Fca Cutcut

.
Introduction
I don't care how poor a man is; if he has family, he's rich. ~Dan Wilcox and Thad Mumford, "Identity Crisis," M*A*S*H It is always said that the family completes the life of a single person. Many people believe that having a family is very important for a person to survive the realities of life. A family is truly one of the essential things that complete a person. Every man whether rich or not needs a family to guide, support, care, protect, nurture and love them. A person considers his/her family as a special gift from God. A lot of unfortunate people always say that even though they dont have the money to buy their needs at least they have their family that will stand with them forever. According to Wikipedia, a community is a group of interacting species sharing an environment. Traditionally a "community" has been defined as a group of interacting people living in a common location. The word is often used to refer to a group that is organized around common values and is attributed with social cohesion within a shared geographical location, generally in social units larger than a household. Community Health Nursing is a service rendered by a professional nurse with the community, groups, families and individuals at home, in health centers, in clinics, in school, in places of work for the promotion of health, prevention of illness, care of the sick at home and rehabilitation. CHN is a learned practice discipline with the ultimate goal of contributing as individuals and in collaboration with others, to the promotion of the clients optimum level of functioning through teaching and delivery of care. The family is considered as the smallest unit of the society and is considered as the fundamental core of the community. The family, as defined by Encarta, is a group of people united by ties of marriage, birth or adoption, who carries a common purpose which is to create and maintain common culture that promotes the physical, mental, emotional and social development of each of its members. It is composed of Father,
Mother and children, who works hand in hand to maintain a good atmosphere among the family members. In the field of Nursing, a family case analysis is necessary in terms of distinguishing the very need of the smallest unit of the society. With this, the numerous actual and potential problems that a family may and subsequently will experience in their daily living will recognized by the student nurses. By means of home visits, the student nurses may help the family become self-reliant especially regarding their health. Through assessment, the group will be able to gather information regarding their present health status, their capability to remain healthy or their coping mechanism and the emotional support an individual family member can expect from other family members of the community. Through this knowledge upon assessment the student nurses will be able to develop plans for needed interventions so that goals would be met. The group have conducted their Family Case Analysis in Barangay Cutcut. The area is economically deprived with a poor environmental condition. The family consists of 8 members, Daddy Crab, who works as a fish vendor, Mommy Shrimp, who also works as a fish vendor. Milkfish, the eldest, next is Tilapia, followed by Lobster, then Hito, lastly, the youngest, Squid. Within the student nurse-family relationship, certainly, there are instances that some problems may be encountered. But with proper guidance, therapeutic and respective way of showing them the purpose of the nursing process, the trust of the family can be earned by the student nurses as days pass by. Cooperation will also be achieved depending on the type of approach the student nurses have used to the family. The primary goal of Community Health Nursing is the prevention of illness and the promotion of health. The student nurses are responsible for attaining these goals through efficient and effective yet simple process which entails a comprehensive health education focusing mainly on the prevention of diseases.
OBJECTIVES
Short-term Student-nurse centered After 2 days of home visits, the student nurses will: Select the family that they will assess for the family case analysis. Establish rapport and a good relationship with the family. State the purpose of the study being conducted. Make a comprehensive assessment, observations and interview the family for other necessary information. Obtain vital signs and perform physical assessment of each family member. Identify and prioritize existing/actual problems of the family. Inspect home and environment. Provide basic health teachings to the family.
Family-centered After 2 days of home visits, the family will: Permit the group to have them as their respondent for the study being conducted. Fully understand the reason for this activity. Recognize the problem that they encounter with regards to their socioeconomic status and their health. Participate in the interviews as well as with the assessment. Identify their beliefs and practices in relation to their health. Show determination in preventing the occurrence of potential problems.
Long-term
Student-nurse centered After 3 weeks of home visits to the adopted family, the student nurses will:
Discuss and give details about the existing and potential problems in the family.
Obtain working relationships at an optimum level. Familiarize themselves with the family members and their needs. Accomplish final interview in order to determine changes from first to last visit.
Conduct the improvement of home and environment and health conditions from the first home visit.
Help family apply health teachings in daily lives. Provide final nursing interventions needed and reinforce the knowledge the family has obtained from the visits.
Evaluate the familys coping abilities in applying the health teachings given.
Family-centered After 3 weeks of home visits, the family will: Understand the problems identified in their family. Cooperate with the student nurses by complying with the health teachings given by the student nurses.
Follow and consistently apply into action the interventions given by the student nurses.
Continue to follow proper regimen in maintaining a healthy lifestyle. Verbalize understanding on good personal hygiene and environmental sanitation to their lives.
Develop self-reliance in managing good health.
Research-centered Specifically the student nurses will be able to answer the following:
Describe the demographic profile of the family: Age Sex Religion Ordinal Position Educational Status Present Health Status Present Health Status Immunization Status
B. Describe the physical profile of the family: Type of Family Family Constellation Dominant family member in terms of decision-making, especially in health crisis
C. Assess the ability and status by utilizing physical examination: Physical status History of present & past illness
Activities of daily living Nutritional status
D. Assess the growth and development of the family members: (below 7y/o) Erick Eriksons Psychological Stages Sigmund Freuds Psychosexual Stages
E. Perform socio-economic, cultural and environmental assessment: Source of income and expenditures Ethnic background and religious affiliation Familys involvement in community activities Familys utilization of community resources Housing condition Food sources, storage and cooking facilities Water supply Toilet facility Drainage system Communication and transportation facility
F. Problem Identification Identify problems Formulate nursing care plans Family coping index
B. Entry, Climate of acceptance, and first few words First home visit: November 14, 2011; 12:30 - 2:00 PM On their first home visit in Barangay Cutcut, it was a very sunny afternoon. On that day, the student nurse conducted their first ocular visit to their respective families.
Upon arrival at Housekeepers familys residence, the student greeted Mommy Shrimp saying, Good afternoon po nay.. Pwede po ba namin kayong ma-assess..?, then she replied, Osige, upo kayo, then the student nurse answered back saying, Ate, ilan po ba kayo nakatira sa bahay?, then she said, Bale walo kami dito kasi wala yung iba kong mga anak. anim lang sa mga anak ko ksma ko dito.. For a few minutes, their group with their nurse instructor had interviewed the Mommy Shrimp. The group had decided to adopt the Seafood Family. The student nurses were welcomed by the mother of the family who is wearing a white shirt and dark blue pants. The father was not around, because of his work. The kids also welcomed the group and communicated with them, they answered their question addressed to them. First, the student nurses established rapport by introducing themselves and explaining to the chosen family the purpose of their visit. The family wholeheartedly agreed on the said study. After that, the student nurses performed initial vital signs taking and assessment on each family member through observations and interview. At the end of their home visit, they asked the mother on what time they would be available for the next visit since the student nurses would be performing an initial physical assessment to all the members of the family. The mother replied that the student nurses are welcome. Before leaving, the student nurses said Thank you po sa oras. Sa susunod po ulit. :)
Second home visit: November 21, 2011; 1:00-2:00 P.M. The following week came; it was Monday afternoon when the student nurses made their home visit. As they reached the area where their adopted family households is, Mommy Shrimp was carrying Squid, while the other kids were playing. After greeting them, the mother offered seats for the student nurse. The student nurses immediately started their work and asked questions which they were not obtained in the first home
visit. Mommy shrimp responded as comprehensive as possible to every questions asked by the student nurses. The head of the family was not seen during the visit since he was working. During that day when the student nurses made their cephalocaudal assessment, they have observed that some of the members have untrimmed, dirty fingernails and has pediculosis. Because of these findings, the student nurses gave health teachings such as explaining to the mother the possible disease that can be acquired from having dirty fingernails like parasitism and teaching the family about proper hand washing before and after eating. regarding pediculosis, the group also provided health teaching about the prevention of transmitting pediculosis to the other members of the family and how it will be treated. Upon observation, the group was able to identify the following problems: inadequate ventilation and lighting; presence of breeding sites,improper garbage disposal, accident hazard, poor toilet facility, presence of cough and colds, Squid has cough and colds. The group provided health teachings regarding the problems identified. Gladly the family agreed to comply. The group also did their documentation. Before the call time, the student nurses left the house by saying, Maraming salamat po, bukas po ulit. Third home visit: November 22, 2011; 1:00-2:00 P.M. The weather was fine when the student nurses made their third home visit. Mommy Tilapia, Hito and Squid were the only present members of the family. The group assessed the present family members. During that day, the student nurses made some interventions such as sweeping the floor, arranging the house, advising Mommy Shrimp to remove sharp materials hanging on the wall, properly disposing their trash, etc. The group also explained to the family the importance of the interventions and the possible consequences they can get with non compliance. The student nurses also did their documentation that time. After a few moments, the group decided to leave and tell the family that they will be returning on next week.
Fourth home visit: November 29, 2011; 1:00-2:00 P.M. It was a sunny afternoon when the student nurses made their fourth home visit, as they reached the house of their adopted family, they greeted them a wonderful afternoon. The student nurse had made their final physical assessment and observation if they are improvement with the members of the family and the environment. The group terminated their relationship with teh Seafood family by saying Thank you and also reminded the family to maintain the cleanliness of the house and continue doing what they taught during the previous home visits. The group then bid goodbye to the Seafood family.
