Compiled FCA 103

I. INTRODUCTION Call it a clan, call it a network, call it a tribe, and call it a family.
Whatever you call it, whoever you are, you need one ~Jane Howard
Human do not thrive by being alone. They are social beings. Hence a man cannot live by depending on himself alone; he needs the company of others for him to be able to share and to be shared by others the experiences that they encounter on their daily lives. He needs others to rely on and to be relied on at times of adversity in his life and he needs somebody to help him achieve the goals that he wants to meet in his life. That is what a family is for, each members of the family plays crucial role in developing the other family members physical, mental and social wellbeing.
A family is defined as two or more people who share goals and values, have long-term commitments to one another, and reside usually in the same dwelling place or it can be collective body of persons who live in one house, and under one head or
manager; ahousehold, including parents, children, and servants, and, as the case may b e, lodgers or boarders that is what we call family (Ardictionary, 2008).
A community is a social group of any size whose members reside in a specific locality, share government, and often have a common cultural and historical heritage (dictionary.reference.com, 2008). From the definition itself that a community is a social group, we can conclude that each and every member of the community plays an important role by interacting with one another just like a family member communicates with another member of the family. Hence, a member of the community can directly or indirectly affects the other member by interacting with them.
The meaning and purpose of Community Health Nursing evolved as time goes by. The World Health Organization defined it as a special field of nursing that combines the skill of nursing, Public Health Nursing, the improvement of conditions in social and physical environment, rehabilitation of illness and disability.
Family Case Analysis Enchanted Family of Brgy. Balibago
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Community Health Nursing gives emphasis on the promotion of health and prevention of illness. Here, the nurse will be able to see the picture of family and community health. The community is the recipient of service provided by the nurse. And as the basic unit of the community, the family is also the basic unit of nursing service (Reyala, 2000).
Many factors nowadays, can sturdily affect the health of a Filipino family and its members health whether directly or indirectly. Among which is the increasing number of broken families or families in which parents are no longer committed to one another or separated by divorce here in the Philippines. In a country where most people still believe that marriage is sacred, the question of whether or not to legalize divorce in the Philippines remains to be one of the biggest issues the Philippine government is faced with today (Miller, 2006). Divorce is linked to a number of serious problems beyond the immediate economic problem of lost income. For instance, the children of divorced parents are more likely to get pregnant and give birth outside of marriage, especially if the divorce occurred during their mid-teenage years,18 and twice as likely to cohabit than are children of married parents. Moreover, divorce appears to result in a reduction of the educational accomplishments of the affected children, weakens their psychological and physical health, and predisposes them to rapid initiation of sexual relationships and higher levels of marital instability. It also raises the probability that they will never marry, especially for boys (Jacobs et al, 2005).
To be able to assess and identify health problems of the families in the community, a Family Case Analysis is done. According to Danilo (2006), Family Case Analysis is a combined process of assessing, interacting, and interviewing. It is a means which nursing practice is focused on the family as the result of care with health as the goal of nursing as the medium channel in providing care. Working with the family is done through home visitation. It encompasses the planning of appropriate interventions based on available resources and acceptance of family members, implication of interventions as planned and, lastly, the evaluation of carried out actions of health teachings provided to the family.
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The purpose of the Family Case Analysis is to present how the family lives in the area, their way of life and their means of survival. It provides broad knowledge of understanding and implementation that the group can use in the care of their family.
The family was recommended by the staff of the Barangay Health Center. The family was chosen after meeting the criteria such as being easily identified to be depressed and deprived, having four (4) or more children with at least two (2) child belonging to the 0-5 age bracket, with visible poor environmental condition and who gives permission to be taken as case for the FCA project
Simple deeds that are done by student nurses may be left behind or remembered but it wont mean anything if it didnt affect the people. Its hard to change how the world is but trying to improve how one lives and giving hope in little ways can affect the way people choose to live and their perspective in life. For this Family Case Analysis, the mission is not how student nurses are going to help them but it should be how the student nurses are going to help the family help themselves.
The adopted family is the Enchanted Family and it is composed of 5 members, a mother, a father, their daughter and 2 of the mothers sisters. The couple was married in 2005 and they moved in Angeles City three years ago with the mothers sisters. All of the 5 members of the family reside in the same household that was pawned to them by a friend for the value of Php 50,000.00. The household is located along the corners of the A. Santos Road Balibago Angeles City. The student nurses were able to conduct 5 home visits to the said family last August 10, 2010 until the 24th day of the same month and year. As nursing process is the indispensible tool that is utilized by the nurse as a guide in providing effective health care to his/her client, the student nurses.
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Entry/ Climate of Acceptance
Balibago is a community near Casino Filipino Angeles which is one jeepney ride away from Angeles University Foundation. Here is where the group had their Community Health Nursing and the group looked for qualified family for the grou ps family case analysis.
On August 10, 2010, a sunny Tuesday afternoon, the group was walking along the streets of Balibago, Angeles City as they were looking for a qualified family with the criteria: depressed, deprived and underserved for the Family Case Analysis. The group caught sight of a small house. The small space in the front door was made to be a mini sari-sari store. Ynang Reyna was sitting in a chair behind a wooden desk piled up with store products. The group greeted her, Good morning po, pwede hong maki abala, student nurses po kami sa Angeles University Foundation. And Ynang Reyna smiled at the student nurses and replied immediately, Anu yon? with a pleasing voice. She knew from the very start that we werent customers. The group answered back saying Bali, naghahanap po kami ng maadopt ho naming family, tapos ho tinutulungan po namin sila sa mga problema po sa loob po ng bahay lalo na po sa kalusugan po ng bawat miyembro po ng pamilya nila. Kung ayos lang ho, kayo po ang napili namin. Ynang Reyna was smiling at the student nurses while they were saying so, and then she replied, Okay, ayos lang. then she gave the student nurses a humorous laugh then asked them to sit down to the chairs placed in front of the store.
The group further introduced themselves. The group also introduced to the family the more comprehensive objectives and purpose of the home visits and how it could benefit both parties. Student nurses also told them on how long they will be going to visit. The group felt whole-heartedly welcomed by the family.
On that day, the group started their observation of the place and assessment of each member the family. They also started interviewing the mother to obtain the familys socio-economic data. However, Ybarro, and Danaya was, unfortunately, not present at that moment for they are working.
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Finally, the group found out that because of the familys hospitality and accommodation, it was not really hard to establish rapport and initiate a trusting relationship with them.
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Objective Student Nurses Centered Short-term
A. 1.
At the end of the 1st home visit, the student nurses shall have:
Familiarized ourselves with the community and its people and chose a family to
be adopted for the family case analysis. Greeted and introduced themselves with the chosen family, familiarized
ourselves with the family members as well as established rapport with them. Explained the purpose of their home visit and the succeeding home visits in the
following days. Obtained necessary information like demographic data, socio-economic and
cultural information. Obtained initial vital signs and performed physical assessment to the family
member. Understood the means of living of the chosen family. If possible, performed immediate nursing care and health teachings to visible
problems in the family. Made an appointment to return
2. Long-term
After 4 days home visits, the Student nurses shall be able to: Impart knowledge to the family to make them self reliant. Educated the family regarding the importance of proper hygiene. Guide the family in identifying actual and potential problems which may be a Generate interventions considering the nurses, community and the familys
hindrance in attaining optimum health.
resources. Give emphasis on the importance and benefits of community health facilities
available.
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Enhance their ability to interact and communicate with people as learning from
the exposure to the community. Evaluate changes in condition after giving interventions.
A. Family-Centered
1. Short-term At the end of the first home visit, the family shall have: Accepted and welcomed the student nurses from AUF. Established rapport with the student nurses. Verbalized willingness to participate in the purpose of the Family Case Analysis. Provided demographical and socio-cultural information needed for the Family
Case Analysis. Acquired knowledge from the health teaching given and know the importance on
having a good health. Accepted the appointment to return of the group.
2. Long Term After 4 days of home visits, the family shall be able to: Apply some of the health teaching that the student nurse had imparted. Become self reliant especially when it comes to health matters. Attain a level of proper hygiene. Maximize the use of resources as needed. Identify health problems that can be a threat in attaining optimum health. Evaluated own changes thru given interventions by the student nurses.
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II. FAMILY CONSTELLATION Present Health Status Ybarro was watching television inside the house when he was first seen by the group. He was Age: 33 years old wearing a red sando and shorts. He has a dark Position in the family: Father brown complexion. His sclera were red because of lack of sleep. His finger and toenails were dirty and (Breadwinner) untrimmed. His teeth were complete but cavities Gender: Male were noticed. His vital signs were taken and recorded as follows: Educational Status: Vocational Temp: 35.9 (per axillae) Graduate (Not Going to School) PR: 68 beats per min RR: 15 breaths per min BP: 110/90 mmHg Ht: 58 Wt: 84.3 kg BMI: 27.73 (Overweight) Ynang Reyna was sitting in a chair when the student nurses first saw her. She was wearing a white lousy Age: 30 years old shirt stained with dirt and above the maong shorts. Position in the family: Mother She has a medium-dark brown complexion with uncombed hair but tied hair. She also scratches her Gender: Female scalp every now and then. Presence of Educational Status: High school pediculosis and visible dandruff flakes were Graduate (Not Going to School) noted. Her teeth are incomplete and are slightly yellowish in color. Her vital signs were taken and recorded as follows: Temp: 36.8 (per axillae) PR: 72 beats per min RR: 17 breaths per min BP: 120/80 mmHg Ht:53 Wt:89.24kg BMI: 36.28 (Obese II) Lira Age: 4 years old and 3 months Lira was first seen when she got out of the house during the interview of Ynang Reyna. She has a light brown complexion. She was wearing a white sando Position in the family: Daughter stained with red sauce and a short. She was playing with a tick or a louse from dog that she was carrying Gender: Female in her palms. Presence of pediculosis was Educational Status: Kinder (Going to noticed. She also have nasal discharges that she School) play with her tongue every now and then while her mother asks her not to. She also have cavities in her milk teeth. Her vital signs were taken and recorded as follows: Ynang Reyna Name Ybarro
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Temp: 37.2 (per axillae) PR: 74 beats per min RR: 22 breaths per min FNRI: 17.94 (Desirable body weight)
Danaya Age: 27 years old Position in the family: Ynang Reynas sister Gender: Male Educational Status: Grade 3 Elementary (Not Going to School)
She was first seen lying on couch watching television when one of the student nurses came in to check the condition of the house. She has a light brown complexion. She was wearing a gray t-shirt and a jogging pant. Presence of pediculosis and visible dadruff flakes were also noticed. She has incomplete teeth with cavities on some. Her vital signs were taken and recorded as follows: Temp: 36.8 (per axillae) PR: 68 beats per min RR: 14 breaths per min BP: 130/90 mmHg Ht: 50 Wt: 53.81 BMI: 21.56 (Normal) Not seen the entire home visits because of her job
Pirena
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III. HEALTH ASSESSMENT (Chepalocaudal- IPPA)
Performing a physical assessment and attaining a health history are done for the evaluation of each family members health status. It is a tool for efficient data collection and will help health care providers to recognize grow deviations from normal. The purpose of physical assessment is to obtain the baseline data about the clients functional abilities and to identify areas of health promotion, disease prevention, establish health diagnosis and plan of care for the family in assessing a family, it is a must to establish rapport, to have a good working relationship, and to gain trust and cooperation from the family. Having a good therapeutic communication has to be utilized in this aspect.
Health assessment requires use of senses; sense of sight, hearing, smelling and sense of touch. Methods of examining include inspection, palpation, percussion and auscultation. Prior to performance of assessment, position the client comfortably; explain what you are going to do, why it is necessary and how he or she can cooperate. Assessment starts from general survey which involves observation of the client/s general appearance, body built and posture, hygiene, height and weight and mental status. Then obtaining the vital signs is essential, and then followed by the head to toe framework of assessment. A foundation of basic anatomy and physiology is the key to develop skill, expertise and appreciation of the whole wide range of findings that are considered normal and abnormal.
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Ybarro, age 33, is the father in the Enchanted Family. His height was 58 and he weighs 84.3 kg.
Vital signs 1st Home Visit (Aug-10-10) 35.9 oC 68 bpm 15 cpm 110/90 mmHg 2nd Home Visit (Aug-16-10) Temp PR RR BP 37.1 oC 67 bpm 16 cpm 120/90 mmHg 3rd Home Visit (Aug-17-10) 35.6 oC 72 bpm 17 cpm 4th Home Visit (Aug-23-10) 36.7 oC 74 bpm 16 cpm 5th Home Visit (Aug-24-10) 37.2 oC 69 bpm 19 cpm 120/90mmHg
Vital Signs
110/80 mmHg 110/90 mmHg
Initial Assessment (August 10, 2010) During the first physical assessment, Ybarro was in their Living room, wearing
red sando and shorts watching television. He seems to be sleepy. A. General Appearance Ybarro has a medium body built. He is conscious and coherent. He has tattoo on his left arm. He has a dark brown complexion with short. He also has yellow stained teeth with cavities. He has untrimmed dirty finger.
B. Physical Assessment
Skull, head and hair Ybarro has no contusions, bruises, scars, nodules or masses on his head. He has coordinated facial movements as evidenced by patients ability to smile, frown, raise his eyebrows and show is teeth. He has short hair which is evenly distributed and presence of dandruff was observed.
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Facial Features
Eyes Eyebrows are symmetrical and evenly distributed. Client blinks when the cornea is touched on its side by a wisp of cotton. He has red eye. Pupils are equally rounded and responsive to light. Both pupils constricts when illuminated, also pupil opposite the one illuminated constricts simultaneously. His pupils constricted when asked to look at a near object, and it dilated when was asked to look at a far object. Clients eyes had able to follow the penlight as it moves on 6 fields of vision.
Ears He has symmetrical ears and tip of the ears are aligned with the outer canthus of the eyes. No presence of cerumen on both ear canals was observed when inspected. Pinna recoils after folded.
Nose His nose is located at the midline, and no discharge or flaring noted; uniform in color; not tender and without lesions, air moves freely when he breathes through the nares, and his facial sinuses are non-tender. Mouth Lips and gums are pinkish in color. The oral mucosa is moist and pinkish in color. He has the ability to purse lips. The uvula is located at the midline of the soft palate. Tongue is located in the midline and can able to move freely. Yellowish color of teeth, with presence of cavities are noted. No mouth sore, no inflammation and no halitosis were observed.
Neck Neck is uniform in color. No enlargement of thyroid gland was observed. His lymph nodes are non palpable. His cricoid cartilage elevates when he was asked to swallow. He has a good sternocleidomastoid and trapezius muscle strength. Nurses asked to extend his neck and move it from side to side and he was able to perform these without any difficulty and pain as eventual opposite pressure is applied.
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Chest Ybarros chest has anterior-posterior to transverse diameter in ratio of 1:2 symmetrical in shape, no inflammation, lesions, tenderness and deformities. He has normal lung expansion as evidenced by thumb separates at 3 cm. He has a good tactile fremitus as assessed by the word ninety-nine and vibration was felt on the palm when uttered these words. Both lung fields are clear. Heart Ybarro has a radial pulse of 68 bpm. Brachial pulse was auscultated and there is a regular rhythm. No presence of abnormal heart sound was auscultated. Breast His skin is uniform in color. No masses and lesion noted upon inspection and palpation. There is no inflammation or discharges seen.
Abdomen Has unblemished abdominal skin and symmetric movements caused by respiration. There were no lesions or masses upon inspection. There is no pain or tenderness upon palpation. Tympany was elicited over the stomach and gas filled bowels upon percussion. Back and spine His back is uniform in color and spine has normal curvature. No pain was reported by Ybarro. Nails Ybarro has untrimmed, dirty finger and toenails. Nail beds are pinkish in color. Nails are smooth in texture with intact tissue around the nail color. There is capillary refill of less than 2 seconds upon blanching the nails. He has negative result with the schamroths test. Skin Ybarro has a brown complexion. Skin is warm to touch with good skin turgor.
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Upper and Lower extremities Ybarros upper and lower extremities are symmetrical in shape and size. He has an upright posture and steady gait with opposing arm swing. He walks unaided and maintains balance. He can extend and flex his extremities with any pain. There are no deformities, tenderness or swelling on the extremities. There is fine distribution of hair. He has symmetry of pulses. Neurologic Examination
Mental Status Ybarro is conscious and coherent when seen. He is oriented and can identify person date and time. He can express oneself by speech. He can recall information from the past by recalling previous health history.
Motor Function His arms are swinging oppose, walks unaided and maintains balance. Cranial Nerves Assessment (YBARRO) Cranial Nerve Assessment Technique Normal Response Clients Response I. Olfactory Ask the client to smell and Client identify the smell of identify with is able to Ybarro was able to the smell his eyes
different identify each different
cologne with each nostril smell separately and with the nostril eyes closed.
separately while
and with eyes closed were closed. unless such
condition like colds is present.
II. Optic
Provide adequate lighting The client should be Ybarro
has
no
and ask client to read from able to read with difficulty in reading a reading material held at a each eye and both especially those
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distance of 36 cm. (14 in.).
eyes.
with
small
font
size. He can read within the distance of 14 inches. III. Oculomotor Reaction to light: Using a penlight and Illuminated and non- The pupil and illuminated non-
approaching from the side, illuminated shine a light on the pupil. should constrict. Observe the response of the illuminated pupil. Shine the light on the pupil again, and observe the response of the other pupil.
illuminated pupil of Ybarro constricted.
Reaction accommodation:
to Pupils constrict when His looking at a near constricted pupils when
Ask client to look at a near object and then at a distant object. Alternate the gaze from the near to the far object. Next, move an object towards the clients nose.
object, dilate when looking at a near looking at a distant object and dilates object, converge when looking at far and when is when near object is object moved towards the converge nose. near object
moved towards the nose. IV. Trochlear Hold a penlight 1 ft. in front Clients eyes should Ybarros eyes had of the clients eyes. Ask the be able to follow the able to follow the client to follow the penlight as it moves. penlight as it
movements of the penlight with the eyes only. Move the penlight upward,
moves on 6 fields of vision.
downward, sideward and diagonally.
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V. Trigeminal
While client looks upward, Client should have a Ybarro lightly touch lateral sclera positive of eye to elicit blink reflex. To have test light reflex, corneal blinked able to touched able
eyes when with to
sensation, respond to light and cotton,
client
close
eyes, deep sensation and respond to light, he able to differentiate can also identify hot from cold. sharp from dull
wipe a wisp of cotton over clients forehead. To test deep sensation, use alternating blunt and sharp ends of an object. to
and hot from cold.
Determine
sensation
warm and cold object by asking client to identify
