it as aproblem at all.

TOTAL 2 2/3

WALKING BAREFOOTED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 2/3

SELF MEDICATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 5/6

PRESCENCE OF BREEDING OR PESTING SITE OF VECTORS OF DISEASES . . 3 1/3

INADEQUATE FOOD INTAKE BOTH IN QUALITY AND QUANTITY . . . . . . . . . . . . . 3

CIGARETTE OR TOBACCO SMOKING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 2/3

Case Case Case Case Case

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