II. Family Constellation Name: Daddy Crab Age: 38 years old Ordinal Position: Father Sex: Male Educational Status: Name: Mommy Shrimp Age: 40 years old Ordinal Position: Mother Sex: Female Educational Status: Nepomuceno Elementary School (Grade 6 graduate) Present Health Status: Daddy Crab was not assessed by the group because he is working the whole day. Present Health Status: It was on the first day that the student nurses met Mommy Shrimp. She was talking to her sister but accommodated the student nurses in the home visit. Her hair is tie with a clip; she is wearing a white tshirt and a white manong pants and white slippers. Nutritional Status: HEIGHT: 2.40m2 WEIGHT: 54kg BMI: 22.5
Vital Signs: Temperature: 36.8 C Pulse Rate: 78bpm Respiratory rate:21 cpm Blood Pressure: 110/80 mmHg Name: Milk Fish Age: 13 years old Ordinal Position: 8th Eldest Sex: Female Educational Status: Name: Tilapia Age: 11 years old Ordinal Position: 9th Eldest Sex: Male Educational Status: Cut Cut Elementary School (Grade 5) Present Health Status: Milk Fish was not assessed by the group because he was at the school the whole day. Present Health Status: It was on the first day that the student nurses met Tilapia. He was playing with his friends. He is dirty and wet. He do not wear his green t-shirt instead he just putting it on his shoulder, he is wearing a pink checkered short and closed half plastic slippers. Nutritional Status: HEIGHT: WEIGHT: BMI: Vital Signs: Temperature: Pulse Rate: Respiratory rate: Name: Lobster Age: 9 years old Ordinal Position: 10th Eldest Sex: Female Educational Status: Cut Cut Elementary School (Grade 2) Blood Pressure: Present Health Status: It was on the first day that the student nurses met Lobster. She was watching television that day. Shes wearing a sky blue sleeveless with white blazer, white
short and white slippers. Nutritional Status: HEIGHT: 131cm WEIGHT: 29 kg BMI: 16.90 Vital Signs: Temperature: 35.8 C Pulse Rate: 87 bpm Respiratory rate: 13 bpm Name: Salmon Age: 8 years old Ordinal Position: 11th Eldest Sex: Male Educational Status: Cut Cut Elementary School (Grade 1) Present Health Status: It was on the first day that the student nurses met Salmon. He was playing with his friends that day. He is dirty and wet. He is wearing a black batman t-shirt with black and white strips short and red slippers. Nutritional Status: HEIGHT: 127 cm WEIGHT: 27 kg BMI: 16.74 Vital Signs: Temperature: 36.3 C Pulse Rate: 81 bpm Respiratory rate: 17 cpm Name: Hito Age: 6 years old Ordinal Position: 12th Eldest Sex: Female Educational Status: Cut Cut Elementary School (Grade 1) Present Health Status: It was on the first day that the student nurses met Hito. She just arrived that day from school. Shes wearing pink sleeveless, black short and pink slippers.
Nutritional Status: HEIGHT: 118cm WEIGHT: 25 BMI: 15.36 Vital Signs: Temperature: 36.4 C Pulse Rate: 75 bpm Respiratory rate: 17 cpm Name: Squid Age: 2 years old Ordinal Position: youngest Sex: Male Educational Status: Not going to school Present Health Status: It was on the first day that the student nurses met Squid. He was carrying by mommy shrimp. He has a cough and colds that day. He was wearing gray shirt and red shorts with slippers on. Nutritional Status: HEIGHT: 114cm WEIGHT: 10kg BMI: 7.69 Vital Signs: Temperature: 36.8 C Pulse Rate: 120 bpm Respiratory rate: 31 cpm
First visits( Nov. 14, 2011, Monday) 1.Daddy crab The group was unable to assess Daddy Crab ,because he's at work the whole day. 2. Mommy shrimp PHYSICAL ASSESSMENT ( Nov. 14, 2011, Monday)
Vital signs: T- 36.8 C P- 78 bpm R- 21 cpm BP- 110/80 mmHg
General Appearance and Mental Status: Upon assessment mommy shrimp was wearing a white printed t-shirt with maong pants , and pair of slippers on.She is cooperative, coherent and oriented to time, place and person, She has steady gait and shows no difficulty recalling events.
Skin Mommy shrimp has been noted to have a dark complexion, with no signs of jaundice, cyanosis and pallor. There are no signs of edema present. She has a normal skin turgor but with dry skin. Hair and Nails She was noted to have long dirty nails, with pinkish nail beds and a capillary refill time of less than 3 seconds. There is no clubbing and lesion noted. She has fair, black hair and well distributed. Her hair is dry with some of white hair, And presence of lies was noted upon assessment, no presence of dandruff noted.
Head and Face There is no abnormal elevation or depression in the skull upon palpation. There is symmetry of facial movements. No nodules or masses.
Eyes Her eyes are aligned and not deviated; eyebrows are thick, black and evenly distributed. There is symmetric movement, with flaking noted on the skin underneath the eyebrows. Her eyelids are symmetric, with no tenderness and nodules. The lacrimal glands are not swollen, the bulbar and palpebral conjunctiva are pink in color. Ears
Auricles are same as facial color and it is aligned with the outer canthus of the eye. They are mobile, firm and not tender upon palpation. Pinna recoils after it is folded with no lesions noted upon assessment. Nose Her nose is straight and the septum is located in the center midline. No deviations have been observed in the shape, size and color of the external nose. No discharges were noted and there is the absence of nasal flaring. Also, no lesions and masses were noted upon palpation.
Lips and Teeth Outer and inner lips are symmetrical. she has the ability to move her lips. Inner lips and buccal mucosa are uniform in color. She has an incomplete set of teeth and his tongue is in central position and she can move it freely.
NECK Neck Muscle Neck muscles are equal in size. No masses and nodules were noted upon palpation. Head movements are coordinated and she can move her head freely.
Lymph Nodes Lymph nodes are not palpable and there is no enlargement noted upon assessment THORAX AND LUNGS Lungs There is full and symmetrical chest expansion. There is effortless and rhythmic respirations and no abnormal breath sounds were heard upon auscultation.
Heart Regular rhythm of apical pulse was noted upon auscultation.
Abdomen
No distention and presence of lesions and masses were observed. she has normal bowel sounds.
Extremities Peripheral pulses are in full pulsations. Limbs are not tender and no edema is present at extremities.
Cranial Nerves Function Assessment Technique To assess the CN I Olfactory Sensory Function: Smell clients Olfactory Nerve, instruct the client to smell familiar scents like alcohol, soap or perfume with each nostril. Cover the other nostril and instruct to close the eyes before identifying the scent The client will be able to identify the scent of alcohol,soap and perfume with each nostril. The client was able to identify the scent of alcohol,soap and perfume with each nostril. Normal Response Clients Response
To assess clients CN II Optic Sensory Function: Visual and Visual Fields Optic Nerve instruct the client to read a word in a newspaper or other reading materials such as (Books) ,at a distance of 14 inches
The client will be able to read a word in the newspaper other reading materials such as (Books) ,at a distance of 14 inches. The clients eye must The client was able to read a word in the books at a distance of 14 inches.
CN III Oculomotor Motor
Function: Extraocular eye movement, movement of sphincter of pupil, movement of ciliary muscle of lens. To assess clients Oculomotor Nerve use a penlight and instruct client to look up down and light the eye of the client. Clients pupil must constrict upon introduction of light as well as when looking at near objects and dilates when looking far objects.
follow the direction of the movement of the penlight and both pupils must constrict and be equally round upon introduction of light as well as when looking at near objects and dilates when looking at far objects.
The clients eye was able to follow the direction of the movement of the penlight and both pupils constricted and were equally round upon introduction of light as well as when looking at near objects and dilates when looking
at far objects.
Function: CN IV Trochlear Motor Extraocular movement, specifically moves eyeball downward, and laterally To assess the clients Trochlear Nerve instruct the client to follow the penlight with his/her eyes without moving its head. To assess clients CN V Trigeminal Motor Function: Sensation of cornea, skin of face, and nasal mucosa Trigeminal Nerve instruct the client to move the jaw downward while applying resistance then use the tip of the cotton to swipe the corneal surface of the eye. To test the sensation of the face use a cotton swab use the tip of the stick for the sharp sensation and the cotton tip for dull The client must be able to open and close her mouth and move his jaw against resistance. Blinking reflex must also be present. The client must determine the difference between the sharp and dull The clients eyes must follow the movement of the object used with coordination. The clients eyes were able to follow the movement of the object used with coordination. The client was able to open and close her mouth and move his jaw against resistance. Blinking reflex was also presented. The client was able to determine the difference between the sharp and dull sensation
sensation
sensation
CN VI Abducens Motor
Function: Extraocular movements, moves eyeball
To assess clients Abducens Nerve instruct the client to follow the examiners finger as it moves from side to side.
The client must be able to follow examiners fingers without strain or difficulty.
The client was able to follow examiners fingers without strain or difficulty.