warmth and coldness. VI. Abducens Hold a penlight 1 ft. in front Both eyes Both eyes of were of the clients eyes. Ask the coordinated, move in Ybarro client to follow
the unison with parallel coordinated move in unison with
movements of the penlight alignment. with the eyes only. Move the penlight through the six cardinal fields of gaze. VII. Facial
parallel alignment.
Ask client to smile, raise Client should be able Ybarro had able to the eyebrows, frown, and to smile, raise distinguish
puff out cheeks, close eyes eyebrows, and puff different tastes, he tightly. Ask client to identify out cheeks and close can able to smile, various tastes placed on tip eyes and sides of tongue. without any frown, and puff
difficulty. The client cheeks, close eyes should also be able and to distinguish eyebrows. raise
different tastes. VIII. Vestibulocochlear Have the client occlude one Client should be able Ybarro heard the ear. Out of the clients to hear the tickling of tickling of the
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sight, place a tickling watch the watch in both watch on his both 2 to 3 cm. ask what the ears. client can hear and repeat with the other ear. Ybarro has steady gait, he can able to Ask walk The client should maintain balance across the room and back have upright posture and has an upright and assess the clients gait. and steady gait and posture. able to maintain the client to ears.
balance. IX. Glossopharyngeal Ask the client to say ah Client should be able Ybarro had able to and have the patient yawn to elicit gag reflex elicit to observe of upward and swallow without and the soft any difficulty. swallow difficulty. gag able reflex to
movement palate.
without
Elicit gag response. Note ability to swallow. X. Vagus Ask the patient to swallow The client should be Ybarro had able to and speak (note able to swallow swallow with
hoarseness)
without difficulty and difficulty and speak speak audibly. audibly.
XI. Accessory
Ask
client
to
shrug Client should be able Ybarro was able to against to shrug shoulders shrug his
shoulders
resistance from your hands and turn head from shoulders and turn and turn against head to side side to side. resistance from his head from one side to the other.
your hand (repeat for other side). XII. Hypoglossal Ask client to protrude The client should be Ybarro moved his without
tongue at midline and then able to move tongue tongue move it side to side. without any difficulty. difficulty.
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Final Assessment (August 24, 2010)
C. General Appearance Ybarro has a medium body built. He is conscious and coherent. He has tattoo on his left arm. He has a dark brown complexion with short. He also has yellow stained teeth with cavities. He has trimmed clean finger and toenails.
D. Physical Assessment
Skull, head and hair Ybarro has no contusions, bruises, scars, nodules or masses on his head. He has coordinated facial movements as evidenced by patients ability to smile, frown, raise his eyebrows and show is teeth. He has short hair which is evenly distributed.
Facial Features
Eyes Eyebrows are symmetrical and evenly distributed. Client blinks when the cornea is touched on its side by a wisp of cotton. Pupils are equally rounded and responsive to light. Both pupils constricts when illuminated, also pupil opposite the one illuminated constricts simultaneously. His pupils constricted when asked to look at a near object, and it dilated when was asked to look at a far object. Clients eyes had able to follow the penlight as it moves on 6 fields of vision. Ears He has symmetrical ears and tip of the ears are aligned with the outer canthus of the eyes. No presence of cerumen on both ear canals was observed when inspected. Pinna recoils after folded. Nose His nose is located at the midline, and no discharge or flaring noted; uniform in color; not tender and without lesions, air moves freely when he breathes through the nares, and his facial sinuses are non-tender.
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Mouth Lips and gums are pinkish in color. The oral mucosa is moist and pinkish in color. He has the ability to purse lips. The uvula is located at the midline of the soft palate. Tongue is located in the midline and can able to move freely. Yellowish color of teeth, with presence of cavities are noted. No mouth sore, no inflammation and no halitosis were observed. Neck Neck is uniform in color. No enlargement of thyroid gland was observed. His lymph nodes are non palpable. His cricoid cartilage elevates when he was asked to swallow. He has a good sternocleidomastoid and trapezius muscle strength. Nurses asked to extend his neck and move it from side to side and he was able to perform these without any difficulty and pain as eventual opposite pressure is applied.
Chest Ybarros chest has anterior-posterior to transverse diameter in ratio of 1:2 symmetrical in shape, no inflammation, lesions, tenderness and deformities. He has normal lung expansion as evidenced by thumb separates at 3 cm. He has a good tactile fremitus as assessed by the word ninety-nine and vibration was felt on the palm when uttered these words. Both lung fields are clear. Heart Ybarro has a radial pulse of 69 bpm. Brachial pulse was auscultated and there is a regular rhythm. No presence of abnormal heart sound was auscultated. Breast His skin is uniform in color. No masses and lesion noted upon inspection and palpation. There is no inflammation or discharges seen. Abdomen Has unblemished abdominal skin and symmetric movements caused by respiration. There were no lesions or masses upon inspection. There is no pain or tenderness upon
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palpation. Tympany was elicited over the stomach and gas filled bowels upon percussion. Back and spine His back is uniform in color and spine has normal curvature. No pain was reported by Ybarro. Nails Ybarro has trimmed, clean finger and toenails. Nail beds are pinkish in color. Nails are smooth in texture with intact tissue around the nail color. There is capillary refill of less than 2 seconds upon blanching the nails. He has negative result with the schamroths test. Skin Ybarro has a brown complexion. Skin is warm to touch with good skin turgor. Upper and Lower extremities Ybarros upper and lower extremities are symmetrical in shape and size. He has an upright posture and steady gait with opposing arm swing. He walks unaided and maintains balance. He can extend and flex his extremities with any pain. There are no deformities, tenderness or swelling on the extremities. There is fine distribution of hair. He has symmetry of pulses.
Neurologic Examination
Mental Status Ybarro is conscious and coherent when seen. He is oriented and can identify person date and time. He can express oneself by speech. He can recall information from the past by recalling previous health history. Motor Function His arms are swinging oppose, walks unaided and maintains balance.
Cranial Nerves Assessment (YBARRO)
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Cranial Nerve
Assessment Technique
Normal Response
Clients Response
I. Olfactory
Ask the client to smell and Client identify the smell of identify
is
able
to Ybarro was able to the smell his eyes
different identify with each different
separately while
and with eyes closed were closed. unless such
II. Optic
Provide adequate lighting The client should be Ybarro
has
no
and ask client to read from able to read with difficulty in reading a reading material held at a each eye and both especially distance of 36 cm. (14 in.). eyes. with small those font
size. He can read within the distance of 14 inches. III. Oculomotor Reaction to light: Using a penlight and Illuminated and non- The pupil and illuminated non-
illuminated pupil of Ybarro constricted.
to Pupils constrict when His looking at a near constricted pupils when
Ask client to look at a near object and then at a distant
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object. Alternate the gaze object, dilate when looking at a near from the near to the far looking at a distant object and dilates object. Next, move an object, converge when looking at far and when is object towards the clients when near object is object nose. moved towards the converge nose. near
object
moved towards the nose. IV. Trochlear Hold a penlight 1 ft. in front Clients eyes should Ybarros eyes had of the clients eyes. Ask the be able to follow the able to follow the client to follow the penlight as it moves. penlight as it
moves on 6 fields of vision.
downward, sideward and diagonally.
V. Trigeminal
While client looks upward, Client should have a Ybarro lightly touch lateral sclera positive of eye to elicit blink reflex. To have test light reflex, corneal blinked able to touched able
eyes when with to
sensation, respond to light and cotton,
client
close
eyes, deep sensation and respond to light, he able to differentiate can also identify hot from cold. sharp from dull
wipe a wisp of cotton over clients forehead. To test deep sensation, use alternating blunt and sharp ends of an object. to
and hot from cold.
Determine
sensation
warmth and coldness. VI. Abducens Hold a penlight 1 ft. in front Both eyes Both eyes of were of the clients eyes. Ask the coordinated, move in Ybarro
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client
to
follow
the unison with parallel coordinated move in unison with
movements of the penlight alignment. with the eyes only. Move the penlight through the six cardinal fields of gaze. VII. Facial
parallel alignment.
Ask client to smile, raise Client should be able Ybarro had able to the eyebrows, frown, and to smile, raise distinguish
puff out cheeks, close eyes eyebrows, and puff different tastes, he tightly. Ask client to identify out cheeks and close can able to smile, various tastes placed on tip eyes and sides of tongue. without any frown, and puff
difficulty. The client cheeks, close eyes should also be able and to distinguish eyebrows. raise
different tastes. VIII. Vestibulocochlear Have the client occlude one Client should be able Ybarro heard the ear. Out of the clients to hear the tickling of tickling of the
sight, place a tickling watch the watch in both watch on his both 2 to 3 cm. ask what the ears. client can hear and repeat with the other ear. Ybarro has steady gait, he can able to Ask walk The client should maintain balance across the room and back have upright posture and has an upright and assess the clients gait. and steady gait and posture. able to maintain the client to ears.
balance. IX. Glossopharyngeal Ask the client to say ah Client should be able Ybarro had able to and have the patient yawn to elicit gag reflex elicit to observe of upward and swallow without and the soft any difficulty. swallow difficulty. gag able reflex to
movement palate.
without
Elicit gag response.
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Note ability to swallow. X. Vagus Ask the patient to swallow The client should be Ybarro had able to and speak (note able to swallow swallow with
hoarseness)
XI. Accessory
Ask
client
to
shrug Client should be able Ybarro was able to against to shrug shoulders shrug his
shoulders
resistance from your hands and turn head from shoulders and turn and turn against head to side side to side. resistance from his head from one side to the other.
your hand (repeat for other side). XII. Hypoglossal Ask client to protrude The client should be Ybarro moved his without
tongue at midline and then able to move tongue tongue move it side to side. without any difficulty. difficulty.
Activities of Daily Living Ybarro usually wakes up around 6 am in the morning; he then starts his day by eating breakfast and reading newspaper while watching/listening to the television until 7 am. He would watch television the whole day or exchange place with Ynang Reyna in watching out for the sari-sari store when Ynang Reyna has to do something inside the house. He usually eats his lunch with the family 11 in the morning or 12 noon. He eats dinner around 7 in the evening and sleeps at around 9 oclock in the evening. He sleeps in he bedroom with Ynang Reyna. He doesnt drink alcohol at all nor smoke tobacco. Ytay is not choosy or pihikan with foods, whatever it is that is served on the table, hell eat it for as long that it is edible. During his duty in the ship, he is usually in night shift, for 12 hours he would wake up by 4 in the afternoon and start working. He would have his break every 3 hours he would eat his meals by those time. And he would sleep by 5 in the early morning. History of Past and Present Illness Ybarro has no history of major illness. Though he sometimes acquire conditions such as colds and flu, he tend to self medicate and buy himself over the counter
Page 24
medicine such as Tempra, Neozep and Bioflu. Although sometimes without medication, the condition would just be gone when he rests for a day or so. Nutritional Status (Ybarro) Classification Underweight Severe Thinness Moderate Thinness Mild Thinness Normal Range Overweight Pre-Obese Obese Obese Class I Obese Class II Obese Class III Age: 33yrs. old Height: 1.73 m Weight: 84.30 kg BMI = Wt. in kg Ht in m2 = 84.30 kg . 1.73m2 = 27.73 (Overweightl) <18.50 <16 16.00 - 16.99 17.00 - 18.49 18.50 - 24.99 25.00 25.00 30.00 30.00 - 34-99 35.00 - 39.99 40 and above BMI (kg/m2)
Page 25
Ynang Reyna, age 30, is the mother in the Enchanted Family. Her height is 5 feet 3 inches tall and weighs 89.24 kilogram. Her waist measures 76 cm and her hips is 89 cm.
Vital signs Vital Signs 1st Home Visit (Aug-10-10) Temp PR RR BP 36.8 oC 72 bpm 17 cpm 110/90 mmHg 2nd Home Visit (Aug-16-10) 3rd Home Visit (Aug-17-10) 35.6 oC 70 bpm 17 cpm 110/80 mmHg 4th Home Visit (Aug-23-10) 36.7 oC 74 bpm 16 cpm 110/90 mmHg 5th Home Visit (Aug-24-10) 36.8 oC 69 bpm 14 cpm 120/90 mmHg
Initial Assessment (August 10, 2010) Ynang Reyna was in the store sitting on a monoblock, watching out for the sari-
sari store when the student nurses conducted the physical assessment,
A.
General Appearance Ynang Reyna has a proportionate body built, dirty appearance, unkempt and has
no body odor. She is conscious and coherent. She has a medium dark brown complexion with pediculosis in her untidy long black curly hair. She also has yellowish teeth and dental cavities.
B.
Physical Assessment
Skull, head and hair Ynang Reyna has a normocephalic skull. No contusions, bruises, scars, nodules or masses noted. She has symmetrical facial movements. She has long thin black hair with pediculosis, excessively dry and evenly distributed with the presence of dandruff.
Page 26
Facial Features
Eyes Her eyebrows are evenly distributed and symmetrically aligned. Her eyelashes are equally distributed. She has a black pupils, anicteric sclera and with pink palpebral conjunctiva. There were no discharges, discoloration or inflammation observed. Her pupils are equally rounded and responsive to light and accommodation. Her eyelids close symmetrically and involuntary blinks 18 blinks per minute.
Ears She has symmetrical ears and auricles are aligned with the outer canthus of the eyes. There is a presence of dry cerumen on both ear canals when inspected. Pinna recoils after folded. She can also hear ticking of the watch on both ears
Nose She has a nose which is uniform in color; septum is on midline, non-deviated, no tenderness or lesions upon inspection and palpation. Air moves freely as the client breathes through the nares. No nasal flaring was observed during inspiration and exhalation. Facial sinuses are non-tender. Mouth She has pinkish and moist lips. Teeth are yellowish. Some are incomplete and with dental carries. She has ability to purse lips. No inflammation. Tongue is on central position, moves freely and non-tender. No mouth sores or stomatitis upon inspection. No halitosis. The uvula is positioned in midline to soft palate. Neck Neck is uniform in color. No enlargement of thyroid gland was observed. Her lymph nodes are non palpable and jugular veins are not distended. Her cricoid cartilage elevates when she was asked to swallow. She has a good sternocleidomastoid and trapezius muscle strength nurses asked to extend her neck and move it from side to side and she was able to perform these without any difficulty and pain as eventual opposite pressure is applied.
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Chest Ynang Reynas chest is symmetrical, no inflammation, lesions, tenderness and deformities. Ynang Reyna has a normal respiratory excursion as evidenced by hands on the lower thorax with fingers laterally placed along the client ribcage and thumb along normally separates at 3 to 5 cm. She has a good tactile fremitus as assessed by the word ninety-nine and vibration was felt on the palm when felt on the palm when uttered these words. There is bilateral symmetry of vocal fremitus both lung fields are clear. Heart Ynang Reyna has a radial pulse of 72 bpm. Brachial pulse was auscultated and there is a regular rhythm. No presence of abnormal heart sound was auscultated. Breast Her skin is uniform in color. No masses and lesion noted upon inspection and palpation. There is no inflammation or discharges seen. Her breasts are round, sagged. The nipples are equal in size. Abdomen There were no lesions or masses upon inspection. She has a flat abdomen. Ynang Reyna has normoactive bowel sounds upon. There is no pain or tenderness upon palpation. There is presence of stretch marks in the abdomen. Back and spine Her back is uniform in color and spine has normal curvature. No pain was reported by Ynang Reyna. Nails Ynang Reyna has a trimmed, clean fingers and toe nails. Nail plate are colorless and convex curved. Nails are smooth in texture with intact tissue around the nail color. There is capillary refill of 3 seconds upon blanching the nails turned to light pink in color. She has negative result with the schamroths test.
Skin
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Ynang Reyna has a brown complexion. There was presence of prickle around her neck and thorax upon inspection. Skin is warm to touch with good skin turgor. She has evenly distributed hair. Upper and Lower extremities Ynang Reyna are symmetrical in shape and size. She has an upright posture and steady gait with opposing arm swing. She walks unaided and maintains balance. She can extend and flex his extremities with any pain. There are no deformities, tenderness or swelling on the extremities. There is fine distribution of hair. She has symmetry of pulses. Neurologic Examination
Mental Status Ynang Reyna is conscious and coherent when seen. She can express oneself by speech. She is oriented and can identify person date and time. She can recall information from the past by recalling previous health history.
Motor Function Her arms are swinging oppose, walks unaided and maintains balance. Cranial Nerves Assessment (YNANG REYNA) Cranial Nerve I. Olfactory Assessment Technique Normal Response is able Clients Response to Ynang Reyna was
Ask the client to smell and Client
identify the smell of cologne identify different smell able to identify the with each nostril separately with and with the eyes closed. each nostril different scents that
separately and with she had smelled. eyes closed unless such condition like
colds is present.
II. Optic
Provide adequate lighting The client should be She was able to
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and ask client to read from a able
to
read
with read with each eye
reading material held at a each eye and both and both eyes. distance of 36 cm. (14 in.). III. Oculomotor Reaction to light: Using a penlight and Illuminated and non- The illuminated and pupil non-illuminated pupil of Ynang eyes.
Reyna constricted.
to Pupils constrict when Her looking object, at a near constricted pupils when
dilate
when asked to look at a when
looking at a distant near object, and it object, converge dilated when near object is Ynang Reyna was moved towards the asked to look at a nose. far object.
IV. Trochlear
Hold a penlight 1 ft. in front Clients eyes should Both eyes are able of the clients eyes. Ask the be able to follow the to client to follow the penlight as it moves. move as
necessary.
movements of the penlight with the eyes only. Move the penlight upward, downward, sideward and diagonally. V. Trigeminal While client looks upward, Client should have a Ynang Reyna was lightly touch lateral sclera of eye to elicit blink reflex. positive reflex, corneal able able to corneal to to elicit reflex, pain
To test light sensation, have respond to light and sensitive
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client close eyes, wipe a deep sensation and stimuli
and
wisp of cotton over clients able to differentiate distinguish hot from forehead. To test deep sensation, use alternating blunt and sharp ends of an object. to hot from cold. cold.
Determine
sensation
warmth and coldness. VI. Abducens Hold a penlight 1 ft. in front Both eyes Both eyes move in of the clients eyes. Ask the coordinated, move in coordination. client to follow the unison with parallel
movements of the penlight alignment. with the eyes only. Move the penlight through the six
cardinal fields of gaze. VII. Facial Ask client to smile, raise the Client should be able She eyebrows, frown, and puff to out cheeks, close smile, raise various performed facial
eyes eyebrows, and puff expressions any
tightly. Ask client to identify out cheeks and close without various tastes placed on tip eyes and sides of tongue. without
any difficulty and able distinguish
difficulty. The client to
should also be able to varied tastes. distinguish tastes. VIII. Vestibulocochlear Have the client occlude one Client should be able Ynang Reyna was ear. Out of the clients sight, to hear the tickling of able to hear tickling place a tickling watch 2 to 3 the cm. ask what the client can ears. hear and repeat with the other ear. She was able to watch in both in both ears. different
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Ask the client to walk across The assess the clients gait.
client
should stand and walk in
the room and back and have upright posture an upright position and steady gait and and able to able to
maintain maintain balance.
balance.
IX. Glossopharyngeal
Ask the client to say ah Client should be able She was able to and have the patient yawn to elicit gag reflex and elicit gag reflex and to observe upward swallow without any able to swallow
movement of the soft palate. difficulty. Elicit gag response. Note ability to swallow. X. Vagus
without difficulty.
Ask the patient to swallow The client should be She was able to and speak (note able to swallow swallow with
hoarseness)
XI. Accessory
Ask
client
to
shrug Client should be able She was able to against to shrug shoulders shrug her
shoulders
resistance from your hands and turn head from shoulders and turn and turn head to side side to side. her head from one side to the other.
against resistance from your hand (repeat for other side). XII. Hypoglossal Ask client to
protrude The client should be She was able to tongue in
tongue at midline and then able to move tongue move move it side to side. without any difficulty.
different directions.
Final Assessment (August 24, 2010) Ynang Reyna was inside the house, watching television when the student nurses
conducted the final physical assessment. C. General Appearance
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Ynang Reyna has a proportionate body built, dirty appearance, unkempt and has no body odor. She is conscious and coherent. She has a medium dark brown complexion. She also has yellowish teeth and dental cavities.
D.
Physical Assessment
Skull, head and hair Ynang Reyna has a normocephalic skull. No contusions, bruises, scars, nodules or masses noted. She has symmetrical facial movements. She has long thin black curly hair, evenly distributed with the presence of dandruff.
Facial Features
Eyes Her eyebrows are evenly distributed and symmetrically aligned. Her eyelashes are equally distributed. She has a black pupils, anicteric sclera and with pink palpebral conjunctiva. There were no discharges, discoloration or inflammation observed. Her pupils are equally rounded and responsive to light and accommodation. Her eyelids close symmetrically and involuntary blinks 18 blinks per minute. Ears She has symmetrical ears and auricles are aligned with the outer canthus of the eyes. There is a presence of dry cerumen on both ear canals when inspected. Pinna recoils after folded. She can also hear ticking of the watch on both ears Nose She has a nose which is uniform in color; septum is on midline, non-deviated, no tenderness or lesions upon inspection and palpation. Air moves freely as the client breathes through the nares. No nasal flaring was observed during inspiration and exhalation. Facial sinuses are non-tender. Mouth She has pinkish and moist lips. Teeth are yellowish. Some are incomplete and with dental carries. She has ability to purse lips. No inflammation. Tongue is on central
Page 33
position, moves freely and non-tender. No mouth sores or stomatitis upon inspection. No halitosis. The uvula is positioned in midline to soft palate. Neck Neck is uniform in color. No enlargement of thyroid gland was observed. Her lymph nodes are non palpable and jugular veins are not distended. Her cricoid cartilage elevates when she was asked to swallow. She has a good sternocleidomastoid and trapezius muscle strength nurses asked to extend her neck and move it from side to side and she was able to perform these without any difficulty and pain as eventual opposite pressure is applied. Chest Ynang Reynas chest is symmetrical, no inflammation, lesions, tenderness and deformities. Ynang Reyna has a normal respiratory excursion as evidenced by hands on the lower thorax with fingers laterally placed along the client ribcage and thumb along normally separates at 3 to 5 cm. She has a good tactile fremitus as assessed by the word ninety-nine and vibration was felt on the palm when felt on the palm when uttered these words. There is bilateral symmetry of vocal fremitus both lung fields are clear.
Heart Ynang Reyna has a radial pulse of 69 bpm. Brachial pulse was auscultated and there is a regular rhythm. No presence of abnormal heart sound was auscultated.
Breast Her skin is uniform in color. No masses and lesion noted upon inspection and palpation. There is no inflammation or discharges seen. Her breasts are round, sagged. The nipples are equal in size.
Abdomen There were no lesions or masses upon inspection. She has a flat abdomen. Ynang Reyna has normoactive bowel sounds upon. There is no pain or tenderness upon palpation. There is presence of stretch marks in the abdomen.
Back and spine
Page 34
Her back is uniform in color and spine has normal curvature. No pain was reported by Ynang Reyna. Nails Ynang Reyna has a untrimmed, clean trimmed finger and toenails. Nail plate are colorless and convex curved. Nails are smooth in texture with intact tissue around the nail color. There is capillary refill of 3 seconds upon blanching the nails turned to light pink in color. She has negative result with the schamroths test. Skin Ynang Reyna has a brown complexion. There was presence of prickle around her neck and thorax upon inspection. Skin is warm to touch with good skin turgor. She has evenly distributed hair.
Upper and Lower extremities Ynang Reyna are symmetrical in shape and size. She has an upright posture and steady gait with opposing arm swing. She walks unaided and maintains balance. She can extend and flex his extremities with any pain. There are no deformities, tenderness or swelling on the extremities. There is fine distribution of hair. She has symmetry of pulses. Neurologic Examination
Mental Status Ynang Reyna is conscious and coherent when seen. She can express oneself by speech. She is oriented and can identify person date and time. She can recall information from the past by recalling previous health history.
Motor Function Her arms are swinging oppose, walks unaided and maintains balance. Cranial Nerves Assessment (YNANG REYNA) Cranial Nerve I. Olfactory Assessment Technique Normal Response is able Clients Response to Ynang Reyna was
Page 35
identify the smell of cologne identify different smell able to identify the with each nostril separately with and with the eyes closed. each nostril different scents that
colds is present.
II. Optic
Provide adequate lighting The client should be She was able to and ask client to read from a able to read with read with each eye
reading material held at a each eye and both and both eyes. distance of 36 cm. (14 in.). III. Oculomotor Reaction to light: Using a penlight and Illuminated and non- The illuminated and pupil non-illuminated pupil of Ynang eyes.
Reyna constricted.
dilate
looking at a distant near object, and it object, converge dilated when near object is Ynang Reyna was moved towards the asked to look at a nose. far object.
IV. Trochlear
Hold a penlight 1 ft. in front Clients eyes should Both eyes are able
Page 36
of the clients eyes. Ask the be able to follow the to client to follow the penlight as it moves.
move
as
necessary.
movements of the penlight with the eyes only. Move the penlight upward, downward, sideward and diagonally. V. Trigeminal While client looks upward, Client should have a Ynang Reyna was lightly touch lateral sclera of eye to elicit blink reflex. positive reflex, corneal able able to corneal to to elicit reflex, pain and
To test light sensation, have respond to light and sensitive client close eyes, wipe a deep sensation and stimuli
wisp of cotton over clients able to differentiate distinguish hot from forehead. To test deep sensation, use alternating blunt and sharp ends of an object. to hot from cold. cold.
Determine
sensation
should also be able to varied tastes.
Page 37
distinguish tastes. VIII. Vestibulocochlear
different
Have the client occlude one Client should be able Ynang Reyna was ear. Out of the clients sight, to hear the tickling of able to hear tickling place a tickling watch 2 to 3 the cm. ask what the client can ears. hear and repeat with the other ear. She was able to Ask the client to walk across The client should stand and walk in the room and back and have upright posture an upright position assess the clients gait. and steady gait and and able to able to maintain maintain balance. watch in both in both ears.
balance.
without difficulty.
hoarseness)
XI. Accessory
Ask
client
to
shoulders
protrude The client should be She was able to
Page 38
tongue
in
Maternal Obstetrical History Ynang Reyna is 30 year old housewife within the reproductive age and with a OB score of G1P1T1P0A0L1M0. According to her, she had her menarche when she was thirteen years old. She gave birth to Lira when she was last May 9, 2006 via in one of the hospital in Surigao del Norte. During her pregnancy she did not experience any abnormalities. Ynang Reyna was only able to consult for her prenatal check up thrice, this is during her 4th month, 6th month and 8th month of pregnancy. She experienced normal pregnancy discomforts such as nausea and vomiting during the first trimester, and it did not interfere with her daily activities, if symptoms became really uncomfortable, she would just smell fumes from ilang-ilang in which according to her would relieve her nausea. During her last trimester she began to feel the weight of the baby and fell back pains, to relieve this discomfort she would just lie in bed and straighten her bag and have a massage from her husband or anyone while she is in a side-lying position. She only had her tetanus toxoid shot twice (during her first prenatal visit and her second prenatal visit). She was able to maintain her pregnancy at its full term and delivered Lira with no further complications. She uses a 28 day pills as their contraceptive method. She and Ybarro are planning to have another baby in due time and after that, she is planning to have a BTL (Bitubal Ligation) because she and her husband mutually wants only 2 kids. History of Past and Present Illness Ynang Reyna did not experience any major illness. She was never confined to a hospital nor was did she ever consulted a doctor because of an illness. She experienced common illness such as fever, cough, colds, headache and diarrhea. The management that Ynang Reyna does is to seek consultation from the Hea lth Center or sometimes drink over-the-counter medications such as antibiotics. Activities of Daily Living (Ynang Reyna) Ynang Reyna usually wakes quarter to 6 in the morning ang cooks for 15 minutes. She will prepare the clothes and foods of lira for an hour and then watch out for
Page 39
the store until 10 in the morning. She would cook for lunch then until 11 am. Then they would eat lunch for an hour afterwards. She would take a nap until 2 30 in the afternoon and watch out for the store until 8 pm. She would watch television for an hour and then goes to sleep. Nutritional Status (Ynang Reyna) Classification Underweight Severe Thinness Moderate Thinness Mild Thinness Normal Range Overweight Pre-Obese Obese Obese Class I Obese Class II Obese Class III Age: 30yrs. old Height: 1.57 m Weight: 89.24 kg BMI = Wt. in kg Ht in m2 = 89.24 kg / 2.46m2 = 36.28 (Obese Class II) Lira, age 4, girl, is the only child of Ynang Reyna and Ybarro. <18.50 <16 16.00 - 16.99 17.00 - 18.49 18.50 - 24.99 25.00 25.00 30.00 30.00 - 34-99 35.00 - 39.99 40 and above BMI (kg/m2)
Vital signs Vital Signs 1st Home Visit (Aug-10-10) Temp PR RR 37.2 oC 74 bpm 22 cpm 2nd Home Visit (Aug-16-10) 37.2 oC 67 bpm 16 cpm 3rd Home Visit (Aug-17-10) 36.6 oC 72 bpm 17 cpm 4th Home Visit (Aug-23-10) 36.7 oC 74 bpm 16 cpm 5th Home Visit (Aug-24-10) 36.2 oC 69 bpm 19 cpm
Initial Assessment
Page 40
During the first physical assessment, Lira was at the store, wearing dirty sando
while playing with a dog louse.
A.
General Appearance Lira has a thin body built. She is conscious and coherent. She has a brown
complexion with pediculosis in her short black hair. She also has incomplete teeth and dental cavities. She has untrimmed dirty fingers and with scars in her legs.
B.
Physical Assessment
Skull, head and hair Lira has a normocephalic skull. No contusions, bruises, scars, nodules or masses noted. She has symmetrical facial movements. She has short straight black hair with pediculosis and evenly distributed with the presence of dandruff.
Facial Features
Eyes Her eyebrows are evenly distributed and symmetrically aligned. Her eyelashes are equally distributed. She has a black pupils, anicteric sclera and with pink palpebral conjunctiva. There were no discharges, discoloration or inflammation observed. Her pupils are equally rounded and responsive to light and accommodation. Ears She has symmetrical ears and auricles are aligned with the outer canthus of the eyes. There is a presence of dry cerumen on both ear canals when inspected. Pinna recoils after folded.
Nose She has a nose which is uniform in color; septum is on midline, non-deviated, no tenderness or lesions upon inspection and palpation. Air moves freely as the client breathes through the nares. No nasal flaring was observed during inspiration and exhalation although presence of excessive clear frothy nasal secretions was observed. Facial sinuses are non-tender.
Page 41
Mouth She has pinkish and moist lips. Teeth are yellowish. Some are incomplete and with dental carries. She has ability to purse lips. No inflammation. Tongue is on central position, moves freely and non-tender. No mouth sores or stomatitis upon inspection. No halitosis. The uvula is positioned in midline to soft palate. Neck Neck is uniform in color. No enlargement of thyroid gland was observed. Her lymph nodes are non palpable and jugular veins are not distended. Her cricoid cartilage elevates when she was asked to swallow. She has a good sternocleidomastoid and trapezius muscle strength nurses asked to extend her neck and move it from side to side and she was able to perform these without any difficulty and pain as eventual opposite pressure is applied.
Chest Lira are symmetrical, no inflammation, lesions, tenderness and deformities. Lira has a normal respiratory excursion as evidenced by hands on the lower thorax with fingers laterally placed along the client ribcage and thumb along normally separates at 3 to 5 cm. She has a good tactile fremitus as assessed by the word ninety-nine and vibration was felt on the palm when felt on the palm when uttered these words. There is bilateral symmetry of vocal fremitus both lung fields are clear.
Heart Lira has a radial pulse of 74 bpm. No presence of abnormal heart sound was auscultated.
Breast Her skin is uniform in color. No masses and lesion noted upon inspection and palpation. There is no inflammation or discharges seen. Abdomen There were no lesions or masses upon inspection. She has a flat abdomen. There is no pain or tenderness upon palpation.
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Back and spine Her back is uniform in color and spine has normal curvature. No pain was reported by Lira.
Nails Lira has a untrimmed, dirty fingers and toe nails. Nail plate are colorless and convex curved. Nails are smooth in texture with intact tissue around the nail color. There is capillary refill of less than 2 seconds upon blanching the nails turned to light pink in color. She has negative result with the schamroths test and it was assessed by putting the nail pad together and a diamond shape was formed in the space between the nails. Skin Lira has a brown complexion. There was presence of prickle around her neck and thorax upon inspection. Skin is warm to touch with good skin turgor. She has evenly distributed hair. Upper and Lower extremities Lira are symmetrical in shape and size. She has an upright posture and steady gait with opposing arm swing. She walks unaided and maintains balance. She can extend and flex her extremities with any pain. There are no deformities, tenderness or swelling on the extremities. There is fine distribution of hair. She has symmetry of pulses.
Mental Status Lira is conscious and coherent when seen. She was able to answer questions such name different colors when asked by the student nurse. Motor Function Lira could move her body with any difficulty or complaint.
Cranial Nerves Assessment (LIRA)
Page 43
Cranial Nerve
Assessment Technique
Normal Response
Clients Response
I. Olfactory
Ask the client to smell and Client identify the smell of identify
is
able
to Lira was able to the scents had
different identify with each different she
separately that
and with eyes closed smelled. unless such
II. Optic
Provide adequate lighting The client should be Lira was able to and ask client to read to tell able paper (14 in) (Allens Test) to tell what tell what animal it
what animal is drawn in the animal it is with each is with each eye eye and both eyes. and both eyes.
III. Oculomotor
Reaction to light: Using a penlight and Illuminated and non- The pupil and illuminated of constricted. illuminated nonpupil Lira
to pupils Pupils constrict when Her looking at a near constricted when object, dilate when asked to look at a looking at a distant near object, and it object, converge dilated when Lira was asked to look
Ask client to look at a near object and then at a distant object. Alternate the gaze from the near to the far object. Next, move an
Page 44
object towards the clients when near object is at a far object. nose. moved towards the nose. IV. Trochlear Hold a penlight 1 ft. in front Clients eyes should Both eyes are of the clients eyes. Ask the be able to follow the able to move as client to follow the penlight as it moves. necessary.
downward, sideward and diagonally. V. Trigeminal While client looks upward, Client should have a Lira was able to lightly touch lateral sclera positive of eye to elicit blink reflex. To test light reflex, corneal elicit able to reflex, pain corneal sensitive stimuli
sensation, respond to light and to
have client
close eyes, deep sensation and and
distinguish
wipe a wisp of cotton over able to differentiate hot from cold. clients forehead. To test deep sensation, use alternating blunt and sharp ends of an object. Determine sensation to hot from cold.
warmth and coldness. VI. Abducens Hold a penlight 1 ft. in front Both eyes Both eyes move of the clients eyes. Ask the coordinated, move in in coordination. client to follow the unison with parallel
movements of the penlight alignment. with the eyes only. Move the penlight through the six cardinal fields of gaze. VII. Facial Ask client to smile, raise Client should be able She performed
Page 45
the eyebrows, frown, and to
smile,
raise various
facial
puff out cheeks, close eyes eyebrows, and puff expressions tightly. Ask client to identify out cheeks and close without various tastes placed on tip eyes and sides of tongue. without any
should also be able varied tastes. to distinguish
different tastes. VIII. Vestibulocochlear Have the client occlude Client should be able Lira was able to one ear. Out of the clients to hear the tickling of hear tickling in
sight, place a tickling watch the watch in both both ears. 2 to 3 cm. ask what the ears. client can hear and repeat with the other ear. Ask the client to walk She was able to across the room and back The client should stand and walk in and assess the clients gait. have upright posture an upright and steady gait and position and able able to maintain to balance. maintain
balance. IX. Glossopharyngeal
Ask the client to say ah Client should be able She was able to and have the patient yawn to elicit gag reflex elicit gag reflex to observe of upward and swallow without and the soft any difficulty. able to
movement palate.
swallow difficulty.
without
Elicit gag response. Note ability to swallow. X. Vagus Ask the patient to swallow The client should be She was able to and speak (note able to swallow swallow with and
hoarseness)
without difficulty and difficulty speak audibly.
speak audibly.
XI. Accessory
Ask
client
to
shrug Client should be able She was able to
Page 46
shoulders
against to shrug shoulders shrug
her and head
resistance from your hands and turn head from shoulders and turn head to side side to side. against resistance from turn her
from one side to the other.
your hand (repeat for other side). XII. Hypoglossal Ask client to
tongue at midline and then able to move tongue move tongue in move it side to side. without any difficulty. different directions.
Final Assessment During the last physical assessment, Lira was inside their living room, watching
her favorite Barbie movie. C. General Appearance Lira has a thin body built. She is conscious and coherent. She has a brown complexion with pediculosis in her short black hair. She also has incomplete teeth and dental cavities. She has trimmed clean finger and toenails and with scars in her legs.
D.
Physical Assessment
Skull, head and hair Lira has a normocephalic skull. No contusions, bruises, scars, nodules or masses noted. She has symmetrical facial movements. She has short straight black hair with pediculosis and evenly distributed with the presence of dandruff.
Facial Features
Eyes Her eyebrows are evenly distributed and symmetrically aligned. Her eyelashes are equally distributed. She has a black pupils, anicteric sclera and with pink palpebral
Page 47
conjunctiva. There were no discharges, discoloration or inflammation observed. Her pupils are equally rounded and responsive to light and accommodation. Ears She has symmetrical ears and auricles are aligned with the outer canthus of the eyes. There is a presence of dry cerumen on both ear canals when inspected. Pinna recoils after folded. Nose She has a nose which is uniform in color; septum is on midline, non-deviated, no tenderness or lesions upon inspection and palpation. Air moves freely as the client breathes through the nares. No nasal flaring was observed during inspiration and exhalation although presence of excessive clear frothy nasal secretions was observed. Facial sinuses are non-tender.
Mouth She has pinkish and moist lips. Teeth are yellowish. Some are incomplete and with dental carries. She has ability to purse lips. No inflammation. Tongue is on central position, moves freely and non-tender. No mouth sores or stomatitis upon inspection. No halitosis. The uvula is positioned in midline to soft palate. Neck Neck is uniform in color. No enlargement of thyroid gland was observed. Her lymph nodes are non palpable and jugular veins are not distended. Her cricoid cartilage elevates when she was asked to swallow. She has a good sternocleidomastoid and trapezius muscle strength nurses asked to extend her neck and move it from side to side and she was able to perform these without any difficulty and pain as eventual opposite pressure is applied. Chest Lira are symmetrical, no inflammation, lesions, tenderness and deformities. Lira has a normal respiratory excursion as evidenced by hands on the lower thorax with fingers laterally placed along the client ribcage and thumb along normally separates at 3 to 5 cm. She has a good tactile fremitus as assessed by the word ninety-nine and
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vibration was felt on the palm when felt on the palm when uttered these words. There is bilateral symmetry of vocal fremitus both lung fields are clear. Heart Lira has a radial pulse of 69 bpm. No presence of abnormal heart sound was auscultated. Breast Her skin is uniform in color. No masses and lesion noted upon inspection and palpation. There is no inflammation or discharges seen. Abdomen There were no lesions or masses upon inspection. She has a flat abdomen. There is no pain or tenderness upon palpation.
Back and spine Her back is uniform in color and spine has normal curvature. No pain was reported by Lira.
Nails Lira has a trimmed, clean fingers and toe nails. Nail plate are colorless and convex curved. Nails are smooth in texture with intact tissue around the nail color. There is capillary refill of less than 2 seconds upon blanching the nails turned to light pink in color. She has negative result with the schamroths test and it was assessed by putting the nail pad together and a diamond shape was formed in the space between the nails. Skin Lira has a brown complexion. There was presence of prickle around her neck and thorax upon inspection. Skin is warm to touch with good skin turgor. She has evenly distributed hair. Upper and Lower extremities Lira are symmetrical in shape and size. She has an upright posture and steady gait with opposing arm swing. She walks unaided and maintains balance. She can
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extend and flex her extremities with any pain. There are no deformities, tenderness or swelling on the extremities. There is fine distribution of hair. She has symmetry of pulses. Neurologic Examination
Mental Status Lira is conscious and coherent when seen. She was able to answer questions such name different colors when asked by the student nurse.
Motor Function Lira could move her body with any difficulty or complaint. Cranial Nerves Assessment (LIRA) Cranial Nerve Assessment Technique Normal Response Clients Response I. Olfactory Ask the client to smell and Client identify the smell of identify with is able to Lira was able to the scents had
different identify each different she
separately that