To assess clients CN VII Facial Sensory and Motor Function: Facial expression, taste Facial Nerve instruct the client to raise eyebrows, show teeth, puff cheeks. Provide client foods with varying taste like sugar and salt
The client must be able to raise eyebrows, show teeth, puff cheeks and identify the correct taste of sugar and salt.
The client was able to raise eyebrows, show teeth, puff cheeks and identify the correct taste of sugar and salt.
Client must CN VIII Function: Hearing and To assess clients be able to repeat the
Vestibulocochlear Sensory
Balance
Vestibulocochlear Nerve instruct the client to listen to whispers youll tell and ask them to repeat it. Allow the client to stand with feet together and arms resting at sides. First with eyes open then closed. To assess clients Glossopharyngeal Nerve instruct the client to swallow. Ask the client to identify different taste in the posterior portion of the tongue.
whispered words. Client must be able to maintain upright posture.
Client was able to repeat the whispered words. Client must be able to maintain upright posture.
CN IX Glossopharyngeal Sensory and Motor
Function: swallowing and gag reflex
The client must be able to swallow without difficulty. Client must be able to identify the taste of salt when administered. The client must be able
The client was able to swallow without difficulty. Client was be able to identify the taste of salt when administered.
CN X Vagus Motor
Function: Sensory of pharynx and larynx, swallowing,
The client was able to speak clearly and without difficulty. Client was
To asses clients Vagus Nerve instruct the client to speak or say one sentence. Ask
to speak clearly and without difficulty. Client must
vocal cord movement and for speaking
the client to swallow.
be able to swallow without difficulty.
able to swallow without difficulty.
CN XI Accessory Motor
Function: head movement, shrugging of shoulders
To assess clients Accessory Nerve instruct the client to move her head in different directions (right, left, up, down and rotate). Ask the client to raise and shrug the shoulder against resistance.
The client must be able to move head and shoulders as instructed, with coordination and without difficulty.
The client was able to move head and shoulders as instructed, with coordination and without difficulty.
CN XII Hypoglossal Motor Function: protrusion of tongue, moves tongue up and down and side to side
To assess clients Hypoglossal Nerve instruct the client to Protrude the tongue and move it side to side
The client must be able to move the tongue without difficulty. The client was able to move the tongue without difficulty
NUTRITIONAL STATUS Age: 41 years old Height: 150 cm Weight: 54 kg Formula: Weight in kilograms (kg) Height in meter squared (m2) Body Mass Index (BMI) = 54 kg 2.40 m2 =
Interpretation:
Body Mass Index (BMI) =
22.5
Healthy Weight Legend: BMI Table ( Based on Asia-Pacific Obesity Guidelines ) Underweight Healthy Weight Overweight At risk Obese I Obese II < 18.5 18.6-22.9 > 23.0 23.0-24.9 25.0-29.9 > 30.0
ACTIVITES OF DAILY LIVING
Mommy usually wakes up at 4:30 to cooked for the breakfast and she will prepare the things that her children need for school. After finishing preparing her children for school, she will go to the market to work. She sells different kinds of fish. At around 10:30a.m, she starts to do the cookinga nd do the household chores. She looks after her children for the rest of the day and sometimes she looks after her neighbors children. they eat dinner at around 7:00 p.m or by the time the children and his husband are all home. She usually sleeps at around 10:00 p.m. after watching her favorite tv drama.
3. Milkfish(Nov.14,2011,monday) The group wasn't able to assess milkfish because she 4.Tilapia(Nov.14,2011,monday)
PHYSICAL ASSESSMENT Vital signs: T- 36.6 C P- 75 bpm R- 17 bpm
General Appearance and Mental Status: The third child was wearing red and black shirt and blue shorts with black slippers. Unlike the 2 elder siblings, Tilapia shows good communication skill. He has a steady gait. Upon assessment, he was coherent and conscious. Skin His skin has uniform brown complexion, absence of edema, with good skin turgor and with some scars on both the lower extremities and upper extremities.
Hair and Nails tilapia hair is short, thin, black and evenly distributed .His hair is tangled, dry and there are presence of lice . He has long, dirty finger nails and pinkish in color. He has dirty toe nails. Capillary test: his nails returned to its usual color in 3 seconds.
Head and Face Tilapia skull is round, symmetrical in contour with no palpable masses and nodules. He has symmetrical facial features with symmetrical face movements as evidence by Tilapia ability to smile, frown and puff cheeks.
Eyes
He has thick eyebrows, black and equally distributed. His Eyelashes are equally distributed. His cornea is white, shiny and has a smooth visible detail of iris. His lacrimal glands have no tearing or edema upon inspection. His pupils constrict when illuminated, and at the same time the unilluminated pupil also constrict when illuminated. His pupils are black in color and they are symmetry in size. Pupils are equally round and reactive to light and accomodation (PERRLA). When looking straight ahead, tilapia can see object in the periphery. tilapia pupils constrict when ask to look the penlight near his nose.
Ears His auricles are soft and non tender, symmetrical in color, pinna recoils after it is folded. No foul odor, with small amount of dry cerumen on both ears. With no palpable lymph nodes on the posterior auricle. The ears are at the same level of the outer cantus of the eyes. Can hear the tick of the watch in both ears, and other normal things/ voice. Nose He has no presence nasal discharges, no nasal flaring noted, and uniform in color. The nasal septum is intact in the midline. The air moves freely when the client breaths through the nares. There are no masses or nodules noted upon palpation.
Lips and Teeth Upon inspection, his lips are dry, dark pink in color, and symmetrical. The tongue is in the center, and pink in color and can move freely. There are no swollen or inflamed tonsils and his tongue are free of any lesions. His gums are pink in color. The uvula is located in the midline of the soft palate. The soft and hard palate are pink in color, without lesions.
NECK Neck Muscle Tilapia can move his neck without difficulty and pain. His neck muscles are equal in size and the head is located at the center. Trachea is in the midline of the neck, carotid and jugular veins are not distended and visible. Thyroid gland ascends when
swallowing but not visible upon inspection. Absence of modules or masses upon palpation.
Lymph Nodes Lymph nodes are not palpable and there is no enlargement noted upon observation and palpation.
THORAX AND LUNGS Lungs Upon inspection, his chest wall rise and fall symmetrically. No deformities in the chest. Effortless respiration was also observed, can breath easily. Absence of abnormal breath sound when auscultated.
Heart Normal contour, no distention and no nodules present. Carotid artery has full pulsations with symmetrical pulse volume. Jugular veins are not visible and with normal rate and regular rhythm The carotid artery was full pulsation with symmetrical pulse volume. Heart rate is in regular rhythm, peripheral pulses are strong/ bounding. The jugular veins are not palpable or distend. Absence of murmurs or any abnormal heart sounds upon auscultation
Abdomen Skin is uniform in color. There is no evidence of liver or spleen enlargement, there are no masses or lesions and any tenderness noted upon palpation. With tympanic sound upon palpation and also an audible bowel sound upon auscultation
Extremities No deformities on the extremities, absence of swelling, edema and tenderness. Muscle size are equal, no tremors noted; no bone deformities and no tenderness noted upon palpation. Peripheral Pulses: there is bounding pulsation on the radial pulse.
Cranial Nerves Function Assessment Technique To assess the clients Olfactory Nerve instruct the client to smell alcohol, soap or nostril. Cover the other nostril and instruct to close the eyes before identifying the scent The client will be able to scent of and perfume with each nostril. Normal Response Clients Response
CN I Olfactory Sensory
Function: Smell
The client was able to identify the scent of alcohol, soap and perfume with each nostril.
familiar scents like identify the perfume with each alcohol, soap
CN II Optic Sensory Function: Visual and Visual Fields
To assess clients Optic Nerve instruct the client to read a word in a newspaper or other reading materials at a distance of 14 inches
The client will be able to read a word in the newspaper or other reading materials at a distance of 14 inches.
The client was able to read a word in the newspaper or other reading materials at a distance of 14 inches.
To assess clients Oculomotor Nerve
The clients eye must
Function: Extraocular eye movement, movement of sphincter of pupil, movement of ciliary muscle of lens.
use a penlight and instruct client to look up down and light the eye of the client. Clients pupil must constrict upon introduction of light as well as when looking at near objects and dilates when looking far objects.
follow the direction of the movement of the penlight and both pupils must constrict and be equally round upon introduction of light as well as when looking at near objects and dilates when looking at far objects.
The clients eye was able to follow the direction of the movement of the penlight and both pupils constricted and were equally round upon introduction of light as well as when looking at near objects and dilates when looking at far objects.
Function: CN IV Trochlear Motor Extraocular movement, specifically moves To assess the clients Trochlear Nerve instruct the client to follow the The clients eyes must follow the movement of The clients eyes were able to follow the movement
eyeball downward, and laterally
penlight with his/her eyes without moving its head.
the object used with coordination. The client
of the object used with coordination.