and with eyes closed smelled. unless such
II. Optic
Provide adequate lighting The client should be Lira was able to and ask client to read to tell able paper (14 in) (Allens Test) to tell what tell what animal it
what animal is drawn in the animal it is with each is with each eye eye and both eyes. and both eyes.
III. Oculomotor
Reaction to light: Using a penlight and Illuminated and non- The pupil and illuminated non-
approaching from the side, illuminated
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shine a light on the pupil. should constrict. Observe the response of the illuminated pupil. Shine the light on the pupil again, and observe the response of the other pupil.
illuminated
pupil
of Super Quattro constricted.
to pupils Pupils constrict when Her looking at a near constricted when object, dilate when asked to look at a looking at a distant near object, and it object,
Ask client to look at a near object and then at a distant object. Alternate the gaze from the near to the far object. Next, move an
converge dilated when Lira when near object is was asked to look object towards the clients moved towards the at a far object. nose. nose. IV. Trochlear Hold a penlight 1 ft. in front Clients eyes should Both eyes are of the clients eyes. Ask the be able to follow the able to move as client to follow the penlight as it moves. necessary.
downward, sideward and diagonally. V. Trigeminal While client looks upward, Client should have a Lira was able to lightly touch lateral sclera positive of eye to elicit blink reflex. To test light reflex, corneal elicit able to reflex, pain corneal sensitive stimuli
sensation, respond to light and to
have client
close eyes, deep sensation and and
distinguish
wipe a wisp of cotton over able to differentiate hot from cold. clients forehead. To test deep sensation, use alternating blunt and hot from cold.
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sharp ends of an object. Determine sensation to
warmth and coldness. VI. Abducens Hold a penlight 1 ft. in front Both eyes Both eyes move of the clients eyes. Ask the coordinated, move in in coordination. client to follow the unison with parallel
movements of the penlight alignment. with the eyes only. Move the penlight through the six cardinal fields of gaze. VII. Facial Ask client to smile, raise Client should be able She the eyebrows, frown, and to smile, raise various performed facial
puff out cheeks, close eyes eyebrows, and puff expressions tightly. Ask client to identify out cheeks and close without various tastes placed on tip eyes and sides of tongue. without any
should also be able varied tastes. to distinguish
different tastes. VIII. Vestibulocochlear Have the client occlude Client should be able Lira was able to one ear. Out of the clients to hear the tickling of hear tickling in
sight, place a tickling watch the watch in both both ears. 2 to 3 cm. ask what the ears. client can hear and repeat with the other ear. Ask the client to walk She was able to across the room and back The client should stand and walk in and assess the clients gait. have upright posture an upright and steady gait and position and able able to maintain to balance. maintain
balance.
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IX. Glossopharyngeal Ask the client to say ah Client should be able She was able to and have the patient yawn to elicit gag reflex elicit gag reflex to observe of upward and swallow without and the soft any difficulty. able to
movement palate.
swallow difficulty.
without
Elicit gag response. Note ability to swallow. X. Vagus Ask the patient to swallow The client should be She was able to and speak (note able to swallow swallow with and
hoarseness)
without difficulty and difficulty speak audibly.
speak audibly.
XI. Accessory
Ask
client
to
shrug Client should be able She was able to against to shrug shoulders shrug her and head
shoulders
resistance from your hands and turn head from shoulders and turn head to side side to side. against resistance from turn her
from one side to the other.
your hand (repeat for other side). XII. Hypoglossal Ask client to
tongue at midline and then able to move tongue move tongue in move it side to side. without any difficulty. different directions.
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Liras Erik Eriksons Psychosocial Development Initiative vs. Guilt (Child, 4-6 Years) The most important event at this stage is independence. The child continues to be assertive and to take the initiative. Playing and hero worshipping are an important form of initiative for children. Children in this stage are eager for responsibility. It is essential for adults to confirm that the child's initiative is accepted no matter how small it may be. If the child is not given a chance to be responsible and do things on their own, a sense of guilt may develop. The child will come to believe that what they want to do is always wrong. In order for a positive outcome in this stage, the child must learn to accept without guilt, that there are certain things not allowed. Children must be guilt free when using imagination. They must be reassured that it is okay to play certain adult roles. If children are not allowed to do things on their own, a sense of guilt may develop and they may come to believe that what they want to do is always wrong.
This period of Erik Eriksons Psychosocial Development was very evident from Lira during intervention periods of the home visits since she would always want to help with the interventions that her mother is doing like sweeping the floor. She would always try to grab the broom from the student nurses and her mother and would always say ako din linis (me too I want to clean). When she got a chance to clean she would play with her barbie and talk to it like the two of them are cleaning.
Liras Freudian Psychosexual Development Phalic Phase (3-5 years) The erogenous zone associated with it as the area of the genitals. However, stimulation of genitals is welcomed as pleasurable and boys, like adult males, may have erections during their sleep and the girl would go on to develop penis envy, the envy felt by females toward the males because the males possess a penis. Children become increasingly aware of their body and are curious about the bodies of other children, but also their parents. Freud observed that children of this age can very often be observed taking off their clothes and playing doctor with each other, or asking their mothers whether she has a penis.
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This phase of Freudians Psychosexual Development was very evident from Lira when the student nurses were able to observe that she is really much attached to her father. One strong indication of it is when she would refuse to go to school one morning because she want to play with her father. Also, Ynang Reyna verbalized that whenever Ybarro would go home from her work every 3 months, Lira would always want to stay with her father and play all day long.
History of Past and present Illness (Lira) Lira did not experience any major illness nor was she hospitalized because of any illness. Aside from fever, cough, colds and diarrhea. The management that Ynang Reyna do is she get advice from the Health Center o usually bring she child at the health center for check up. Ynang Reyna also uses over theOver the counter for Lira like Tempra for kids whenever she has fever.
Activities of Daily Living (Lira) Lira wakes up at 6:30 in the morning and would eat breakfast and watch TV for 1 hour and 15 minutes. She would prepare for school for the next 45 minutes. She would stay at school until 12 noon. at 12 noon, when she got home from school, she would eat her lunch alone while watching television. She would o her homeworks from 1pm to 2pm and then watch or play until 6pm then. She would eat dinner with the family until 7 pm and then watch television until 9 pm and then sleep. Nutritional Status (Lira) Age: 4 years old and 3 months yrs. Old 17.94 kg
Weight:
FNRI Interpretation: Normal
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Danaya, age 30, is the mother in the Enchanted Family. Her height is 5 feet 3 inches tall and weighs 42 kilogram. Her waist measures 76 cm and her hips is 89 cm. 1st Home Visit (Aug-10-10) Temp PR RR BP 36.8 oC 68 bpm 17 cpm 130/90 mmHg 2nd Home Visit (Aug-16-10) 37.2 oC 70 bpm 19 cpm 130/90 mmHg 3rd Home Visit (Aug-17-10) 35.6 oC 74 bpm 17 cpm 120/80 mmHg 4th Home Visit (Aug-23-10) 36.9 oC 65 bpm 16 cpm 120/90 mmHg 5th Home Visit (Aug-24-10) 36.8 oC 69 bpm 17 cpm 130/90 mmHg
Vital Signs
Initial Assessment (August 10, 2010) Danaya was in inside the house watching television with Ybarro when the student nurses cunducted the physical assessment
E.
General Appearance Danaya has a proportionate body built, dirty appearance, unkempt and has no
body odor. She is conscious and coherent. She has a medium dark brown complexion with pediculosis in her untidy long black straight hair. She also has yellowish teeth and dental cavities.
F.
Physical Assessment
Skull, head and hair Danaya has a normocephalic skull. No contusions, bruises, scars, nodules or masses noted. She has symmetrical facial movements. She has long thin black hair with pediculosis, excessively dry and evenly distributed with the presence of dandruff.
Facial Features
Eyes
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Her eyebrows are evenly distributed and symmetrically aligned. Her eyelashes are equally distributed. She has a black pupils, anicteric sclera and with pink palpebral conjunctiva. There were no discharges, discoloration or inflammation observed. Her pupils are equally rounded and responsive to light and accommodation. Her eyelids close symmetrically and involuntary blinks 18 blinks per minute.
Ears She has symmetrical ears and auricles are aligned with the outer canthus of the eyes. There is a presence of dry cerumen on both ear canals when inspected. Pinna recoils after folded. She can also hear ticking of the watch on both ears Nose She has a nose which is uniform in color; septum is on midline, non-deviated, no tenderness or lesions upon inspection and palpation. Air moves freely as the client breathes through the nares. No nasal flaring was observed during inspiration and exhalation. Facial sinuses are non-tender. Mouth She has pinkish and moist lips. Teeth are yellowish. Some are incomplete and with dental carries. She has ability to purse lips. No inflammation. Tongue is on central position, moves freely and non-tender. No mouth sores or stomatitis upon inspection. No halitosis. The uvula is positioned in midline to soft palate.
Neck Neck is uniform in color. No enlargement of thyroid gland was observed. Her lymph nodes are non palpable and jugular veins are not distended. Her cricoid cartilage elevates when she was asked to swallow. She has a good sternocleidomastoid and trapezius muscle strength nurses asked to extend her neck and move it from side to side and she was able to perform these without any difficulty and pain as eventual opposite pressure is applied. Chest Danayas chest is symmetrical, no inflammation, lesions, tenderness and deformities. Danaya has a normal respiratory excursion as evidenced by hands on the
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lower thorax with fingers laterally placed along the client ribcage and thumb along normally separates at 3 to 5 cm. She has a good tactile fremitus as assessed by the word ninety-nine and vibration was felt on the palm when felt on the palm when uttered these words. There is bilateral symmetry of vocal fremitus both lung fields are clear.
Heart Danaya has a radial pulse of 68 bpm. Brachial pulse was auscultated and there is a regular rhythm. No presence of abnormal heart sound was auscultated.
Breast Her skin is uniform in color. No masses and lesion noted upon inspection and palpation. There is no inflammation or discharges seen. Her breasts are round, sagged. The nipples are equal in size.
Abdomen There were no lesions or masses upon inspection. She has a flat abdomen. Danaya has normoactive bowel sounds upon. There is no pain or tenderness upon palpation. There is presence of stretch marks in the abdomen.
Back and spine Her back is uniform in color and spine has normal curvature. No pain was reported by Danaya.
Nails Danaya has a trimmed, clean fingers and toe nails. Nail plate are colorless and convex curved. Nails are smooth in texture with intact tissue around the nail color. There is capillary refill of 3 seconds upon blanching the nails turned to light pink in color. She has negative result with the schamroths test. Skin Danaya has a brown complexion. There was no presence of prickle around her neck and thorax upon inspection. Skin is warm to touch with good skin turgor. She has evenly distributed hair.
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Upper and Lower extremities Danaya are symmetrical in shape and size. She has an upright posture and steady gait with opposing arm swing. She walks unaided and maintains balance. She can extend and flex his extremities with any pain. There are no deformities, tenderness or swelling on the extremities. There is fine distribution of hair. She has symmetry of pulses. Neurologic Examination
Mental Status Danaya is conscious and coherent when seen. She can express oneself by speech. She is oriented and can identify person date and time. She can recall information from the past by recalling previous health history.
Motor Function Her arms are swinging oppose, walks unaided and maintains balance. Cranial Nerves Assessment (DANAYA) Cranial Nerve I. Olfactory Assessment Technique Normal Response is able Clients Response to Danaya was able identify the
identify the smell of cologne identify different smell to with each nostril separately with and with the eyes closed. each
nostril different scents that
colds is present.
II. Optic
reading material held at a each eye and both and both eyes. distance of 36 cm. (14 in.). III. Oculomotor Reaction to light: eyes.
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Using
penlight
and Illuminated and non- The illuminated and pupil non-illuminated pupil of Danaya
constricted.
dilate
looking at a distant near object, and it object, converge dilated when near object is Danaya was asked moved towards the to look at a far nose. object.
IV. Trochlear
necessary.
movements of the penlight with the eyes only. Move the penlight upward, downward, sideward and diagonally. V. Trigeminal While client looks upward, Client should have a Danaya was able lightly touch lateral sclera of eye to elicit blink reflex. positive reflex, corneal to able elicit corneal
to reflex, sensitive to stimuli and
To test light sensation, have respond to light and pain wisp of cotton over clients able to differentiate cold. forehead. To test deep sensation, use hot from cold.
client close eyes, wipe a deep sensation and distinguish hot from
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alternating blunt and sharp ends of an object. to
Determine
sensation
should also be able to varied tastes. distinguish tastes. VIII. Vestibulocochlear Have the client occlude one Client should be able Danaya was able ear. Out of the clients sight, to hear the tickling of to hear tickling in place a tickling watch 2 to 3 the cm. ask what the client can ears. hear and repeat with the other ear. She was able to Ask the client to walk across The client should stand and walk in the room and back and have upright posture an upright position assess the clients gait. and steady gait and and able to able to maintain maintain balance. watch in both both ears. different
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balance.
without difficulty.
hoarseness)
XI. Accessory
Ask
client
to
shoulders
Final Assessment Danaya was inside the house, watching television when the student nurses conducted the final physical assessment.
G.
General Appearance Danaya has a proportionate body built, dirty appearance, unkempt and has no
body odor. She is conscious and coherent. She has a medium dark brown complexion. She also has yellowish teeth and dental cavities.
H.
Physical Assessment
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Skull, head and hair Danaya has a normocephalic skull. No contusions, bruises, scars, nodules or masses noted. She has symmetrical facial movements. She has long thin black straight hair, evenly distributed with the presence of dandruff.
Facial Features
Eyes Her eyebrows are evenly distributed and symmetrically aligned. Her eyelashes are equally distributed. She has a black pupils, anicteric sclera and with pink palpebral conjunctiva. There were no discharges, discoloration or inflammation observed. Her pupils are equally rounded and responsive to light and accommodation. Her eyelids close symmetrically and involuntary blinks 18 blinks per minute.
Ears She has symmetrical ears and auricles are aligned with the outer canthus of the eyes. There is a presence of dry cerumen on both ear canals when inspected. Pinna recoils after folded. She can also hear ticking of the watch on both ears
Nose She has a nose which is uniform in color; septum is on midline, non-deviated, no tenderness or lesions upon inspection and palpation. Air moves freely as the client breathes through the nares. No nasal flaring was observed during inspiration and exhalation. Facial sinuses are non-tender. Mouth She has pinkish and moist lips. Teeth are yellowish. Some are incomplete and with dental carries. She has ability to purse lips. No inflammation. Tongue is on central position, moves freely and non-tender. No mouth sores or stomatitis upon inspection. No halitosis. The uvula is positioned in midline to soft palate. Neck Neck is uniform in color. No enlargement of thyroid gland was observed. Her lymph nodes are non palpable and jugular veins are not distended. Her cricoid cartilage
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elevates when she was asked to swallow. She has a good sternocleidomastoid and trapezius muscle strength nurses asked to extend her neck and move it from side to side and she was able to perform these without any difficulty and pain as eventual opposite pressure is applied.
Chest Danayas chest is symmetrical, no inflammation, lesions, tenderness and deformities. Danaya has a normal respiratory excursion as evidenced by hands on the lower thorax with fingers laterally placed along the client ribcage and thumb along normally separates at 3 to 5 cm. She has a good tactile fremitus as assessed by the word ninety-nine and vibration was felt on the palm when felt on the palm when uttered these words. There is bilateral symmetry of vocal fremitus both lung fields are clear. Heart Danaya has a radial pulse of 69 bpm. Brachial pulse was auscultated and there is a regular rhythm. No presence of abnormal heart sound was auscultated. Breast Her skin is uniform in color. No masses and lesion noted upon inspection and palpation. There is no inflammation or discharges seen. Her breasts are round, sagged. The nipples are equal in size. Abdomen There were no lesions or masses upon inspection. She has a flat abdomen. Danaya has normoactive bowel sounds upon. There is no pain or tenderness upon palpation. There is presence of stretch marks in the abdomen.
Back and spine Her back is uniform in color and spine has normal curvature. No pain was reported by Danaya. Nails Danaya has a untrimmed, clean trimmed finger and toenails. Nail plate are colorless and convex curved. Nails are smooth in texture with intact tissue around the
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nail color. There is capillary refill of 3 seconds upon blanching the nails turned to light pink in color. She has negative result with the schamroths test. Skin Danaya has a brown complexion. There was no presence of prickle around her neck and thorax upon inspection. Skin is warm to touch with good skin turgor. She has evenly distributed hair. Upper and Lower extremities Danaya are symmetrical in shape and size. She has an upright posture and steady gait with opposing arm swing. She walks unaided and maintains balance. She can extend and flex his extremities with any pain. There are no deformities, tenderness or swelling on the extremities. There is fine distribution of hair. She has symmetry of pulses.
Mental Status Danaya is conscious and coherent when seen. She can express oneself by speech. She is oriented and can identify person date and time. She can recall information from the past by recalling previous health history. Motor Function Her arms are swinging oppose, walks unaided and maintains balance. Cranial Nerves Assessment (DANAYA) Cranial Nerve I. Olfactory Assessment Technique Normal Response is able Clients Response to Danaya was able identify the
identify the smell of cologne identify different smell to with each nostril separately with and with the eyes closed. each
nostril different scents that
colds is present.
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II. Optic
reading material held at a each eye and both and both eyes. distance of 36 cm. (14 in.). III. Oculomotor Reaction to light: Using a penlight and Illuminated and non- The illuminated and pupil non-illuminated pupil of Danaya eyes.
constricted.
dilate
looking at a distant near object, and it object, converge dilated when near object is Danaya was asked moved towards the to look at a far nose. object.
IV. Trochlear
necessary.
movements of the penlight with the eyes only. Move the penlight upward, downward, sideward and diagonally.
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V. Trigeminal
While client looks upward, Client should have a Danaya was able lightly touch lateral sclera of eye to elicit blink reflex. positive reflex, corneal to able elicit corneal
to reflex, sensitive to stimuli and
To test light sensation, have respond to light and pain wisp of cotton over clients able to differentiate cold. forehead. To test deep sensation, use alternating blunt and sharp ends of an object. to hot from cold.
client close eyes, wipe a deep sensation and distinguish hot from
Determine
sensation
should also be able to varied tastes. distinguish tastes. VIII. Vestibulocochlear Have the client occlude one Client should be able Danaya was able ear. Out of the clients sight, to hear the tickling of to hear tickling in place a tickling watch 2 to 3 the cm. ask what the client can ears. watch in both both ears. different
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hear and repeat with the other ear.
Ask the client to walk across The client should She was able to the room and back and have upright posture stand and walk in assess the clients gait. and steady gait and an upright position able to maintain and able to
balance.
maintain balance.
without difficulty.
hoarseness)
XI. Accessory
Ask
client
to
shoulders
History of Past and Present Illness
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Danaya did not experience any major illness. She was never brought to a hospital because of a severe illness. She experienced common illness such as fever, cough, colds, headache and diarrhea. Ynang Reyna manages it by giving her over-thecounter medications such as tempre, neozep and Bioflu.
Activities of Daily Living (Danaya) Danaya would usually wake up by 7am then she would start her day by eating breakfast for 30 minutes, after that she would clean the house while watching/listening to the television she would eat her lunch from 11 am until 12 noon then watch television again until 6 pm. From time to time she would exchange position with Ynang Reyna in watching out for the store when
Nutritional Status (Danaya)

Classification Underweight Severe Thinness Moderate Thinness Mild Thinness Normal Range Overweight Pre-Obese Obese Obese Class I Obese Class II Obese Class III <18.50 <16 16.00 - 16.99 17.00 - 18.49 18.50 - 24.99 25.00 25.00 30.00 30.00 - 34-99 35.00 - 39.99 BMI (kg/m2)
Age: Height: Weight:
27yrs. old 1.58 m 53.81 kg
BMI = Wt. in kg Ht in m2 = 53.81 kg . 1.58m2 = 21.56 (Normal)
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IV. SOCIO ECONOMIC, CULTURAL AND ENVIRONMENTAL ASSESSMENT
A.
Type of family Enchanted Family is considered to be an extended type of family because it is
composed of a couple (married), Ynang Reyna (mother) and Ybarro (father) with their daughter, Lira, and two sisters of the mother, Danaya and Pirena.
B. Dominant family members in terms of decision making especially to health care Ybarro and Ynang Reyna go hand in hand in terms of decision-making, they consult each other in terms of planning and budgeting for their family, they also discuss matters concerning their childs schooling financially and emotionally. When problem arises, they make sure that both of them will handle and solve the problem. But in terms of problems concerning emergency and health Ynang Reyna is the chief decision maker since she is the one who is always present in the house. An example of health matters wherein Ynang Reyna is more responsible for is immunization. This is because Ybarro is busy at his work giving Ynang Reyna the authority to decide on matters that needs an urgent decision. C. Source of income, expenditures The Enchanted Family's main source of income comes from Ybarros income from being a seaman. Ybarro has a fixed monthly income of Php 21, 000 pesos a month which she sends most (17,000) to Ynang Reyna at monthly basis, the remaining of his salary, is used for his own choice. Another source of income of the family is the mini sari-sari store which earns about 1,500 a day but since they need to restock the store in thrice a week, with a grocery worth of 3,000 pesos each, they just earn about 1,500 from it ever week which is Php 6,000 a month. These amounts are for the utilization of their needs like food, schooling of Lira, other monthly bills and for sending money to their relatives in the province. It is used in buying over the counter medications when necessary. With the combined salary/earnings of Ybarro and Ynang Reyna, the group can say that this is abviously enough to shoulder every expense they have in the household. According to NEDA, each individual should at least have Php 2768.60 when the total monthly income of the family is divided among the total family members. The total monthly income of the family is approximately Php 23,000 and when divided among the 5 members, each member would have Php 4,600 therefore the family is not
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considered poor. Despite the above average income of the family, the Enchanted family does not have financial asset for emergency purposes, not a single member of the family owns a bank account. They just usually borrow money from their relatives to which most of the time to Ybarros mother who resides 2 blocks away from their house. Breakdown of Monthly expenses Expenditures Food Money sent to relatives in Surigao Danaya & Pirenas monthly allowance Electric Bill Liras school monthly bill Water Bill Mineral Water Liras monthly school allowance Weekly transportation for grocery Weekly transportation going to Manila Garbage Collection Total Monthly Cost 9,000 5,000 3,000 1,000 750 500 600 400 250 500 60 Php 21,060
Other expenses of the Enchanted Family includes clothes, toys of Lira, increase in bills, Liras school supplies, eating in a restaurant, usually Jollibee after Sundays mass etc. D. Working hours Since Ybarro is a seaman, he is always away mostly for a long period of time about 2-3 months and when he goes home, he usually stay for 1-2 months. During his duty in the ship, he is usually in night shift, for 12 hours he would wake up by 4 in the afternoon and start working. He would have his break every 3 hours he would eat his meals by those time. And he would sleep by 5 in the early morning. Although Ynang Reyna visits him at Pier in Manila every weekend usually Saturday. Ynang Reyna facilitates their mini store from 6 am in the morning until 10 in the evening the whole week except Saturday and Sunday morning.
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E. Ethnic background & religious affiliation Enhanted Family resides in Barangay Balibago, Angeles City. Ybarros family is from Mabalacat Angeles City, this is also where he grew up. On the other hand, Ynang Reynas family originated from Surigao Del Norte and so as her sisters. This is where they spent their childhood up to their early 20s until they moved here in Angeles City. Ynang Reyna and Danaya speaks Visayan native dialect as well as Tagalog, although Pirena can only speak their Visayan native dialect and this is evidenced by her ability to communicate with her sisters very well, and her poor communication with the student nurses because they cannot speak Visayan and so they have to use gestures to facilitate understanding between them and Pirena. According to Ynang Reyna, they belong to the New Kingdom of Christ religion. But since the religion is not known here in Luzon, they just go to CCC (Christian Center Chapel) for Born Again Christians located in Clarkview. She told the nurse that there is no difference at all between Born-again Christian and New Kingdom of Christ and that people from that church warmly accepts them. They attend the holy mass every Sunday morning at the mentioned church. Other practices that they do related to their religious convictions is praying before eating, not going to clubs for it is forbidden to them.
F. Significant order(s) role in the family The most significant persons involved in their lives is Ybarros mother living just 2 blocks away from their house because she is the one that the family runs to whenever there is a problem that cannot be solved by the family.
G. Health habits/ beliefs The family only used the Health Care Center in their community twice, this is when Ynang Reyna was pregnant for Lira and for Liras immunizations. From time to time, some of the member of their families acquire illness such as There has been no health or emergency situation yet that happened to any member of the family, but if such eventualities occurs, according to Ynang Reyna, she would not bother bring the sick to health care center since she is not sure of the operating hours of the said facility, instead she would go to Angeles University Medical Center or Ospital Ning Angeles since the two are just one tricycle ride away from their home. The Enhanted Family also believes in some Philippine traditional home medications such as applying vinegar to the face of
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the family member who has mumps, and covering the newborns belly button to prevent kabag or accumulation of air in the abdomen. H. Family involvement in community activities
The family is ill-informed with the activities in their community, therefore they have never participated in any of them such as in mothers class. I. Familys utilization of community resources The only community facility that Enhanted Family usually utilizes is the. A.D.R. Health Center since it is just near their house.
J. Housing condition The house is concrete, which is made up of hollow blocks, it has a floor area of 13.84m x 6.2m. Its total floor area is 44.28 m2. In order for the house to be considered as adequate, the total floor area should be divided among the total members of the family and each should at least have 3m2. In the case of the Enhanted Family, each of them would only have at least 8.86m2. With this, the house is considered adequate for them. The house only has only two 0.9x0.45 m (.405m2) windows that is found in the comfort room and in the kitchen. The window in their bedroom measuring 0.77x0.79 cannot be considered as a source of ventilation to the house because it was already concealed with wood since it is an opening to their neighbors house. Another structure in the house that could be considered as a source if ventilation is their one and only door to get in and out of the house. It can be considered as source of ventilation since they always keep it open allowing the air flow in and out of the house. The door measures 2.04x0.91 m (1.86m2). The total area of structures conducive for proper ventilation of the house is 2.26 m2. For the ventilation of a house to be considered to be adequate, the total area of sructures of ventilation (2.67m2) should be divided to the 20% of the total floor area (8.86 m2), the quotient should be 1, if it is 0.99, there is inadequate ventilation. In the case of the Enchanted Family, the quotient was only 0.3, therefore the ventilation of the Enchanted Familys house is inadequate. The house has only 1 room with Ynang Reyna and Ybarro sleeps together in this room with their bed, while Danaya, Pirena and Lira sleeps in a banig set-up in their living room during the night. The Enhanted Family only has 4 appliances in the house, a Television set, 2 Electric Fans, a
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refrigerator, and a DVD set.. There are presence of accident hazards too. Some sharp objects that are within reach of children were noted as well as the presence of rodents and insects. The bulb in their living room is broken which makes the room pitched dark during daytime especially in nighttime. This served as a basis for the student nurses to say that the familys house have an inadequate lighting. Their trash can in the house is a sack that is uncovered, and garbage collectors get it at least twice or thrice a week. K. Food sources, storage & cooking facilities Enhanted Family just get their rice from their own mini sari-sari store and whenever they need it. In terms of cooking and storage facility, they just use they have a refrigerator for proper storage of their foods They usually buy their recipes and indregient for their viand when they go to grocery for their sari-sari store restock. L. Water supply The source of water supply of the family is NAWASA. They own it and they have 2 faucet, one in the kitchen lavatory and the other one is in the bathroom. Ynang Reyna say that they dont use it as a source of drinking water but just for laundry and for showering although the water is said to be potable. They just get their supply of drinking water in from Mineral Water Station near their house in which in their opinion, more potable and safe. M. Toilet Facility Enhanted Family has their own toilet facility. It is located at the far end of their house. Its toilet with water carriage. It has a fair sanitation. The toilet bowl itself is clean, there are no fecal materials noted but the smell of the comfort room is stinky that is why the group considered it as having a fair sanitation. N. Drainage system The drainage system of the family is open type. It is also located in the outside the house. It is dirty and has a stinky smell. There are some garbage and trashes noted. Molds are also noted. There is no obstruction present at the drainage system, which makes the flow continuous. O. Social & health facilities available The family benefits from the services offered by the Barangay Health Center; this is where all their received their full immunizations. Other social facilities available in their
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community are bars and casino. These establishments are just walking distance from their house but they do not go to such vicinities since according to Ynang reyna, it is against their religious convictions. Ynang Reyna owns 2 cellular phone, the one she uses for her cellphone reloading business and the other one for her personal use, which most of the time she uses to communicate with her husband and other relatives. P. Communication & transport system Danaya and Pirena owns their individual phone and when they need load, they could just ask Ynang Reyna for it. Ybarro also owns a phone that he uses to call Ynang Reyna thrice a week. Their transporation system are jeepneys and tricycles since they do not own any private vehicle. Ynang reyna would usually go to grocery stores via a public utility jeepney and would go back home with a tricycle ride since she is already carrying heavy groceries.
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V. PROBLEM IDENTIFICATION A.List of Problem IdentifiedProblem Prioritization
Problem Inadequate Personal Belongings Or Utensils Poor Personal Hygiene Unsanitary Food Handling Improper Drainage Poor Lighting (Night Time And Daytime) Presence Of Accident Hazards Presence Of Breeding Or Resting Sites For Insects Or Rodents
Score 2.84 2.67 2.34 2.34 2.34 2.34 2.34
Rank 1 2 3.2 3.2 3.2 3.2 3.2
B. Priority Setting B. Priority Setting Problem # 1: Inadequate Personal Belongings or Utensils
Criteria
Computation
Scor e
Justification
Nature of the problem
2/3x1
0.67
Having inadequate personal belongings and utensils could lead to health
threatening problems such as transfer of microorganisms, infections and the like because of lack in utensils wherein the repeated use of these equipments are likely to occur and the possibility that they will borrow from their neighbors. Therefore, the problem is a health threat. Modifiability Problem Current Knowledge Family Resources of the 1/2x2 1 Current Knowledge > The family knows that they have inadequate personal belongings or
utensils but they do not know the possible consequences of the situation and they
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Nurses Resources Community Resources
are busy in their store so they didnt bother to think of the effects of this
problem. Family Resources > The familys resources, specifically financial, are adequate to alleviate the existing problem. They could buy utensils available in the market which is just a jeepney ride away from their home but mother said that they have a plan to sell their house so she is contented on what things or utensils they have. Nurses Resources > Knowledge, time and effort to give health teachings to the family regarding the possible consequences that might happen due to existing problem such as diarrhea, risk for infection or of acquiring communicable diseases. Community Resources > There were no available community resources to solve their problem. The community cannot afford to provide
enough personal utensils that may help the family. Therefore, modifiable. Preventive Potential Gravity Duration Current Management 2/3x1 0.67 Gravity > The problem is not considered as severe because the families still has their own belongings and have the option not the problem is partially
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Exposure of any high risk group
to borrow from their neighbors. They do not put much attention to this problem because they are contented of having few belongings or utensils. Duration > The problem existed since they
transferred in their house in balibago because they lived in province before and most of their utensils and things are in their previous house. Current Management > The family performs certain
management like washing of kitchen utensils very well before using it. Exposure of any high risk group > The whole family is exposed to this problem, like transfer of microorganism through borrowing other utensils from their neighbors. Therefore, the problem has moderate preventive potential. Salience 1/2 x 1 0.5 The family recognized it as a problem but it does not need an immediate Attention. They are more concern with their food rather than other things. Total: 2.84
Problem # 2: Poor Personal Hygiene
Criteria
Computatio n
Score
Justification
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2/3 x 1
0.67
The
problem
is
conducive
for
the
occurrence of various conditions such as parasitism and diseases depending on body part affected. The existence of the disease condition is not yet present. But poor personal hygiene could greatly the
contribute to the occurrence of
problem; therefore the problem is a health threat. Modifiability Problem Current Knowledge Family Resources Nurses Resources Community Resources of the 1/2x2 1 Current Knowledge > The family doesnt know that having poor hygiene could affect their health this could be a result of the family members low educational achievement since the mother is a high school graduate and although the father is a vocational course graduate, he is not always present in the house and his course is not a health or science related course. There lack of acknowledgement about the existence of the problem is reflected through their lack of intervention regarding the presence of the problem. Family Resources > The family still has physical resources to make efforts of improving personal
hygiene, like practicing taking a bath daily, doing oral and nail care since nobody among them is disabled in any way. They also have financial resources since they are not considered poor. They also has the tools to provide the members at least
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basic needs such as soap, toothpaste, toothbrush, etc. Nurses Resources > The student nurses is always available and also has the proper knowledge to provided health teachings about the effects of poor hygiene; the appropriate knowledge to do hair, nail oral and general body care and the enough time for home visits for health teachings. Community Resources > There are sari-sari stores near their house or even their own sari-sari stores to where they can avail their basic needs and a health centers health teachings regarding improvement of personal
hygiene. The community health center is also available and contains charts and posters that promotes proper hygienic measure for its community members. Therefore, modifiable. Preventive Potential Gravity Duration Current Management Exposure of any high risk group 3/3x1 1 Gravity > The problem is moderately severe because of their poor personal hygiene, their health is affected, as evidenced by tooth decay on all family members. Duration > The problem existed a long time ago, years before Ynang Reyna and Ybarro got the problem is partially
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married because even before, they do not practice good personal hygiene as it is not important to them because of their
unawareness of the consequences of the aforementioned problem Current Management > There are measures done by the family to address the problem such as trying to provide basic needs, asking their child to take a bath daily, brush her teeth, and not to play with dirt. Exposure of any high risk group > The child is primarily the high-risk group being involved. Therefore, the problem has moderate preventive potential. Salience 0/2 x 1 0 During the home visits, when the situation was presented to the family, they did not recognize it as a problem. For them it is not a big deal and that they have not realized even before that this could affect health. Total: 2.67
Problem #3.2: Improper Drainage
Criteria
Computatio n
Score
Justification
2/3x1
0.67
The family has open type drainage, flowing and trashed drainage system which is located in front of their house and
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emits very foul odor water; it is also conducive for the growth of insect that can cause certain disease especially to
mosquitoes that can cause malaria or dengue. The existence of the problem is not a health condition but could possess great potential in harming the health of every member of the family, therefore it could be considered as a health threat. Modifiability Problem Current Knowledge Family Resources Nurses Resources Community Resources of the 1/2x2 1 Current Knowledge >The family lacks knowledge or they are not aware about the importance of
keeping the drainage system clean and keeping it flowing moreover they are busy of their own work. Family Resources >The family has the materials in cleaning their drainage. Their initiative and effort are just needed to provide pathway and flowing drainage. Nurses Resources >The student nurses are available to provide health teachings and interventions to the family with regards to having proper drainage system. They also have the proper knowledge and skills in helping the family to solve the problem Community Resources >The community has a certain program for keeping the environment clean and the Barangay health workers are very active
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in
reminding
them
to
keep
their
environment clean. Therefore, modifiable. Preventive Potential Gravity Duration Current Management Exposure of any high risk group 2/3x1 0.67 Gravity >The problem is not severe since the family did not yet experience problems regarding this concern. Duration > The problem existed since they the problem is partially
transferred in their house 3 years ago. Current Management >The family does not take any action to solve the problem. No interventions are done to keep the drainage system clean. Exposure of any high risk group >The family is affected in this problem, especially their child, since she is always playing near the drainage. Therefore, the problem has moderate preventive potential. Salience 0/2x1 0 The family does not recognize the
problem at all that is why the family does not take immediate action against the problem. Total: 2.34
Problem # 3.2: Poor Lighting (Night time and Daytime)
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Criteria
Computatio n
Score
Justification
2/3x1
0.67
Having poor lighting within the household may lead to visual impairments and are at risk of accidents due to lack of sufficient light, coming from the sun at daytime and inadequate watts of light bulbs during nighttime could possibly increase the risk of the family members for accident since they cannot properly see presence of sharps objects that they may step on Therefore, the problem is a health threat.
Modifiability Problem Current Knowledge
of
the
1/2x2
1 Current Knowledge >The family lacks knowledge about the inadequacy of their lighting. They do not know the possible consequences that might happen. Family Resources
Family Resources Nurses Resources Community Resources
>The family may raise their curtains hanging on their windows to let the sunlight in during daytime and fix the broken light as soon as possible Nurses Resources >Health teachings were given by the student nurses such as telling them the possible outcomes of having poor lighting and advising them to raise the curtains hanging on their windows to let the sunlight in during daytime. Community Resources >There are no available resources in the
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community problem. Therefore, modifiable. Preventive Potential Gravity Duration Current Management Exposure of any high risk group 2/3x1 0.67 Gravity
that
may
eradicate
the
the
problem
is
partially
>The problem is not severe since it does not yet cause injury to the family. Duration > The problem existed since they
transferred in their house 3 years ago. Current Management >The family is not doing anything to eradicate the problem because they are used to it. Exposure of any high risk group >The whole family is affected on the problem, especially at night they are prone to accidents. Therefore, the problem has moderate preventive potential.
Salience
0/2x1
The family does not recognize it as a problem because of lack of knowledge on the importance of having adequate
lighting, and because they are used to it. Total: 2.34
Problem # 3.2: Presence of Accident Hazards
Criteria
Computatio n
Score
Justification
2/3 x 1
0.67
The presence of pieces of broken glass
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and rusty nails that are scattered beside the house where the child usually play could cause an accident in the future. Knifes, forks and other utensils were not in their proper places which their child can possibly reach. Therefore, the problem is a health threat. Modifiability Problem Current Knowledge Family Resources Nurses Resources Community Resources of the 1/2 x 2 1 Current Knowledge > The family does not know that the things that are around them are accident
hazards or that it may cause them injury because the parents does not have initiative to get rid or to arrange those things in a place that are not in reach of their children. Family Resources > The family has the resources to arrange those things that are not in reach of the children as simple as their initiative to do it and also, they have cleaning materials to remove them. Nurses Resources > The knowledge and time of the nurses are the resources they could offer to the family in helping them in this existing problem. Community Resources > The community is always reminding the people about their surroundings that may cause harm to them.
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Therefore, modifiable. Preventive Potential Gravity Duration Current Management Exposure of any high risk group 2/3 x 1 0.67 Gravity
the
problem
is
partially
> The problem is not that severe because the family did not have the experience of having injury with those accident hazards. Duration > The problem existed since they
transferred in their house. Current Management > The family does not solve the problem since they just let their child play on those things and they do not arrange them in a way that children or any family member might be injured.s Exposure of any high risk group > The whole family is affected because the accident hazards are just around their living room and kitchen where they stay most of the time. Therefore, the problem has a moderate preventive potential. Salience 0/2 x 1 0 The family does not recognize the
problem even if those accident hazards are obviously seen in their surroundings. Total: 2.34
Problem # 3.2: Presence of Breeding or Resting Sites for Insects or Rodents
Criteria
Computatio
Score
Justification
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n Nature of the problem 2/3 x 1 0.67 The open and stagnant drainage system can be a breeding site for rodents and insects that may be a carrier that of may
pathogenic
microorganisms
cause disease to the family. Therefore, the problem is a health threat. Modifiability Problem Current Knowledge Family Resources Nurses Resources Community Resources of the 1/2x2 1 Current Knowledge > The family is not knowledgeable about the importance of keeping the place free from presence of breeding sites. Also the family is not aware on some ways to eliminate these breeding sites. Family Resources > The family is capable of eliminating the presence of breeding sites in their home by cleaning it everyday. Nurses Resources > The student nurses should provide ways to teachings about some ways to eradicate the presence of breeding sites. And also student nurses can assist the family in cleaning the breeding site. Community Resources > The health center emphasizes the importance of having a clean
environment, thus free from presence of breeding sites. Therefore, modifiable. the problem is partially
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Preventive Potential Gravity Duration Current Management Exposure of any high risk group
2/3x1
0.67 Gravity > The problem is not severe since the family does not on the yet experience and
complication
problem
behavioral change is needed to eradicate this problem. Duration > The problem existed since they
transferred in their house. Current Management > Even though family is aware of the existing problem still there is no
intervention being done to eradicate the problem. Exposure of any high risk group > The whole family is affected to this problem especially to their child it could cause parasitism. Therefore, the problem has moderate preventive potential. Salience 0/2 x 1 0 The family does not recognize it as a problem since they are used to it and they have not yet experienced any problem from it. Total: 2.34
Problem # 3.2: Inadequate Personal Belongings or Utensils
Criteria
Computatio n
Score
Justification
2/3x1
0.67
Having inadequate personal belongings
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and
utensils
could
lead
to