The client was able to open and close her mouth and move his jaw against resistance. Blinking reflex was also presented. The client was able to determine the difference between the sharp and dull sensation
CN V Trigeminal Motor
Function: Sensation of cornea, skin of face, and nasal mucosa
To assess clients Trigeminal Nerve instruct the client to move the jaw downward while applying resistance then use the tip of the cotton to swipe the corneal surface of the eye. To test the sensation of the face use a cotton swab use the tip of the stick for the sharp sensation and the cotton tip for dull sensation To assess clients
must be able to open and close her mouth and move his jaw against resistance. Blinking reflex must also be present. The client must determine the difference between the sharp and dull sensation
The client must be able to follow examiners fingers without strain The client was able to follow examiners
Function: Extraocular movements, moves
Abducens Nerve instruct the client to follow the examiners finger as it moves from
eyeball
side to side.
or difficulty.
fingers without strain or difficulty.
CN VIII Vestibulocochlear Sensory
Function: Hearing and Balance
To assess clients Vestibulocochlear Nerve instruct the client to listen to whispers youll tell and ask them to repeat it. Allow the client to stand with feet together and arms resting at sides. First with
Client must be able to repeat the whispered words. Client must be able to maintain upright posture and foot stance. Client was able to repeat the whispered words. Client must be able to maintain upright posture and foot stance.
eyes open then closed. To assess clients Glossopharyngeal Nerve instruct the client to swallow. Ask the client to identify different taste in the posterior portion of the tongue. The client must be able to swallow without difficulty. Client must be able to identify the taste of salt when administered. The client CN X Vagus Motor Function: Sensory of pharynx and larynx, swallowing, vocal cord movement and for speaking To assess clients CN XI Accessory Function: head movement, Accessory Nerve instruct the client to move her head in different The client must be able to move head The client was able to move head must be able To asses clients Vagus Nerve instruct the client to speak or say one sentence. Ask the client to swallow. to speak clearly and without difficulty. Client must be able to swallow without difficulty. The client was able to speak clearly and without difficulty. Client was able to swallow without difficulty.
Motor
shrugging of shoulders
directions (right, left, up, down and rotate). Ask the client to raise and shrug the shoulder against resistance.
and shoulders as instructed, with coordination and without difficulty.
and shoulders as instructed, with coordination and without difficulty.
CN XII Hypoglossal Motor
Function: protrusion of tongue, moves tongue up and down and side to side
The client must be able to move the tongue without difficulty.
The client was able to move the tongue without difficulty
NUTRITIONAL STATUS Age: 11 years old Height: 129 cm Weight: 31 kg Formula: Body Mass Index (BMI) = Weight in kilograms (kg) Height in meter squared (m2)
18.6
Interpretation:
Underweight Legend:
Body Mass Index Emaciated Underweight Normal Overweight Obese A. ACTIVITES OF DAILY LIVING Tilapia usually wakes up at 5:30 in the morning to prepare for school and eat breakfast. At around 6:30 a.m together with siblings, they walk to go to school. By 12 nn, Hee goes. He used to play with her playmates around their vacinity. He like to play kite. He has good appetite when eating. he sleeps around 8:00 in the evening. Below 15 15 18.9 19 24.9 25 29 30 39.9
5.Lobster PHYSICAL ASSESSMENT
Vital signs: T- 35.8 C P- 87 bpm R- 13 bpm General Appearance and Mental Status: Lobster was wearing a sky blue sleeveless with white blazer, white short and white slippers.She is cooperative, coherent and oriented to person, time and place. She has a sense of reality, shows no difficulty recalling past event,
Skin She has brown-colored skin which is generally uniform. No lesions and edema have been noted. She has good skin turgor, which turned back to previous state in less than 2 seconds when pinched.
Hair and Nails Her nail plates are colorless and have concave curves. They are still slightly long and untrimmed. Her nail beds returned to previous state in less than three seconds after pressure was applied.
Head and Face There is no abnormal elevation or depression in the skull upon palpation. There is symmetry of facial movements. No nodules or masses. Her hair is slightly blandy in color. It is evenly distributed and presence of lies was noted. No presence of lesions was noted.
Eyes Her eyes are aligned and not deviated; eyebrows are thick, black and evenly distributed. There is symmetric movement, with flaking noted on the skin underneath the eyebrows. Her eyelids are symmetric, with no tenderness and nodules. The lacrimal glands are not swollen, the bulbar and palpebral conjunctiva are pink in color.
Ears Her auricles are same as facial color and it is aligned with the outer canthus of the eye. They are mobile, firm and not tender upon palpation. Pinna recoils after it is folded. She has normal hearing sounds. Nose Her nose is straight and her septum is located in the midline. No deviations have been observed in the shape, size and color of the external nose. No discharges were
noted and there is the absence of nasal flaring. Also, no nodules and masses were noted upon palpation.
Lips and Teeth Outer lips are symmetrical. She exhibits ability to move her lips. Inner lips and buccal mucosa are uniform in color. She has an incomplete set of teeth and her tongue is in central position and she can move it freely.
NECK Neck Muscle There is absence of difficulty in moving the neck. The muscles are equal in size and head is in the center. She can move the head in circular motion. The trachea is in the center while the thyroid gland ascends when swallowing. No nodules and masses felt.
THORAX AND LUNGS Lungs There is full and symmetrical chest expansion. There is effortless and rhythmic respirations and no adventitious or abnormal breath sounds were heard upon auscultation.
Heart Normal contour, no distention and no nodules present. Carotid artery has full pulsations with symmetrical pulse volume. Jugular veins are not visible and with normal rate and regular rhythm
Abdomen
No distention and presence of lesions and masses were observed. She has normal bowel sounds.
Extremities Peripheral pulses are in full pulsations. Limbs are not tender and no edema is present at extremities. Cranial Nerves Function Assessment Technique To assess the clients Olfactory Nerve instruct the client to smell familiar scents like alcohol, soap or perfume with each nostril. Cover the other nostril and instruct to close the eyes before identifying the scent To assess clients CN II Optic Sensory Function: Visual and Visual Fields Optic Nerve instruct the client to read a word or other reading materials such as (Books) in a newspaper at a The client will be able to read a word in the newspaper or other reading materials such as The client was able to read a word in the newspaper or other reading materials such as (Books) at The client will be able to identify the scent of alcohol, soap and perfume with each nostril. Normal Response Clients Response
Function: Smell
The client was able to identify the scent of alcohol, soap and perfume with each nostril.
distance of 14 inches
(Books) at a distance of 14 inches.
a distance of 14 inches
Function: Extraocular eye movement, movement of sphincter of pupil, movement of ciliary muscle of lens. To assess clients Oculomotor Nerve use a penlight and instruct client to look up down and light the eye of the client. Clients pupil must constrict upon introduction of light as well as when looking at near objects and dilates when looking far objects.
The clients eye must follow the direction of the movement of the penlight and both pupils must constrict and be equally round upon introduction of light as well as when looking at near objects and dilates when looking at far objects.
The clients both eyes was able to follow the direction of the movement of the penlight, both pupils constricted and were equally round upon introduction of light as well as when looking at near objects and dilates when looking at far objects.
Function:
CN IV Trochlear Motor
Extraocular movement, specifically moves eyeball downward, and laterally
To assess the clients Trochlear Nerve instruct the client to follow the penlight with his/her eyes without moving its head. To assess clients
The clients eyes must follow the movement of the object used with coordination. The client must be able to open and close her mouth and move his jaw against resistance. Blinking reflex must also be present. The client must determine the difference between the sharp and dull sensation
The clients right eye was able to follow the movement of the object used with coordination.
The client was able to open and close her mouth and move his jaw against resistance. Blinking reflex was also presented. The client was able to determine the difference between the sharp and dull sensation
CN V Trigeminal Motor
Function: Sensation of cornea, skin of face, and nasal mucosa
Trigeminal Nerve instruct the client to move the jaw downward while applying resistance then use the tip of the cotton to swipe the corneal surface of the eye. To test the sensation of the face use a cotton swab use the tip of the stick for the sharp sensation and the cotton tip for dull sensation To assess clients
The client must be able to follow The client was
CN VI
Function:
Abducens Nerve instruct the client
Abducens Motor
Extraocular movements, moves eyeball.
to follow the examiners finger as it moves from side to side.
examiners fingers without strain or difficulty.
able to follow examiners fingers.
To assess clients Vestibulocochlear Nerve instruct the client to listen to whispers youll tell and ask them to repeat it. Allow the client to stand with feet together and arms resting at sides. First with eyes open then
Client must be able to repeat the whispered words. Client must be able to maintain upright posture and foot stance. Client was able to repeat the whispered words. Client must be able to maintain upright posture and foot stance.
closed. To assess clients Glossopharyngeal Nerve instruct the client to swallow. Ask the client to identify different taste in the posterior portion of the tongue. The client must be able to swallow without difficulty. Client must be able to identify the taste of salt when administered. The client CN X Vagus Motor Function: Sensory of pharynx and larynx, swallowing, vocal cord movement and for speaking. must be able To asses clients Vagus Nerve instruct the client to speak or say one sentence. Ask the client to swallow. to speak clearly and without difficulty. Client must be able to swallow without difficulty. To assess clients Accessory Nerve instruct the client to move her head in different directions (right, The client must be able to move head and shoulders as The client was able to speak clearly and without difficulty. Client was able to swallow without difficulty.
The client was able to swallow without difficulty. Client was able to identify the taste of salt when administered.
The client was able to move head and shoulders as instructed,
left, up, down and rotate). Ask the client to raise and shrug the shoulder against resistance.
instructed, with coordination and without difficulty.
with coordination and without difficulty.
The client was able to move her tongue without difficulty.
NUTRITIONAL STATUS Age: 9 years old Height: 131 cm Weight: 29 kg Formula: Body Mass Index (BMI) = Weight in kilograms (kg) Height in meter squared (m2)
16.90.
Interpretation:
Underweight Legend:
Body Mass Index Emaciated Underweight Normal Overweight Obese Morbidly Obese ACTIVITES OF DAILY LIVING Below 15 15 18.9 19 24.9 25 29 30 39.9 40 and above
Lobster usually wakes up 5:30 in the morning to prepare for school and eat breakfast. At around 6:30 a.m together with siblings, they walk to school. By 12 nn, She goes home for lunch and goes back to school at 1pm. Around 3:30 pm, She is already at home. She used to play with her playmates and also helps her mother with the household chores. She sleeps at 8:00 in the evening.
6.Salmon PHYSICAL ASSESSMENT
Vital signs: T- 36.3 C P- 81 bpm R- 17 bpm General Appearance and Mental Status: Salmon was wearing a a black batman t-shirt with black and white strips short and red slippers. He is shy to express himself through speech. He has a steady gait. He is conscious when the assessment was done.
Skin Dark brown in color which is evenly distributed, dry skin and warm to touch and with good skin turgor. No lesions upon assessment.
Hair and Nails Hair is black, dry, no presence of dandruff, with presence of lice. Fingernails are short but dirty. Toenails are not trimmed and dirty, no discoloration of the nails beds, pinkish in color, no clubbing of nails.
Head and Face Head is symmetrical in shape, no presence of lesions or wounds.
Eyes Normal papillary constriction, bulbar and palpebral conjunctiva are pink in color, eyes are symmetrical.
Ears Ears are symmetrical, color same as facial skin and evenly distributed, no presence of lesions or wounds, pinna recoils when folded.
Nose No presence of discharges upon assessment. Lips and Teeth Lips are pink in color and evenly distributed, presence of dental carries and missing teeth. NECK Color is evenly distributed, no presence of lesions or wounds.
Lymph Nodes
No presence of tenderness in lymph nodes when palpated, no presence of masses and nodules
THORAX AND LUNGS Lungs Color is evenly distributed, chest is properly aligned and proportionate, spine is also properly aligned.
Heart Normal contour, no distention and no nodules present. Carotid artery has full pulsations with symmetrical pulse volume. Jugular veins are not visible and with normal rate and regular rhythm. Abdomen Evenly distributed color, no presence of lesions and wounds. Extremities Arms and legs are symmetrical in shape and size. Noted good ROM with equal strength.
Cranial Nerves Function Assessment Technique To assess the clients Olfactory Nerve instruct the client to smell familiar scents like alcohol, or perfume with each nostril. Cover the other nostril and instruct to close The client will be able to identify the scent of alcohol, soap and perfume with each nostril. Normal Response Clients Response
Function: Smell
The client was able to identify the scent of alcohol,soap and perfume with each nostril.
the eyes before identifying the scent
The client will CN II Optic Sensory Function: Visual and Visual Fields To assess clients Optic Nerve instruct the client to read a word in a newspaper at a distance of 14 inches be able to read a word in the newspaperor other reading materials such as (Books) at a distance of 14 inches. To assess clients CN III Oculomotor Motor Function: Extraocular eye movement, movement of sphincter of pupil, movement of ciliary muscle of lens. Oculomotor Nerve use a penlight and instruct client to look up down and light the eye of the client. Clients pupil must constrict upon introduction of light as well as when looking at near objects and dilates when looking far objects. The clients eye must follow the direction of the movement of the penlight and both pupils must constrict and be equally round upon introduction of light as well as when The clients eye was able to follow the direction of the movement of the penlight and both pupils constricted and were equally round upon introduction of The client was able to read a word in the newspaper or other reading materials such as (Books) at a distance of 14 inches.
looking at near objects and dilates when looking at far objects.
light as well as when looking at near objects and dilates when looking at far objects.
Function: CN IV Trochlear Motor Extraocular movement, specifically moves eyeball downward, and laterally To assess the clients Trochlear Nerve instruct the client to follow the penlight with his/her eyes without moving its head. To assess clients CN V Trigeminal Motor Function: Sensation of cornea, skin of face, and nasal mucosa Trigeminal Nerve instruct the client to move the jaw downward while applying resistance then use the tip of the cotton to swipe the The client must be able to open and close her mouth and move his jaw against resistance. Blinking The clients eyes must follow the movement of the object used with coordination. The clients eyes were able to follow the movement of the object used with coordination.
The client was able to open and close her mouth and move his jaw against resistance. Blinking reflex was also
corneal surface of the eye. To test the sensation of the face use a cotton swab use the tip of the stick for the sharp sensation and the cotton tip for dull sensation
reflex must also be present. The client must determine the difference between the sharp and dull sensation
presented. The client was able to determine the difference between the sharp and dull sensation
The client must be able to raise eyebrows, show teeth, puff cheeks and identify the correct taste of sugar
and salt.
To assess clients Vestibulocochlear Nerve instruct the client to listen to whispers youll tell and ask them to repeat it. Allow the client to stand with feet together and arms resting at sides. First with eyes open then closed. To assess clients Glossopharyngeal Nerve instruct the client to swallow. Ask the client to identify different taste in the posterior portion of the tongue. The client must be able to swallow without difficulty. Client must be able to identify the taste of salt when administered. The client Client must be able to repeat the whispered words. Client must be able to maintain upright posture and foot stance. Client was able to repeat the whispered words. Client must be able to maintain upright posture and foot stance.
Function:
must be able
The client was
CN X Vagus Motor
Sensory of pharynx and larynx, swallowing, vocal cord movement and for speaking
To asses clients Vagus Nerve instruct the client to speak or say one sentence. Ask the client to swallow.
to speak clearly and without difficulty. Client must be able to swallow without difficulty.
able to speak clearly and without difficulty. Client was able to swallow without difficulty.
CN XII Hypoglossal Motor Function: protrusion of tongue, moves tongue up and down and side to side
The client must be able to move the tongue without difficulty. The client was able to move the tongue without difficulty
NUTRITIONAL STATUS Age: 8 y/o years old Height: 127 cm Weight: 27 kg Formula: Body Mass Index (BMI) = Weight in kilograms (kg) Height in meter squared (m2)
Body Mass Index (BMI)
= =
16.74 Underweight
Interpretation:
Legend:
Body Mass Index Emaciated Underweight Below 15 15 18.9
Normal Overweight Obese Morbidly Obese ACTIVITES OF DAILY LIVING
19 24.9 25 29 30 39.9 40 and above
Salmon usually wakes up at 5:30 in the morning to prepare for school and eat breakfast. At around 6:30 a.m together with siblings, they walk to go to school. By 12 nn, he goes home. he eats his Lunch and dinner together with his family. Salmon used to play with his playmates, butbefore that, he finishes first his homeworks. He sleeps at around 8:00 in the evening.
Growth and Development Erik Eriksons Psychosocial Stage Industry vs. Inferiority At the school-going stage, the child extends beyond the home to the school and the emphasis is on academic performance. There is a movement from play to work. If before the child could play at activities with little or almost no attention given to the quality of results, now he needs to perform and produce good results. The child learns that he can gain recognition from parents, teachers and peers by being efficient in his school work. The attitudes and opinions of others become important. If children are praised for doing their best and encouraged to finish tasks then work enjoyment and industry may result. Children's efforts to master school work help them to grow and form a positive self-concept and find themselves, who they really are. Upon arriving from school, Salmon will do his assignments or homeworks if there is and will play if there are none. Before, he plays the moment he arrives home, now he does his school works first. During his play time with his siblings, cousins or play mates, his learning increases by giving attention to the results of his moves and gaining knowledge from it as well. He now aims for good results as he strives to win in any game that he plays. Parents and teachers are also the important persons in his life at this stage. He listens and acknowledges his parents especially his mother. He follows
what his mother tells him, goes whenever he is called and eats and sleep whenever he is being told. And in school, he listens attentively to his teacher and would not want to be scolded. He gives these people importance in his life and the opinions of others become important to him as well. What he does in school and at home and the people around him most importantly his parents and teachers help him to grow and develop and mold him to become a good person and find himself, him as a person.
Sigmund Freuds Psychosexual Stage- Latency Stage During the latent period, the child begins around the time that children enter into school and become more concerned with peer relationships, hobbies, and other interests. The latent period is a time of exploration in which the sexual energy is directed into other areas such as intellectual pursuits and social interactions. This stage is important in the development of social and communication skills and self-confidence. Salmon attention is diverted to his school mates, play mated and other activities and interests. He is focused and attentive on things that matters his school and the people around him. This stage is important because through these, his social skills, communication, and self-confidence are developed. The people around him will determine who he will be in the future.