health
threatening problems such as transfer of microorganisms, infections and the like because of lack in utensils wherein the repeated use of these equipments are likely to occur and the possibility that they will borrow from their neighbors. Therefore, the problem is a health threat. Modifiability Problem Current Knowledge Family Resources Nurses Resources Community Resources of the 1/2x2 1 Current Knowledge > The family knows that they have inadequate personal belongings or
utensils but they do not know the possible consequences of the situation. Family Resources > The familys resources, specifically financial, are adequate to alleviate the existing problem. They could buy utensils available in the market which is just a jeepney ride away from their home. Nurses Resources > Knowledge, time and effort to give health teachings to the family regarding the possible consequences that might happen due to existing problem such as diarrhea, risk for infection or of acquiring communicable diseases. Community Resources > There were no available community resources to solve their problem. The community cannot afford to provide
enough personal utensils that may help
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the family. Therefore, modifiable. Preventive Potential Gravity Duration Current Management Exposure of any high risk group 2/3x1 0.67 Gravity > The problem is not considered as severe because the families still has their own belongings and have the option not to borrow from their neighbors. They do not put much attention to this problem because they are contented of having few belongings or utensils. Duration > The problem existed since they the problem is partially
transferred in their house. Current Management > The family performs certain
management like washing of clothes everyday. Exposure of any high risk group > The whole family is exposed to this problem, like transfer of microorganism through borrowing other utensils from their neighbors. Therefore, the problem has moderate preventive potential. Salience 1/2 x 1 0.5 The family recognized it as a problem but it does not need an immediate Attention. They are more concern with their food rather than other things. Total: 2.84
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PROBLEM #3.2: UNSANITARY FOOD HANDLING CRITERIA COMPUTATION SCORE JUSTIFICATION
Nature of the Problem
2/3 x 1
.67
The problem is categorized as health threat because it could
Health Threat
lead to certain disease conditions like malnutrition, diarrheal disease, and decrease immune resistance susceptibility to illness.
Modifiability of the Problem
1/2 x 2
The problem is partially modifiable.
Current X knowledge and interventions Resources of the family Resources of the student nurses Resources of the community
Current knowledge and interventions: The family does not have enough knowledge about the importance of proper food handling and preparation. Resources of the family: The family in is able to
participate
interventions
such as cleaning the place where they cook as well as the utensils they use in cooking. And they are able to practice proper food handling.
Resources of the student nurses: The student nurses time and
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skills are available through provision of health teachings such as possible effects
unsanitary food handling. Resources of the community: The health centre is able to provide health teachings on effects of the aforementioned problems.
Preventive Potential
2/3 x 1
.67
The problem has a moderate preventive potential.
Gravity/ Severity
Gravity/ Severity: The problem is not severe since the family does not
Duration
experience the extent of damage that can be brought
Current Management Exposure to
about by the problem.
Duration: The problem has been existing for a long time.
any high risk group
Current Management: The family lacks initiative in getting rid of the problem. Thus, no interventions are being done by the family to eradicate or at least minimize the problem. The possibility of improper food preparation that
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may lead to malnutrition and diarrheal diseases can be reduced or eliminated if proper management is done as soon as possible.
Exposure to any high risk group: The young ones are highly at risk for developing not only food borne diseases but more so malnutrition.
Salience
0/2 x 1
The family does not recognize the problem as a condition needing change. Because they are unaware of what unsanitary food handling can cause.
Total score
2.34
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VI. FAMILY NURSING CARE PLAN Problem #1: Inadequate Personal Belongings or Utensils
CUES
ANALYSIS OF THE PROBLEM
OBJECTIVES
NURSING INTERVENTION
RATIONALE
METHOD OF FAMILY CONTACT
RESOURCES REQUIRED
EXPECTED OUTCOME
S>0
>inadequate knowledge as
Short term: >after 2 hours of home visit, the family will be able to understand the importance of recycling available resources.
>Assess family level of understanding
>to know up to what extent will he/she give teachings to the family
Home visit
>time, effort, knowledge of student nurses
Short term: >after 2 hours of home visit the family shall have
O> -repeated to alternative clothings -borrowed glasses, plates and spoon and fork courses open to them.
Cooperation >Assess the familys available resources >to establish >Encourage resourcefulness of the family >to know the appropriate interventions and participation of the family
understood the importance of recycling available resources
Long term: >after 2 home visits, the family will be able to have functioning
family to recycle things
Long term: >after 2 home
>to maximize >Advise family to improvise things that are the available resources that can be of great
visit, the family shall have functioning
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facilities
lacking using their environmental resources
need if recycled
facilities.
>for the family to be knowledgeable
>Explain to the family the importance of recycling materials
on what they are doing
Problem # 2: Poor Personal Hygiene
CUES
OBJECTIVES
NURSING INTERVENTION
RATIONALE
RESOURCES REQUIRED
EXPECTED OUTCOME
S>0
>inability to recognize the
Short Term: >After 1 hour of nursing interventions, the family will be able to verbalize the importance of
>Establish rapport
>To gain trust of the family to be able facilitate better understanding, for the family to cooperate easily in
>home visit
>time, effort and cooperation of both the family and student nurses
Short Term: >the family shall have verbalized the importance of proper and good personal hygiene
O>dirty and untrimmed fingernails and toenails seen on all members of
presence of a problem due to inadequate knowledge about health or probably
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the family except Inang Reyna >Yellow stains, and cavities in the teeth seen in all family members.
tardiness.
proper and good personal hygiene
achieving the set goals that could satisfy both parties
>knowledge of the student nurses regarding hygiene Long Term: >the family shall have demonstrated the correct hygiene measures and practices to improve their personal hygiene
Long Term: >after 5 home visits, the family will be able to demonstrate the correct hygiene measures and practices to improve their personal hygiene as evidenced by an improvement in their personal hygiene (trimmed and >Explain to the family the possible implications of poor personal hygiene (risk for >Assess each family member of his/her personal hygiene through interview and identify the possible factors that affect the family >To encourage them to participate in solving the familys problem and to increase >To determine the proper actions to be performed in the family regarding the problems
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clean toenails, brushing of teeth twice a day or as frequent as possible, wearing sleepers or flip flops)
having illnesses, infections and discrimination especially to the child) as well as the advantages of correcting them (avoidance of illnesses and infections, looking clean and increasing their selfesteem)
their salience to the problem
>To facilitate >Encourage and teach the parents to facilitate proper bathing and care of the body to their child. >To promote >Provide further health and for bonding and to prevent occurrence of infections or diseases
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health teachings and help in improving their personal hygiene
them to know the importance of personal hygiene
>To >Assist in bathing of their child giving importance in utilization of shampoo, cleaning hidden areas like back of the ears, groin and armpit. >To encourage children to have a clean nails demonstrate proper bathing and facilitate self reliance
>Teach proper nail trimming and ask the mother to trim the nails of her child. Also,
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inform the family that dirty nails can be a cause of illnesses such as diarrhea.
>Remind each family member about wearing of slippers and the consequences of not wearing them such as risk for injury to their feet that could lead be infected.
>To know importance of wearing slippers
>Demonstrate proper brushing of teeth. Tell >To facilitate proper tooth
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them the importance of brushing of teeth and the consequences of poor dental hygiene (upper respiratory tract infection, cavities, bad breath or halitosis and ask them to perform it in front of the student nurses
brushing , encourage them to brush their teeth regularly, and for the group to be able to assess the effectiveness of the health teaching and learning capabilities of the each
Cues
Analysis of Problem
Problem #: 3.2 Unsanitary Food Handling And Preparation Objectives Nursing Rationale Methods Intervention Short Term: -After 4 hours of home visits, the mother will be able to recognize the importance of -Explain the importance of proper food handling -To invoke awareness among family - Home visits members
Resources
Evaluation
Subjective: -
-Inadequate knowledge on
Student Nurses: -
Objective: the Food is not importance of washed proper food
-Instruct not to -To prevent - Environmental store foods that or avoid food
Short Term: -The mother shall have recognized the importance of proper food handling and
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carefully and preparation the kitchen is and handling. beside the comfort room. The kitchen is a good site for the proliferation of vectors that can bring about different diseases.
proper food handling and preparation. Long Term: -After 3 days of home visits, the family will exhibit or demonstrate proper food handling with the aid of health teachings given.
easily get spoiled
poisoning
assessment
knowledge and skills
preparation. Long Term: -The family shall have exhibited or demonstrated proper food
- Interview
- time and effort
- Health teachings
- health teachings
Family: - time and effort cooperation of the family members
handling with the aid of health teachings given
Problem # 3.2: Improper Drainage System
CUES
OBJECTIVES
NURSING INTERVENTIONS
RATIONALE
RESOURCES EXPECTED REQUIRED OUTCOME
S> Minsan magtapon si
Inability to make
Short term: After the 1
> Establish rapport
>To gain trust of the family to
> Home visit
> Cooperation and
Short term: After the 1
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Lira ng plastic ng chichiria na pinagkainan niya kahit sabihin kong tapon niya sa basuharahan.
decisions with respect to taking appropriate health action due to:
hour of home visit, the family will be able to verbalize their awareness towards the problem.
be able facilitate better understanding, for the family to cooperate easily in achieving the set goals that could satisfy both parties
understanding hour of of the family home visit, the family > Time, effort and knowledge of the student nurses shall have verbalized their awareness towards the problem.
> Low O> stagnant water at the front of the house near their bathroom with presence of garbages (plastic wrappers) salience of the problem Long term; After 3 days >Inadequate of home visit, knowledge as to alternative courses of action open to them the family will be able to begin doing action like cleaning their drainage by removing the plastic wrappers as evidenced by, if not totally > Assess for the existing problem (the smell of the drainage, amount of garbage in the drainage and the possibility of cleaning the drainage)
Long term; > To plan for an appropriate interventions to be made After 3 days of home visit, the family shall have begun doing action like digging a new drainage for the passage of water.
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absence of foul smell at least lessening of the it, and the drainage system free of any garbage and not throwing plastic wrappers to it. > Discuss to the family the disadvantages of having an improper drainage system (foul smell in front of their house, site for breeding of vectors like mosquito, possibilities of the drainage system to be clogged and cause flood during rainy days) > To encourage them to make action in solving the problem > Explain to the family the problem with regards to the drainage system > To create awareness to the family
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> Advise them to correct the drainage by making a new passageway for the water >To prevent further formation of stagnant water which leads to prevention of the occurrence of diseases
> Assist in cleaning the drainage which facilitates proper flowing of water > To help and to encourage the family to maintain a flowing drainage
Problem # 3.2: Poor lighting (night time and day time)
CUES
ANALYSIS OF THE
OBJECTIVES
RATIONALE
METHOD OF FAMILY
RESOURCES REQUIRED
EXPECTED OUTCOME
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PROBLEM S> Sira nga ung ilaw dian (pointing to the bulb in their living room). May problema ata sa wiring, tapos ung bintana sa kwarto di man pwedeng buksan, kasi kabilang bahay na iyon. As verbalized by Inang Reyna >Inability to provide a home environment which is conducive to health maintenance and personal development due to inadequate family resources specifically financial constraints and limited financial resources Long Term: >After 3 days of home visits, the family will be able to demonstrate improvement on their lighting by opening their curtains and O> the fixing the >Explain the importance of good and proper lighting to the family such as good lighting could decrease the possibility of having injury >to create awareness on the problem and to encourage them to do some actions Short Term: >After 1 home visit, the family will be able to verbalize understanding of the importance of proper lighting >Establish rapport >To gain trust of the family to be able facilitate better understanding, for the family to cooperate easily in achieving the set goals that could satisfy both parties
CONTACT >home visit >cooperation and understanding of the family Short Term: >the family shall have verbalized understanding >knowledge, time and effort of the student nurses Long Term: >the family shall have demonstrated improvement on their lighting of the importance of proper lighting
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familys house shows:
broken bulb as soon as possible
since they can take a view of their surroundings better to see if
-dark lighting even when day time -light bulb in the living room is not working.
there is any sharp objects and alsi it could decrease the chance of having eye problems since reading in the dark could harm their eyes, it could serve as a good breeding ground for rodents since rodents like dark places
>Advise them to utilize a light bulb or any source of especially during night time > To prevent injury and to facilitate proper lighting
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>During day time, instruct them to open windows and curtains to allow entry of light >To allow entrance of sunlight and to save electricity if with the presence of light bulb >Advise family to perform important activities that could be done in the morning like cleaning. >To prevent accident in doing activities at night
Problem # 3.2: Accident hazards
CUES
OBJECTIVES
RATIONALE
RESOURCES REQUIRED
EXPECTED OUTCOME
S>O
>Inability to
Short Term:
>Establish rapport
>To gain trust
>home visit
>cooperation
Short Term:
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provide a O>The familys house shows: home environment which is conducive to health -Presence of rusty nails scattered in their front houseknives in the house that are within reach of their child, poor lighting. a. lack of knowledge of preventive measures b. lack of skill in carrying out measures to improve home environment maintenance and personal development due to:
>After one hour nursing intervention through the time allotted for home visit, the family will be able to recognize the things that may cause injury in their house and environment and remove possibly hazardous objects that could be the cause of injury and place knives in a safer, out of reach for >Explain to the family the >Assess for the presence of the accident hazards by looking for presence of other sharp, poisonous and defective electrical devices.
of the family to be able facilitate better understanding, for the family to cooperate easily in achieving the set goals that could satisfy both parties
of the family
>the family shall have
>knowledge of the student nurses
recognized the things that may cause injury
>motivation coming from the student nurses
in their house and environment
>To serve as the baseline data for planning and implementing the interventions Long Term: >the family shall have intervened on the presence of harmful objects in their house >For them to understand the and surroundings
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children, place
importance of keeping their house organized
interventions that will be performed
Long Term: >After 3 days of home visits, the family will intervene on the presence of harmful objects in their house and surroundings. >Tell the family to >Encourage the mother to keep the pointed utensils in a place where it is not in reach of the children >To alarm the family with >To prevent injury to the family especially to the children
keep those pointed regards to the objects, rusty nails and in the safe place where children can not reach them >To know >Discuss first aid measures for cuts and proper cleaning of interventions in case of accident and to avoid things the may cause harm
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wounds (washing wound with soap and running water and bringing the injured family member to the nearest health care facility if the source of injury can be contaminated and be a cause of tetanus.
further complications
Problem # 3.2: Presence of breeding or Resting Sites for Insects and Rodents
CUES
OBJECTIVES
RATIONALE
METHODS OF FAMILY CONTACT
RESOURCES REQUIRED
EXPECTED OUTCOME
S>Meron ngang mga daga at ipis. Pag hapon madaming
>inability to recognize the presence of a problem due to lack
Short Term: >After one home visit the family will be able to
>Establish rapport
>To gain trust of the family to be able facilitate better understanding,
>home visit
>cooperation and understanding of the family
Short Term: >the family shall be be able to identify the
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lamok kaya nageelectric fan nalang kami.
of knowledge
identify the already existing problem as evidenced by
for the family to cooperate easily in achieving the set goals that could satisfy both parties
>time, effort and knowledge of the students
already existing problem as evidenced by verbalization of understanding regarding the
O>presence of stagnant water, presence of garbage near the house, poor lighting, and holes in the house, presence of left over foods in their kitchen lavatory.
verbalization of understanding regarding the existing problem. >Assess the possible sources of the existing Long Term: >after 3 days of home visits, the family will begin doing actions to improve their environmental conditions AEB cleaning their surroundings, >Explain and discuss the importance of intervening in the problem and the possible diseases that may occur (Malaria & Dengue from problem
>To know the interventions that will be made
existing problem.
Long Term: >the family >To encourage the family to implement the plans and to create awareness to the family shall have began doing actions to improve their environmental conditions AEB cleaning their surroundings
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cleaning their drainage system, improving lighting conditions, and using insect repellants.
mosquitoes, Hantavirus and rabies from mouse) >To prevent occurrence of >Encourage the family to correct and improve the status of their drainage system and their environment >To maintain >Provide health teachings on the maintenance of their environment and surroundings >To lessen the >Instruct the family to properly seal their trash can, throw away left over foods or breeding ground of the rodents. and promote health within the family diseases
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if it is still edible, place properly in the refrigirator
>To prevent >Encourage the family to avoid stocking many things on their surroundings the insects from staying especially mosquitoes from staying their.
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VII. FAMILY COPING INDEX
Initial Category 1 3 5 1
Final 3 5 Justification
Physical Independence:
Initial Visit:
This category is concerned with the ability to move about, to get out of bed, to take care of daily grooming, walking, etc. Note that it is the family competence that is
The entire family member is able to take care of their own task and needs. Their one and only child is able to provide care for herself such as taking a bath and dressing up but she is usually guided by her mother. The mother provides care for her child. Although they have the ability to do their daily task and improve their personal hygiene, it was evident that they were not doing it since the student nurses were able to identify that one of the problem existing in the family is their poor personal hygiene. The only hindrance in this category is their lack of willingness to do the necessary task. Like most Filipino family, the
measured- even though an individual is independent, if the family is for able this. to The
compensate
family is important-hence, if the focus of care is poor, for instance, if the mother is giving care to a handicapped child that she shared with other members of the family, the independence might be considered incomplete. The causes of independence may vary however. Lack of
Enchanted Family does not recognize the existence of the problem not unless it had already caused any harm to any member of their family. This is where the duty and responsibility of the student nurses would enter. They would provide interventions in form of health teaching and guide the family towards to goal of self reliance through
independence in the family may be due to actual physical incapacity, the inability of know-how, the willingness or fear of doing necessary tasks.
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their home visits.
Final Visit:
After 5 days of home visit, the family members were able to identify their deficit in their in caring for their personal hygiene. They were able to identify, through the teachings of the student nurses, the possible
consequences of their poor personal hygiene. With these in hand and with the guidance of the student nurses, the Enchanted Family was able to do certain actions and intervention
directed towards the improvement in their poor personal hygiene.
Therapeutic Competence:
Initial Visit:
This category includes all the procedures or treatment
The competence of the family in this category is considered to be low since it was reflected during the assessment that they do not have enough or adequate knowledge about treating a sick person, such as giving the proper medications. Their
prescribed for the care of illness, such as and giving using
medications appliances,
dressings,
exercises, and relaxation and special diets.
knowledge about medications is only limited to those common medical especially those being
treatment,
commercialized through media. They do not know anything about what diet
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and what exercise should a sick person have. Their only concept of therapeutic management is by giving the sick person over-the-counter medicines
which they have quick access since a drug store is just near their house.
Final Visit:
After
the
implementation
and
health teachings of the student nurses to the family, the family was able to increase their knowledge with regards to situations that may concern their health. This includes proper sickness
medications for common
such as fever, coughs, diarrhea, colds etc, it also includes proper moderate exercise that would involve exercising 30 minutes a day 3 to six times a week, and also they were able to identify problems that may arouse from their sedentary lifestyle dietary habit. With the following mentioned above, the family was able to move from low to moderate therapeutic competence.
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Knowledge condition:
of
health Initial Visit:
This category is concerned with the particular health
The
Enchanted
Family
was
categorized to have a low competence in their knowledge of health condition as because of many factors. One of it is that the family misinterprets health conditions like fever, which they usually encounter, would not harm other members wellness and might lead to transmission of the illness. It could also be reflected through their hygiene as what was mentioned above. They also do not utilize the health center that much since they do not know what the health care facility could offer them.
condition that is the occasion for care, knowledge of the disease or disability, of
understanding
communicability of diseases and modes of transmission, understanding of general
patterns of development of a newborn baby and the basic needs of infants for physical care and tender loving care.
Final Visit:
The student nurse provided health teachings to the family, and the family did practice what was taught to them. The student nurses also provided the Ynang Reyna with brochures coming from the health center for topics like dengue as this may help them very well to increase their knowledge about it and increase the probability of preventing of preventing the
occurrence of the disease condition. The student nurses also provided them with information regarding the services
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that the health center could provide them such as free consultation. They sincerely agreed to the student nurses that it would do no harm to them if they check the mentioned community health facility once in a while. With their increase in knowledge regarding their health condition, the student nurses gave the family a score of moderate competence.
Application of principles of general hygiene:
Initial Visit:
The student nurses classified the This is concerned with family action in relation to family to have a low competence with their application of principles of general hygiene since their current situation is not favorable to good health. The entire member of the Enchanted Family does not exercise, and this resulted to malnutrition (Overweight and Obesity) in some of the members of the family. One of their so-called modes of relaxation is watching television while eating junk foods. This cannot be considered relaxation but rather
maintaining family nutrition, securing adequate rest and relaxation for family members and carrying out accepted preventive measures such as immunizations, appraisal and medical safe
homemaking habits in relation to storing and preparing food.
sedentary. Another is playing Tongits , a popular Filipino rummy card game, that Ybarro and Ynang Reyna would play with their neighbors and friends all