7.Hito PHYSICAL ASSESSMENT Vital signs: T- 36.4 C P- 75 bpm R- 17 bpm
General Appearance and Mental Status:
Hito was wearing pink sleeveless, black short and pink slippers. Like her other siblings she was shy in communicating with the group. She has a thin body built, with a steady gait.
Skin Hito was noted to have brown complexion, no signs of jaundice & cyanosis, she has warm skin; no edema present; normal skin turgor; presence of scar in lower & upper extremities.
Hair and Nails Hair is black, straight; evenly distributed & with the presence of pediculosis. Nails are long with polish; no cyanosis & pallor because of polished nails, capillary refill cannot be noted & performed.
Head and Face Hito has a shape of oblong face, no presence of nodules & tenderness with symmetric facial expression noted Eyes Eyes were aligned and not deviated, eyebrows are thick, black and evenly distributed, eyelids are symmetrical with no tenderness & lesions noted, symmetric movement of eyes. Sclera is white; cornea is clear; bulbar and palpebral conjunctiva are pink in color, lacrimal apparatus are not swollen. Dark brown iris and equally round pupils are reactive to light and accommodation.
Ears auricle is brown in color, symmetry, firm, mobile, and aligned with the outer canthus. Pinna recoils when folded, no presence of nodules & tenderness. No presence of cerumen in both ears. Show a positive reaction in watch tick responses.
Nose
External nose is symmetrical in shape & uniform in color, no presence of nodules, masses and tenderness. The nasal septum is intact & in the midline. No lesions & ulcers present. Sinuses are not palpable and tender. Breathes normally through nares.
Lips and Teeth lips are symmetrical, dark brown in color. No presence of nodules or tenderness present. The mucosa is pinkish in color. Her teeth is incomplete. She has 26 teeth present. The gums are pinkish in color. Her teeth have a presence of plague with yellow color; has dental caries. The tongue is in the middle moving freely side to side. No presence of halitosis.
NECK Neck Muscle Head and neck are in the middle. The same color as the skin. There is no discomfort & no presence of lesions or masses. The trachea is in the midline. Thyroid is not visible & not swelling upon palpation. Equal strength in the muscles of sternocleidomastoid noted.
THORAX AND LUNGS Lungs The chest is symmetric; there is symmetric chest expansion with no tenderness or nodules present. Symmetric expiratory excursion & vocal fremitus. Breath sounds are clear. Spine is vertically aligned noted. Spiral column is straight. Breathing pattern is regular & normal rate & rhythm noted.
Heart No bruits heard upon auscultating; pulsation are symmetrical & full. Normal heart sounds & no murmurs noted.
Abdomen No distention and presence of lesions and masses were observed. He has normoactive bowel sounds.
Extremities Peripheral pulses are in full pulsations. Limbs are not tender and no edema is present at extremities. Cranial Nerves Function Assessment Technique To assess the CN I Olfactory Sensory Function: Smell clients Olfactory Nerve instruct the client to smell familiar scents like alcohol, coffee or perfume with each nostril. Cover the other nostril and instruct to close the eyes before identifying the scent The client will be able to identify the scent of alcohol, and perfume with each nostril. The client was able to identify the scent of alcohol,and perfume with each nostril. Normal Response Clients Response
To assess clients Optic Nerve instruct the client to read a word in a newspaper at a distance of 14 inches
The client will be able to read a word in the newspaper at a distance of 14 inches.
The client was able to read a word in the newspaper at a distance of 14 inches.
The clients CN III Oculomotor Motor Function: Extraocular eye movement, movement of sphincter of pupil, movement of ciliary muscle of lens. To assess clients Oculomotor Nerve use a penlight and instruct client to look up down and light the eye of the client. Clients pupil must constrict upon introduction of light as well as when looking at near objects and dilates when looking far objects. eye must follow the direction of the movement of the penlight and both pupils must constrict and be equally round upon introduction of light as well as when looking at near objects and dilates when looking The clients eye was able to follow the direction of the movement of the penlight and both pupils constricted and were equally round upon introduction of light as well as when looking at near objects and dilates
at far objects.
when looking at far objects.
Function: CN IV Trochlear Motor Extraocular movement, specifically moves eyeball downward, and laterally To assess the clients Trochlear Nerve instruct the client to follow the penlight with his/her eyes without moving its head. To assess clients CN V Trigeminal Motor Function: Sensation of cornea, skin of face, and nasal mucosa Trigeminal Nerve instruct the client to move the jaw downward while applying resistance then use the tip of the cotton to swipe the corneal surface of the eye. To test the sensation of the face use a cotton The client must be able to open and close her mouth and move his jaw against resistance. Blinking reflex must also be present. The client must determine The clients eyes must follow the movement of the object used with coordination. The clients eyes were able to follow the movement of the object used with coordination. The client was able to open and close her mouth and move his jaw against resistance. Blinking reflex was also presented. The client was able to determine the
swab use the tip of the stick for the sharp sensation and the cotton tip for dull sensation
the difference between the sharp and dull sensation
difference between the sharp and dull sensation
To assess clients Vestibulocochlear Nerve instruct the client to listen to whispers youll tell and ask them to repeat it. Allow the client to stand with feet together and arms resting at sides. First with eyes open then closed. To assess clients Glossopharyngeal Nerve instruct the client to swallow. Ask the client to identify different taste in the posterior portion of the tongue. The client must be able to swallow without difficulty. Client must be able to identify the taste of salt when administered. The client Client must be able to repeat the whispered words. Client must be able to maintain upright posture and foot stance. Client was able to repeat the whispered words. Client must be able to maintain upright posture and foot stance.
CN X
Function:
must be able To asses clients to speak
The client was able to
Vagus Motor
Sensory of pharynx and larynx, swallowing, vocal cord movement and for speaking
Vagus Nerve instruct the client to speak or say one sentence. Ask the client to swallow.
clearly and without difficulty. Client must be able to swallow without difficulty.
speak clearly and without difficulty. Client was able to swallow without difficulty.
The client CN X Vagus Motor Function: Sensory of pharynx and larynx, swallowing, vocal cord movement and for speaking To asses clients Vagus Nerve instruct the client to speak or say one sentence. Ask the client to swallow. must be able to speak clearly and without difficulty. Client must be able to swallow without difficulty. To assess clients CN XI Accessory Motor Function: head movement, shrugging of shoulders Accessory Nerve instruct the client to move her head in different directions (right, left, up, down and rotate). Ask the The client must be able to move head and shoulders as instructed,
The client was able to speak clearly and without difficulty. Client was able to swallow without difficulty.
The client was able to move head and shoulders as instructed, with coordination and
client to raise and shrug the shoulder against resistance.
with coordination and without difficulty.
without difficulty.
ERIK ERIKSONs PSYCHOSOCIAL STAGE (Initiative vs Guilty) NUTRITIONAL STATUS Age: 6 years old Height: 118 cm Weight: 25 Formula: Body Mass Index (BMI) = Weight in kilograms (kg) Height in meter squared (m2)
Body Mass Index (BMI) =15.36 kg/m

Interpretation:
Underweight Legend:
Body Mass Index Emaciated Underweight Normal Overweight Obese Morbidly Obese ACTIVITES OF DAILY LIVING Below 15 15 18.9 19 24.9 25 29 30 39.9 40 and above
Hito usually wakes up 5:30 in the morning to prepare for school and eat breakfast. At around 6:30 a.m together with siblings, they walk to go to school. By 12 nn, She goes home. She used to play with her playmates. She eats lunch and dinner with her family. She has good appetite. She sleeps at around 8:00 in the evening.
VIRTUE : Will Purpose : Ego Quality Learning initiative is learning how to do things. Children can initiate motor activities of various sorts of their own and no longer respond to imitate the actions of other children or their parents. When children are given much freedom and opportunity to initiate motor play, their sense of initiative is reinforced. Initiative is also encouraged when parents answer to a childs query (intellectual initiative) and dont exhibit fantasy or play. If children are made to feel their motor activity is bad, their questions are nuisance, or their play is silly and stupid, they may develop a sense of guilt over selfinitiated activities that will persist in later life. Hito is in the age where inquiries are always done. According to his mother, he always asks about certain things out of nowhere. Hito as stated by her mother, She always asks about certain things. She always plays anything and spends much time on playing. Oftentimes, when Hito asks many queries, Salmon scolds at her and tells him to stop. Afterwhich, Hito has tantrum and hit his mother.
SIGMUND FREUDs PSYCHOSEXUAL STAGE (Phallic Stage) This stage is often described as the most critical one for personality development. It can last from ages 4-7 and is characterized by a shifting of focus away from the anus and toward the genitals, and the genitals of others. The conflicts associated with this stage are different for men and women, but are generally defined as desire to possess the care-giver of the opposite sex, and eliminate the same-sex care-giver. Hito is very possessive when it comes to her father. During sleeping hours, she used to sleep beside her mother. Everytime she sees her mother that sleeps beside her father, she will get mad and asks her mother to move to another place.
8.Squid PHYSICAL ASSESSMENT
Vital signs: T- 36.8 C P- 120 bpm R- 31 bpm
General Appearance and Mental Status: Squid was seen playing outside the house with his cousin and some playmates before the initial assessment and was running around. He was wearing gray shirt and red shorts with slippers on.