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night long until early in the morning. This would rather provide stress to them since they would be deprived of sleep and if they would lose the game. Lira is a completely immunized child although Ynang Reyna only received her tetanus toxoid shot twice. The family only has a few utensils to use since they would reason out that they would sell the house in due time so why bother buy those? Their
refrigerator could ensure the proper storage of their food.
Final Visit:
Improvement in their application of principles for general hygiene was very much observed during the evaluation process of the Family Case Analysis. The student nurses were able to see that the entire family is now trying to improve their personal hygiene by taking a bath daily. Lira in this case would take a bath before the student nurses would arrive to impress them. In turn, the student nurses would praise her to reinforce her good actions. Other members of the family would as much as they can to clean the house before the student nurses would arrive to
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impress them. They would also try to use their time in cleaning as their way of exercising. Therefore the student
nurses gave them a score of moderate competency in this category.
Health care attitudes:
Initial Visit:
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.
The family does not perceive any health Reynas threat from their that present Wala
situation. This is manifested by Ynang verbalization
naman kaming problema, okay lang naman kami when asked what factors in their present situation could inflict harm or threat to their health despite the fact that the student nurses were able to identify problems in the family and their house. This is the reason why the student nurses classified the family to have a low competency towards their health care attitudes.
Final Visit: After being told on what problems that the family have and the possible consequences of their lack of action towards the problem, the Enchanted family easily understood what they are trying to imply and with that they were able to be more conscious with the existence of the problem in their household and the family moved from
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a level of low to moderate competency.
Emotional Competence:
Initial Visit:
This category has to do with the maturity and integrity with which the members of the family are able to meet the usual stresses and problems of life, and to plan for happy and fruitful living. This
Whenever the family has problem with their relationship to one another, especially Ybarro and Ynang Reyna, they talk about it and they do the tradition of many Filipino family which they call inuupuan ang problema. In this process the head of the family would call and facilitate an open forum and every member of the family would be sitting in their kitchen table to address the problem. In this way they are able to meet and solve stress related problems by the means of talking to come up with a solution or a decision would be for the sake of the greater good.
involves the degree to which individuals necessary accept the
disciplines
imposed by ones family and culture; the development and maintenance of individual decision; to meet to with
responsibility and and willingness
reasonable accept
obligations, adversity
fortitude, and to consider the needs of others as well as ones own.
Final Visit:
The family is able to maintain a reasonable degree of emotional
calmness even in a stressful situation. From the start up until their last home visit, the family was able to maintain their proper communication between one another. It was very much evident during the process of intervention when they cooperates not only to the student nurses but also to other members of
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the family.
Family living patterns:
Initial Visit: All of the members of the family get
This category is concerned largely with the interpersonal or group aspects of family lifehow well the members of the family get along with one another, the ways in which they make decisions affecting the family as a whole, the degree to which they support one another and do things as a family, the degree of the
along very well. Final Visit: Still the student nurses taught the child to respect her parents and aunties by pagmamano and saying po and opo and the child do it, as evidenced by pagmamano to her parents whenever she arrives after going to school.
respect
and
affection
show for one another, the ways in which the manage the family budget, the kind of discipline that prevails.
Physical Environment:
Initial Visit: Their physical environment is
This category is concerned with the home and community or work environment as it affects family health. This includes the conditions for
indeed poor. Most of the problems identified by the student nurses were related to their physical environment. Their house has poor ventilation and also poor lighting condition. The
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housing, presence of accident hazards, screening, plumbing, facilities of cooking and for privacy; level of community (deteriorated or modern,
drainage system located in front of their house is stagnant. There is presence of rodents and some parts of the house would be a good breeding ground. They only have a few utensils. Sharp objects such as knife are within reach of children.
presence of social hazards such as bars, street gangs, delinquency, pest such as rats, etc.), availability and conditions of schools and
Final Visit: The family improved the cleanliness of the interior of the house but the surrounding environment still needs more interventions. This was
transportation.
evidenced by the cleaner environment. The family was able to increase their competence in this category when the student nurses provided them the proper guidance on what to do to eliminate the existing problem and prevent it from reoccurrence. They were able to put this teachings into action like fixing their broken bulb to improve the lighting condition of the house, cleaning and not throwing garbage in their drainage system, moving sharp object out of reach of children and using insecticides and traps to eradicate presence of rodents in their house. Some of the problems like their inadequate ventilation would require a more complex work since it would involve reconstructing of the house, therefore the student nurses just provided them with the teaching
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that the airway should not be blocked by anything so as not to aggravate the existing problem.
Use of community facilities:
Initial Visit:
This category has to do with the degree to which family members know about and the wisdom with which they use available resources for community health,
They do not usually use the facilities present in their community especially the health center. Therefore they are not familiar to what services they could avail from that facility.
education, and welfare. The coping ability does not
Final Visit: The student nurses provided
indicate the level of the need for services, but rather the degree to which they can cope when they must seek such aid.
them with the information regarding the services and benefits that they could get from the health center of Barangay Balibago. They family insured the student nurses that they would go to the health center if health problems in their family would arise.
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VIII. LEARNING DERIVED
I personally learned the importance of the family in the society, as the basic unit of the society, it is important to maintain the health of the family. Comparing the family with the human body, as when one part of the body is infected, later on the whole body will be affected systemically, just like with the family and society, when a family is considered ill, later on the society will be systemically affected.
I also learned the importance of good communicating skill. With the absence of a good communicating skill the student nurse will not be able to establish rapport with his/ her client, thus affecting the assessment process, making the problem identification and prioritization be difficult, thus, altering the maximum care you may give to the family.
I have learned that the best way to help the family with their health needs is thru health teachings. With proper knowledge and enhanced skills a family can provide care to each and every member of them to prevent any harm or any factors that may alter their health.
Finally, I have learned the meaning of the word teamwork. Being compared with the community, every family plays an important role in the movement of the community itself towards a better quality of life. Same with a team, a team needs to do their job as a whole. No one plays alone, No one goes the opposite the way of his own man, and no one leaves someone. -YANGUAS, BRYAN CHRISTOPHER R.
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Family Case Analysis is a very hard work and a big challenge that needs understanding ,patience, knowledge and skills.
As a student nurse, we need to do many work in this case analysis, at first I think that it wouldnt easy for us to do this case analysis because it takes a long process to do the interventions and to help the family to identify their problems in their current situations, I was then asking myself on what are the things I can help to our adopted family since I was only a student nurse without any experienced prior to their existing problems, and besides I cannot even help them especially in their financial needs, but then as time goes by I challenged my self to finish this work and to cooperate well with my group mates, and to dedicate myself in doing this family case analysis. When we started this case analysis, Ive learned many things about life. During our home visits to our family and in the community, I found out that I was so blessed because God provided me with a good lifestyle and a healthy living, but I know God has a purpose for every thing. When we met our family and started to established rapport to each of the family members, they open o us that life is not always on the bed of roses instead they said that in their situation and in tat kind of environment, the only way to keep them strong is their faith in Lord, because they believed that whatever their situation theyre experiencing today God is always on their side, that He will never leave them. In their situation, Ive learned that having faith with the Lord, you can survive every thing. Another lesson Ive learned is that part of the vibrancy of any family is also dealing with their weakness, fear, stresses itself, nobody is perfect so the only way to overcome this situations in the family is having a hundred percent trust to each other and to love each other deeply and to just enjoy life, with a joyful and glad heart. Enjoying the company of each of the member of the family and just to always be happy, just smile whenever they experience their problems is the best way to resolve their struggles in life.
Ive also learned how to become friendly and makibagay with other people whom I ever met nor saw before, it gives me a lot of confidence and it helps me to improved self-reliance. I can say that our duty in Community Health Nursing is the best experienced I ever had in my second year level. It has a great impact in my life that I will surely cherished for the rest of my life. The lessons Ive learned, I will apply it to my own
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life when I have my own family and until the time I will become a successful nurse in the future. It helps me to mold myself as a better person, as a good student nurse and as well as when I become a competent nurse in the future. -JESSICA BANSIL
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IX. SOCIOGRAM & DOCUMENTATION
Legends Physical Assessment/VS Taking
Interview
Student Nurses
Problem Identification
Intervention/Implementation
Achievement of Self-reliance
Bidding Goodbye
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First Home visit (August 10, 2010)
Ybarro
Ynang Reyna
Danaya
Lira
The diagram above illustrates what had happened during the first day of home visit to the Enchanted Family. The community was in Balibago, the community setting is very similar to other communities that the student nurses have been to, so it was very easy for them to fit in into the community. In their search for a family for them to adopt, the student nurses attention was caught by a small house with a mini sari-sari store on one of the corners of A. Santos street. The student nurses were curious about what will be the reaction of the family. This is when the student nurses have introduced themselves to the family and stated their purpose and and goals to the family. The family, especially Ybarro and Ynang Reyna accepted the student wholeheartedly. The student nurses also conducted their initial assessment to each family member. Establishing rapport to each and every member of the family is vital because in time that the student nurses were able to gain their trust, it would be easier for them to
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communicate to the family members that will facilitate understanding between them and the student nurses and above all, this trust can be a way for the family to cooperate more easily with the intervention and teachings that will be provided by the student nurses. With these in hand both parties will be satisfied. This is the reason why during their initial physical assessement, the student nurses also grabbed the opportunity to establish rapport to the family members. Although the Ytay and Ynay wholeheartedly accepted the student nurses, Lira and Danaya were still uncomfortable with the student nurses that they just have met. Because there was still some time after conducting their initial physical assessment to all family members, the student nurses were able to conduct their interview with regards to the socio-econmic status of the family. Plan of Activities Objectives of the Day Met Partially Met Familiarize self to the community setting (Way of living) Search for a family to adopt State their purpose and goals for the family Conduct Initial Physical Assessment Interview the family for informations regarding their socio-economic status Establish rapport to all member of the family Schedule another visit Unmet
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One of the student nurse smiling enthusiastically in front of their adopted familys house as she was conducting physical assessment with her weighing scale to every member of the family.
Making the conversation as lively as possible for her to be able to establish rapport to the family members, the student nurse is interviewing one of the them regarding informations about their the
socioeconomic status important data
while jotting down
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Second home visit (November 16, 2010)
The diagram above shows the process of the activity during the 2nd home visit. During the second home visit the student nurses the student nurses continued their physical assessment and their interview to the family. To be able to work efficiently, the student nurses were divided the work into two, one interviewing the family members and the other obtaining their vital signs and physical assessment. The major goal of the student nurses for that very day was to assess problems that were present in the family. After they searched and inspected every angle of the house and assessed thoroughly the health condition of each family member the student nurses were able to identify 5 problems. During this time, the student nurses were able to communicate to Danaya and Lira. Finally, they were able to establish rapport to the two. They are now more often and fond of talking to the student nurses. After those activities, the student nurses left the family for the mean time and scheduled another home visit. After this, the student nurses identified solutions to the problems present in the family and planned carefully what would there intervention be on the next home visit. Plan of Activities
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Objectives of the Day
Met
Partially Met
Unmet
Continue physical assesment Continue interview and data gathering Assess problems present in the household Establish rapport to all family members Schedule another visit Carefully plan for the interventions to be implented with regards to the problems identified
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The two pictures shown above shows the one and only bedroom of the house. The room is dark because the light bulbs were broken. Also the window inside the house is completely blocked by a wood since the window will already lead to the house of their neighbors. These are some of the problems that the student nurse were able to identify during this home visit.
Untrimmed and dirty nails of Lira is shown in the picture above which is a strong indicator that she has a poor personal hygiene. Third home visit (August 17, 2010)
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On the third day of home visit the group the major concern of the student nurses was to conduct their interventions to the problems identified during their previous home visit. Many things were discussed between the student nurses and the family regarding the problems. The family members were able to identify the problems that the student nurses were able to observe and also they were able to take grasp of the reality in short period of time regarding the need for intervention for the problems. The student nurses emphasized that they need the cooperation of each and every member of their family to whatever task that they may need to accomplish to eradicate the existence of the problem and that the student nurses will only serve as a guide for them in this process. With these in hand, they would be able to gain self-reliance or independency which, at the first place, the goal of the entire Family Case Analysis towards the family. Although during this process, the student nurses were able, again, to identify three problems present in the family. After the implementation of the the planned interventions, the student nurses left the family and scheduled another visit. They planned afterwards on
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the interventions that they should accomplish the next home visit with respect to the problems lately identified. Plan of Activities Objectives of the Day Met Partially Met Put planned interventions into actions Obtain Vital Signs Discuss to the family the importance of cooperation and that the student nurses would only guide them during the process Identify more problems Schedule another visit Plan interventions for lately identified problems Unmet
Being able to identify the existence of the problem, Danaya volunteered herself to clean
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the house immediately shortly after it was explained to her the importance of doing such.
Ynang Reyna is trimming Liras nail as she had learned the consequences of not keeping them clean and short.
The student nurses noticed the sharp objects such as these knives are within reach of Lira and this is hazardous and could impose health threat to all members of the family especially to her that she may mishandle the knives or point and harm other family members with it.
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The immediate action of the student nurses was to place It in a safe place and explain to the parents why such simple things could impose threat to the family.
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Fourth home visit (August 23, 2010)
On the fourth day of home visit the group there were only few things left for the group to do, and that is to provide intervention with regards to the latter identified problems. They were able to put their plan into action more easily than their last home visit since the each of the family members are now able to participate further during the activity because they are now more comfortable in doing such as they have done it before. After implementing the plans, the student nurses conducted health teachings to the family not only regarding to the problems that they are/had experiencing/experienced but also to the problems that they may encounter in the future such as what to do when one of the family gets sick and what interventions should they give to the patient and the availability of health care facilities in their community. Plan of Activities
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Objectives of the Day
Met
Partially Met
Unmet
Put planned interventions into actions Obtain Vital Signs Provide health teachings to the family Schedule another visit
After telling the family last home visit how could their rooms inadequate lighting could be a health threat to them, on their next home visit, the family proudly showed that they got their bulb light fixed and the student nurses praised them to reinforce their right-doings
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Fifth/Last home visit (August 24, 2010)
On the final home visit, the student nurses did the final assessment to each member of the Enchanted Family. Through the very active participation of the Enchanted Family, the goals that were established by the student nurses before and during the previous visits were successfully met. The family was able to learn how to manage their current problems with the guidance of the student nurses which then leads them to be a self reliant family. But as the old saying goes, every good thing has its own end. The group had to bid goodbye to the now self reliant family. But before they left the family, the student nurses brought together with them a small bucket of ice cream to celebrate with the family and the student nurses were able to achieve; a harmonious relationship
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that provided one another with an excellent cooperation towards the goal of attaining a self reliant and independent family.
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X. FLOOR PLAN AND SPOT MAP
Not source of ventilation
Source of ventilation
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Drug Store
Barangay Health Center
Enchanted Familys House
SPOTMAP
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Appendix APPENDIX A: Weight (kg) for Age of Boys and Girls (0-72 months) BOYS AGE (Mont hs) 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Below Normal (Very low) 1.8 2.2 2.7 3.2 3.7 4.1 4.6 5.0 5.3 5.7 5.9 6.2 6.4 6.6 6.7 6.9 7.0 7.2 7.3 7.5 7.6 7.7 7.9 8.0 Below Normal (Low) Fro To m 1.9 2.3 2.3 2.8 2.8 3.4 3.3 4.0 3.8 4.6 4.2 5.2 4.7 5.8 5.1 5.4 5.8 6.0 6.3 6.5 6.7 6.8 7.0 7.1 7.3 7.4 7.6 7.7 7.8 8.0 8.1 6.3 6.8 7.1 7.5 7.8 8.0 8.2 8.4 8.6 8.7 8.8 9.0 9.1 9.3 9.4 9.6 9.7 Normal Fro m 2.4 2.9 3.5 4.1 4.7 5.3 5.9 6.4 6.5 7.2 7.6 7.9 8.1 8.3 8.5 8.7 8.8 9.0 9.1 9.2 9.4 9.5 9.7 9.8 To 4.3 5.6 6.8 7.7 8.5 9.2 9.8 10. 3 10. 8 11. 3 11. 7 12. 0 12. 4 12. 7 13. 0 13. 2 13. 5 13. 7 13. 9 14. 1 14. 4 14. 6 14. 8 15. 0 Abo ve Nor mal 4.4 5.7 6.9 7.8 8.6 9.3 9.9 10.4 10.9 11.4 11.8 12.1 12.5 12.8 13.1 13.3 13.6 13.8 14.0 14.2 14.5 14.7 14.9 15.1 Below Normal (Low) Fro To m 1.0 2.1 2.3 2.7 2.8 3.2 3.3 3.8 3.8 4.4 4.2 4.9 4.7 5.4 5.1 5.4 5.8 6.0 6.3 6.5 6.7 6.8 7.0 7.1 7.3 7.4 7.6 7.7 7.8 8.0 8.1 5.8 6.2 6.5 6.8 7.1 7.3 7.5 7.7 7.9 8.1 8.2 8.4 8.5 8.7 8.9 9.0 9.2 GIRLS Normal Fro m 2.2 2.8 3.3 3.9 4.5 5.0 5.5 5.9 6.3 6.6 6.9 7.2 7.4 7.6 7.8 8.0 8.2 8.3 8.5 8.6 8.8 9.0 9.1 9.3 To 4.0 5.1 6.1 7.0 7.7 8.4 9.0 9.6 10. 1 10. 5 10. 9 11. 3 11. 6 11. 9 12. 2 12. 4 12. 6 12. 9 13. 1 13. 3 13. 5 13. 8 14. 0 14. 2 Abo ve Nor mal 4.1 5.2 6.2 7.1 7.8 8.5 9.1 9.7 10.2 10.6 11.0 11.4 11.7 12.0 12.3 12.5 12.7 13.0 13.2 13.4 13.6 13.9 14.1 14.3
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24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48
8.3 8.4 8.5 8.6 8.8 8.9 9.0 9.1 9.2 9.4 9.5 9.6 9.7 9.8 9.9 10.0 10.1 10.2 10.3 10.4 10.5 10.6 10.7 10.8 10.9
8.4 8.5 8.6 8.7 8.9 9.0 9.1 9.2 9.3 9.5 9.6 9.7 9.8 9.9 10. 0 10. 1 10. 2 10. 3 10. 4 10. 5 10. 6 10. 7 10. 8 10. 9 10. 9
10. 0 10. 1 10. 2 10. 3 10. 4 10. 5 10. 6 10. 8 10. 9 11. 0 11. 1 11. 2 11. 3 11. 4 11. 6 11. 7 11. 8 11. 9 12. 0 12. 2 12. 3 12. 4 12. 5 12. 7 12. 8
10. 1 10. 2 10. 3 10. 4 10. 5 10. 6 10. 7 10. 9 11. 0 11. 1 11. 2 11. 3 11. 4 11. 5 11. 7 11. 8 11. 9 12. 0 12. 2 12. 3 12. 4 12. 5 12. 7 12. 8 12. 9
15. 7 15. 9 16. 1 16. 3 16. 6 16. 8 17. 0 17. 2 17. 4 17. 6 17. 8 18. 0 18. 3 18. 5 18. 7 18. 9 19. 1 19. 3 19. 5 19. 7 19. 9 20. 1 20. 4 20. 6 20. 8
15.8 16.0 16.2 16.4 16.7 16.9 17.1 17.3 17.5 17.7 17.9 18.1 18.4 18.6 18.8 19.0 19.2 19.4 19.6 19.8 20.0 20.2 20.5 20.7 20.9
8.4 8.5 8.6 8.7 8.9 9.0 9.1 9.2 9.3 9.5 9.6 9.7 9.8 9.9 10. 0 10. 1 10. 2 10. 3 10. 4 10. 5 10. 6 10. 7 10. 8 10. 9 11. 0
9.3 9.5 9.7 9.8 10. 0 10. 1 10. 2 10. 4 10. 5 10. 7 10. 8 10. 9 11. 1 11. 2 11. 3 11. 4 11. 5 11. 7 11. 8 11. 9 12. 0 12. 1 12. 2 12. 3 12. 5
9.4 9.6 9.8 9.9 10. 1 10. 2 10. 3 10. 5 10. 6 10. 8 10. 9 11. 0 11. 2 11. 3 11. 4 11. 5 11. 6 11. 8 11. 9 12. 0 12. 1 12. 2 12. 3 12. 4 12. 6
14. 6 14. 9 15. 2 15. 6 15. 9 16. 1 16. 4 16. 7 17. 0 17. 2 17. 5 17. 8 18. 0 18. 3 18. 5 18. 7 19. 0 19. 2 19. 4 19. 6 19. 8 20. 1 20. 3 20. 5 20. 7
14.7 15.0 15.3 15.7 16.0 16.2 16.5 16.8 17.1 17.3 17.6 17.9 18.1 18.4 18.6 18.8 19.1 19.3 19.5 19.7 19.9 20.2 20.4 20.6 20.8
Page 147
49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72
10.9 11.0 11.1 11.2 11.3 11.4 11.5 11.5 11.6 11.7 11.8 11.9 11.9 12.0 12.1 12.2 12.2 12.3 12.4 12.5 12.5 12.6 12.7 12.8
11. 0 11. 1 11. 2 11. 3 11. 4 11. 5 11. 5 11. 6 11. 7 11. 8 11. 9 11. 9 12. 0 12. 1 12. 2 12. 2 12. 3 12. 4 12. 5 12. 5 12. 6 12. 7 12. 8 12. 9
12. 9 13. 0 13. 2 13. 3 13. 4 13. 6 13. 7 13. 8 13. 9 14. 1 14. 2 14. 3 14. 5 14. 6 14. 7 14. 9 15. 0 15. 1 15. 3 15. 4 15. 5 15. 7 15. 8 15. 9
13. 0 13. 2 13. 3 13. 4 13. 6 13. 7 13. 8 13. 9 14. 1 14. 2 14. 3 14. 5 14. 6 14. 7 14. 9 15. 0 15. 1 15. 3 15. 4 15. 5 15. 7 15. 8 15. 9 16. 0
21. 0 21. 2 21. 4 21. 7 21. 9 22. 1 22. 3 22. 6 22. 8 23. 0 23. 3 23. 5 23. 7 24. 0 24. 2 24. 5 24. 7 25. 0 25. 2 25. 5 25. 7 26. 0 26. 3 26. 6
21.1 21.3 21.5 21.8 22.0 22.2 22.4 22.7 22.9 23.1 23.4 23.6 23.8 24.1 24.3 24.6 24.8 25.1 25.3 25.6 25.8 26.1 26.4 26.7
11. 0 11. 1 11. 2 11. 3 11. 4 11. 5 11. 6 11. 6 11. 7 11. 8 11. 9 12. 0 12. 0 12. 1 12. 2 12. 3 12. 3 12. 4 12. 5 12. 6 12. 6 12. 7 12. 8 12. 9
12. 6 12. 7 12. 8 12. 9 13. 0 13. 1 13. 2 13. 3 13. 4 13. 5 13. 6 13. 7 13. 8 13. 9 14. 0 14. 1 14. 2 14. 3 14. 4 14. 5 14. 6 14. 7 14. 8 14. 9
12. 7 12. 8 12. 9 13. 0 13. 1 13. 2 13. 3 13. 4 13. 5 13. 6 13. 7 13. 8 13. 9 14. 0 14. 1 14. 2 14. 3 14. 4 14. 5 14. 6 14. 7 14. 8 14. 9 15. 0
20. 9 21. 1 21. 3 21. 5 21. 7 21. 9 22. 2 22. 4 22. 6 22. 8 23. 0 23. 2 23. 5 23. 7 23. 9 24. 1 24. 4 24. 6 24. 9 25. 1 25. 4 25. 7 25. 9 26. 2
21.0 21.2 21.4 21.6 21.8 22.0 22.3 22.5 22.7 22.9 23.1 23.3 23.6 23.8 24.0 24.2 24.5 24.7 25.0 25.2 25.5 25.8 26.0 26.3
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Page 149
APPENDIX B: Immunization Schedule Minimum Interval Between Doses
Vaccine 1. BCG
Maximum Age at 1st Dose At birth or any time after birth
Number of Doses 1
Reasons
2. DPT
6 weeks
3. OPV
6 weeks
4. Hepatitis B
At birth
5. Measles
9 months
BCG given at the earliest possible age protects against the possibility of infection from other family members 4 weeks An early start with DPT reduces the chance of severe pertussis 4 weeks The extent of protection against polio is increased the earlier the OPV is given 6 weeks interval An early start of from 1st dose to Hepatitis B reduces 2nd dose; 8 the chance of being weeks interval infected and from 2nd dose to becoming a carrier 3rd dose At least 80% of measles can be prevented by immunization at this age
Page 150
APPENDIX C: BMI Guideline Based on World Health Organization (2008) Classification Underweight Severe Thinness Moderate Thinness Mild Thinness Normal Range Overweight Pre-Obese Obese Obese Class I Obese Class II Obese Class III <18.50 <16 16.00 - 16.99 17.00 - 18.49 18.50 - 24.99 25.00 25.00 30.00 30.00 - 34-99 35.00 - 39.99 40 and above BMI (kg/m2)
Page 151