Skin Dark Brown in color, moisten skin and warm to touch with good skin turgor.
Hair and Nails
Dry, no presence of dandruff, color black. Fingernails and toenails are dirty, no discoloration of the nail beds, pinkish in color, no clubbing of nails.
Head and Face Head is oblong, no presence of lesions or wounds.
Eyes Normal papillary constriction, bulbar and palpebral conjunctiva are slightly pale. Has normal visual field.
Ears Ears are symmetrical, color same as facial skin, no presence of lesions or wounds, presence of dirt.
Nose Absence of Nasal dischrge. He can breathe properly, no presence of lesions Lips and Teeth Lips are pink in color and is evenly distributed, absence of dental caries and missing teeth.
NECK Neck Muscle Color is evenly distributed, presence of rashes at the back of the neck.
Lymph Nodes Lymph nodes are not palpable and there is absence of pain.
THORAX AND LUNGS Lungs
Upon inspection, his chest wall rise and fall symmetrically. No deformities in the chest, but difficulty of breathing. presence wheezes sounds upon auscultated.
Heart Regular rate and rhythm upon auscultation. No murmurs heard upon auscultation. Pulsations of precordium are not visible by mere inspection.
Cranial Nerves Function Assessment Technique To assess the clients Olfactory Nerve instruct the The client client to smell familiar scents like alcohol, coffee or perfume with each nostril. Cover the other will be able to identify the scent of alcohol, coffee and perfume with Normal Response Clients Response
Function: Smell
The client was not able to identify the scent of alcohol, coffee and perfume with each
nostril and instruct to close the eyes before identifying the scent
each nostril.
nostril because he was only 2y/old.
To assess clients Optic Nerve instruct the client to read a word in a newspaper at a distance of 14 inches.
The client will be able to read a word in the newspaper at a distance of 14 inches.
The client was not able to read a word in the newspaper at a distance of 14 inches.becaus e he was only 2y/old.
To assess clients CN III Oculomotor Motor Function: Extraocular eye movement, movement of sphincter of pupil, movement of ciliary muscle of Oculomotor Nerve use a penlight and instruct client to look up down and light the eye of the client. Clients pupil must constrict upon introduction of
The clients eye must follow the direction of the movement of the penlight and both pupils must constrict and be equally The clients eye was not able to follow the direction of the movement of the penlight because he was only 2y/old.
lens.
light as well as when looking at near objects and dilates when looking far objects.
round upon introduction of light as well as when looking at near objects and dilates when looking at far objects.
Function: CN IV Trochlear Motor Extraocular movement, specifically moves eyeball downward, To assess the clients Trochlear Nerve instruct the client to follow the penlight with his/her eyes The clients eyes must follow the movement of the object used with coordination. The client must be able to open and close her mouth and move his jaw against resistance. Blinking reflex must also be present. The The clients eyes were able to follow the movement of the object used with coordination. The client was able to open and close her mouth and move his jaw against resistance. Blinking reflex was also presented. The client was not
and laterally without moving its head. To assess clients CN V Trigeminal Motor Function: Sensation of cornea, skin of face, and nasal mucosa Trigeminal Nerve instruct the client to move the jaw downward while applying resistance then use the tip of the cotton to swipe the corneal surface of the eye. To test the
sensation of the face use a cotton swab use the tip of the stick for the sharp sensation and the cotton tip for dull sensation
client must determine the difference between the sharp and dull sensation
able to determine the difference between the sharp and dull sensation because he was only 2y/old.
Function: Extraocular movements , moves eyeball
CN VII Facial Sensory and Motor
Function: Facial expression.
To assess clients Facial Nerve instruct the client to raise eyebrows, show teeth, puff cheeks.
The client must be able to raise eyebrows, show teeth, puff cheeks .
The client was able to raise eyebrows, show teeth, puff cheeks.
To assess clients Vestibulocochlear Nerve instruct the client to listen to whispers youll tell and ask them to repeat it.. To assess clients Glossopharyngea l Nerve instruct the client to swallow. Ask the client to identify different taste in the posterior portion of the tongue.
Client must be able to repeat the whispered words. Client was able to repeat the whispered words.
CN IX Glossopharyngea l Sensory and Motor
The client must be able to swallow without difficulty. Client must be able to identify the taste of salt when administered .
The client was able to swallow without difficulty. Client was not able to identify the taste of salt when administered because he was only 2y/old. .
The client CN X Vagus Motor Function: Sensory of pharynx and larynx, swallowing, vocal cord must be able To asses clients Vagus Nerve instruct the client to speak or say one sentence. to speak clearly and without difficulty. Client must The client was not able to speak clearly . Client was able to swallow without
movement and for speaking
Ask the client to swallow.
be able to swallow without difficulty.
difficulty.
To assess clients CN XI Accessory Motor Function: head movement, shrugging of shoulders Accessory Nerve instruct the client to move her head in different directions (right, left, up, down and rotate). Ask the client to raise and shrug the shoulder against resistance. The client must be able to move head and shoulders as instructed, with coordination and without difficulty. The client was able to move head and shoulders as instructed, with coordination and without difficulty.
Will: Autonomy vs. Shame & Doubt (Toddlers, 18 mo. to 3 years)
Psychosocial Crisis: Autonomy vs. Shame & Doubt As the child gains control over eliminative functions and motor abilities, they begin to explore their surroundings. The parents still provide a strong base of security from which the child can venture out to assert their will. The parents' patience and encouragement helps foster autonomy in the child. Children at this age like to explore the world around them and they are constantly learning about their environment. Caution must be taken at this age while children may explore things that are dangerous to their health and safety. At this age, children develop their first interests. They begin to feed themselves, wash and dress themselves, and use the bathroom. If caregivers encourage self-sufficient behavior, toddlers develop a sense of autonomy--a sense of being able to handle many problems on their own. But if caregivers demand too much too soon, refuse to let children perform tasks of which they are capable, or ridicule early attempts at self-sufficiency, children may instead develop shame and doubt about their ability to handle problems. Squid start to be independent or being autonomy, though he just only 2yrs.old, he dont want to be carried by his mom,he want to walk by his own.but still his mom give him security, because squid might fall anytime,when he walk.
SIGMUND FREUDs PSYCHOSEXUAL STAGE (Anal stage) oddlers from ages 2 to 3 have reached Freud's second stage of psychosexual development. Freud believed that children at this age connect their developing understanding of societal rules and regulations to the pleasure they find in controlling their bowel movements. He theorized that if a person is frustrated while being toilet trained, she may become "fixated" at this anal stage and grow into an adult who is stingy, stubborn, compulsively messy or compulsively clean. According to mommy shrimp, squid already now how to go to the rest room,if he feel the urge of toileting,but sometimes he cannot control his bowel movement,and he will going to have a bowel to the floor, but still mommy shrimp will not able to punishing his
children, everytime he cannot control his bowel movement. instead she will rewarding his child of trying to control his bowel movement. NUTRITIONAL STATUS Age: 2 years old Height: 114 cm Weight: 10 kg Formula: Body Mass Index (BMI) = Weight in kilograms (kg) Height in meter squared (m2)
Body Mass Index (BMI)
= =
07.69 Emiciated
Interpretation:
Legend:
Body Mass Index Emaciated Underweight Normal Overweight Obese Morbidly Obese Below 15 15 18.9 19 24.9 25 29 30 39.9 40 and above
ACTIVITES OF DAILY LIVING According to Mommy shrimp, Squid wakes up 8:00 in the morning and will eat breakfast. After finishing his breakfast, he will play inside their house together with his nieces. And at around 12, they will eat their lunch with his other siblings.
Squid was used to take a nap in the afternoon. He usually goes to sleep together with his siblings at aroung 8pm.
2nd visits (Nov.21.2011, monday) 1.Daddy crab The group wasn't able to assess Daddy Crab because he is at work the whole day. 2. Mommy shrimp Vital signs: T- 35.8 C P- 80 bpm R- 22 bpm Bp- 110/80mmhg
General Appearance and Mental Status: Upon assessment mommy shrimp was wearing a white sando with pink stripped shorts , and pair of slippers on.She is cooperative, coherent and oriented to time, place and person. She has a normal skin turgor but with dry skin. Her nails were still untrimmed and dirty. Her hair is still dry and presence of lies was still noted upon assessment
3. Milkfish The group wasn't able to assess Milkfish because Milkfish was at school the whole day.
4.Tilapia The group wasn't able to assess Salmon because He was not home during the visit. 5.Lobster Vital signs: T- 35.5 C P- 80 bpm
R- 19 bpm General Appearance and Mental Status: Lobster was wearing a yellow green t-shirt and white shorts. presence of pediculosis and lies, with short hair. She is cooperative, coherent and oriented to person, time and place.
6.Salmon The group wasn't able to assess Salmon because He was not home during the visit.