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I. INTRODUCTION Call it a clan, call it a network, call it a tribe, and call it a family.

Family Case Analysis Enchanted Family of Brgy. Balibago

Family Case Analysis Enchanted Family of Brgy. Balibago

Family Case Analysis Enchanted Family of Brgy. Balibago

Entry/ Climate of Acceptance

Family Case Analysis Enchanted Family of Brgy. Balibago

Family Case Analysis Enchanted Family of Brgy. Balibago

Objective Student Nurses Centered Short-term

problems in the family. Made an appointment to return

hindrance in attaining optimum health.

Family Case Analysis Enchanted Family of Brgy. Balibago

having a good health. Accepted the appointment to return of the group.

Family Case Analysis Enchanted Family of Brgy. Balibago

Family Case Analysis Enchanted Family of Brgy. Balibago

Family Case Analysis Enchanted Family of Brgy. Balibago

III. HEALTH ASSESSMENT (Chepalocaudal- IPPA)

Family Case Analysis Enchanted Family of Brgy. Balibago

110/80 mmHg 110/90 mmHg

Family Case Analysis Enchanted Family of Brgy. Balibago

Family Case Analysis Enchanted Family of Brgy. Balibago

Family Case Analysis Enchanted Family of Brgy. Balibago

different identify each different

and with eyes closed were closed. unless such

condition like colds is present.

Provide adequate lighting The client should be Ybarro

Family Case Analysis Enchanted Family of Brgy. Balibago

distance of 36 cm. (14 in.).

illuminated pupil of Ybarro constricted.

to Pupils constrict when His looking at a near constricted pupils when

moves on 6 fields of vision.

downward, sideward and diagonally.

Family Case Analysis Enchanted Family of Brgy. Balibago

eyes when with to

sensation, respond to light and cotton,

and hot from cold.

warm and cold object by asking client to identify

the unison with parallel coordinated move in unison with

Family Case Analysis Enchanted Family of Brgy. Balibago

without difficulty and difficulty and speak speak audibly. audibly.

Family Case Analysis Enchanted Family of Brgy. Balibago

Final Assessment (August 24, 2010)

Family Case Analysis Enchanted Family of Brgy. Balibago

Family Case Analysis Enchanted Family of Brgy. Balibago

Cranial Nerves Assessment (YBARRO)

Family Case Analysis Enchanted Family of Brgy. Balibago

to Ybarro was able to the smell his eyes

different identify with each different

and with eyes closed were closed. unless such

condition like colds is present.

Provide adequate lighting The client should be Ybarro

illuminated pupil of Ybarro constricted.

to Pupils constrict when His looking at a near constricted pupils when

Ask client to look at a near object and then at a distant

Family Case Analysis Enchanted Family of Brgy. Balibago

moves on 6 fields of vision.

downward, sideward and diagonally.

eyes when with to

sensation, respond to light and cotton,

and hot from cold.

warm and cold object by asking client to identify

Family Case Analysis Enchanted Family of Brgy. Balibago

the unison with parallel coordinated move in unison with

Elicit gag response.