7.Hito Vital signs: T- 36.3 C P- 78bpm R- 20 bpm General Appearance and Mental Status: Hito was wearing a green uniform and a pair of slippers.She Still has the presence of lies upon assessment. She is still shy to express himself through speech. she has a steady gait. He is conscious when the assessment was done. 8.Squid Vital signs: T- 36.7 C P- 121 bpm R- 34 bpm General Appearance and Mental Status: Salmon was wearing a white sando and a pair of slippers.With clean and short nails.no presence of lies was noted.He is very clumsy when we assess him,because he is just a 2y/old.
3nd visits (Nov.22.2011, Tuesday) 1.Daddy crab
The group wasnt able to assess Daddy crab because he is at work the whole day. 2. Mommy shrimp Vital signs: T- 36.1C P- 91 bpm R- 20bpm Bp- 110/80mmhg General Appearance and Mental Status: Upon assessment mommy shrimp was wearing a blue sando with cream shorts , and pair of slippers on. She is cooperative, coherent and oriented to time, place and person. She has a normal skin turgor and moisten skin. Her nails were now trimmed and clean. Her hair is still dry and presence of lies was still noted upon assessment.
3. Milkfish The group wasn't able to assess Milkfish because Milkfish was at school the whole day. 4.Tilapia The group wasn't able to assess Salmon because He was not home during the visit. 5.Lobster The group wasn't able to assess Lobster because Lobster was at school at the time of the home visit. 6.Salmon The group wasn't able to assess Salmon because he was not home during the visit. 7.Hito Vital signs: T- 36.3C P- 95 bpm R- 24bpm
General appearance: Hito was wearing a pink dress and a pair of slippers.She Still has the presence of lies upon assessment. She is still shy to express himself through speech. she has a steady gait. He is conscious when the assessment was done.
8.Squid Vital signs: T- 36.7 C P- 121 bpm R- 34 bpm General Appearance and Mental Status: Squid was wearing a white printed sando and a pair of slippers.With clean and short nails,Absence of lies.He is playing together with his cousins.
Final Visits (Nov.29,2011,tuesday) 1.Daddy crab The group wasnt able to assess Daddy crab because he is at work the whole day.
2. Mommy shrimp PHYSICAL ASSESSMENT
Vital signs: T- 35.9 C P- 81 bpm R- 19 cpm BP- 110/80 mmHg
Upon assessment mommy shrimp was wearing a white t-shirt with brown shorts, and pair of slippers on.She is cooperative, coherent and oriented to time, place and person, She has steady gait and shows no difficulty recalling events.
Skin Mommy shrimp has been noted to have a dark complexion, with no signs of jaundice, cyanosis and pallor. There are no signs of edema present. He has a normal skin turgor but with moisten skin. Hair and Nails SHe was noted to have short nails, with pinkish nail beds and a capillary refill time of less than 3 seconds. There is no clubbing and lesion noted. She has fair, black hair and well distributed. Her hair is dry with some white hair, And still, the presence of lies noted upon assessment, no presence of dandruff noted.
Head and Face There is no abnormal elevation or depression in the skull upon palpation. There is symmetry of facial movements. No nodules or masses.
Eyes Her eyes are aligned and not deviated; eyebrows are thick, black and evenly distributed. There is symmetric movement, with flaking noted on the skin underneath the eyebrows. Her eyelids are symmetric, with no tenderness and nodules. The lacrimal glands are not swollen, the bulbar and palpebral conjunctiva are pink in color. Ears Auricles are same as facial color and it is aligned with the outer canthus of the eye. They are mobile, firm and not tender upon palpation. Pinna recoils after it is folded with no lesions noted upon assessment. Nose Her nose is straight and the septum is located in the center midline. No deviations have been observed in the shape, size and color of the external nose. No
discharges were noted and there is the absence of nasal flaring. Also, no lesions and masses were noted upon palpation.
Lips and Teeth Outer and inner lips are symmetrical. she has the ability to move her lips. Inner lips and buccal mucosa are uniform in color. she has a incomplete set of teeth and his tongue is in central position and she can move it freely.
NECK Neck Muscle Neck muscles are equal in size. No masses and nodules were noted upon palpation. Head movements are coordinated and she can move her head freely.
Lymph Nodes Lymph nodes are not palpable and there is no enlargement noted upon assessment THORAX AND LUNGS Lungs There is full and symmetrical chest expansion. There is effortless and rhythmic respirations and no abnormal breath sounds were heard upon auscultation.
Heart Regular rhythm of apical pulse was noted upon auscultation.
Abdomen No distention and presence of lesions and masses were observed. she has normal bowel sounds.
Extremities
Peripheral pulses are in full pulsations.presence of bruises on the right forearm of the shoulders.
3. Milkfish The group wasn't able to assess Milkfish because Milkfish was at school during the home visit.
4.Tilapia The group wasn't able to assess Salmon because He was not home during the visit. 5.Lobster PHYSICAL ASSESSMENT
Vital signs: T- 36.4 C P- 84bpm R- 18bpm General Appearance and Mental Status: Lobster was wearing a Blue t-shirts and blue shorts with short hair. He is cooperative during our final assessment, coherent and oriented to person, time and place. Skin He has brown-colored skin which is generally uniform. No lesions and edema have been noted. He has good skin turgor, which turned back to previous state in less than 2 seconds when pinched.
Hair and Nails His nail plates are colorless and have concave curves. Nails are trimmed. His nail beds returned to previous state in less than three seconds after pressure was applied.
Head and Face
There is no abnormal elevation or depression in the skull upon palpation. There is symmetry of facial movements. No nodules or masses. His hair is dark in color. It is evenly distributed and presence of lies was noted. No presence of lesions was noted.
Eyes His eyes are aligned and not deviated; eyebrows are thick, black and evenly distributed. There is symmetric movement, with flaking noted on the skin underneath the eyebrows. His eyelids are symmetric, with no tenderness and nodules. The lacrimal glands are not swollen, the bulbar and palpebral conjunctiva are pink in color.
Ears His auricles are same as facial color and it is aligned with the outer canthus of the eye. They are mobile, firm and not tender upon palpation. Pinna recoils after it is folded. He has normal hearing sounds. Nose His nose is straight and her septum is located in the midline. No deviations have been observed in the shape, size and color of the external nose. No discharges were noted and there is the absence of nasal flaring. Also, no nodules and masses were noted upon palpation.
Lips and Teeth Outer lips are symmetrical. he exhibits ability to move her lips. Inner lips and buccal mucosa are uniform in color. She has an incomplete set of teeth and her tongue is in central position and she can move it freely.
NECK Neck Muscle There is absence of difficulty in moving the neck. The muscles are equal in size and head is in the center. He can move the head in circular motion. The trachea is in the center while the thyroid gland ascends when swallowing. No nodules and masses felt.
THORAX AND LUNGS Lungs There is full and symmetrical chest expansion. There is effortless and rhythmic respirations and no adventitious or abnormal breath sounds were heard upon auscultation.
Heart Normal contour, no distention and no nodules present. Carotid artery has full pulsations with symmetrical pulse volume. Jugular veins are not visible and with normal rate and regular rhythm
Abdomen No distention and presence of lesions and masses were observed. SHe has normal bowel sounds.
Extremities Peripheral pulses are in full pulsations. Limbs are not tender and no edema is present at extremities
6.Salmon PHYSICAL ASSESSMENT
General Appearance and Mental Status: Salmon was wearing a red tshirt and maong shorts and a pair of slippers. He is still shy to express himself through speech. But he is very cooperative on us during our assessment. He has a steady gait. He is conscious when the assessment was done.
Skin Dark brown in color which is evenly distributed, dry skin and warm to touch and with good skin turgor. No lesions upon assessment.
Hair and Nails Hair is black, dry, no presence of dandruff, with presence of lice. Fingernails are short and clean. Toenails are trimmed, no discoloration of the nails beds, pinkish in color, no clubbing of nails.
Head and Face Head is symmetrical in shape, no presence of lesions or wounds.
Eyes Normal papillary constriction, bulbar and palpebral conjunctiva are pink in color, eyes are symmetrical.
Ears Ears are symmetrical, color same as facial skin and evenly distributed, no presence of lesions or wounds, pinna recoils when folded.
Nose No presence of discharges upon assessment. Lips and Teeth Lips are pink in color and evenly distributed, presence of dental carries and missing teeth.
NECK Color is evenly distributed, no presence of lesions or wounds.
Lymph Nodes No presence of tenderness in lymph nodes when palpated, no presence of masses and nodules
THORAX AND LUNGS Lungs Color is evenly distributed, chest is properly aligned and proportionate, spine is also properly aligned.
Heart Normal contour, no distention and no nodules present. Carotid artery has full pulsations with symmetrical pulse volume. Jugular veins are not visible and with normal rate and regular rhythm. Abdomen Evenly distributed color, no presence of lesions and wounds. Extremities Arms and legs are symmetrical in shape and size. Noted good ROM with equal strength. 7.Hito PHYSICAL ASSESSMENT
Hito was in stripped blue blouse and maong shorts.On our final visits shes now very cooporative, and no longer shy.
Skin Hito was noted to have brown complexion, no signs of jaundice & cyanosis, she has warm skin; no edema present; normal skin turgor; presence of scar in lower & upper extremities.
Hair and Nails Hair is black, straight; evenly distributed & with the presence of pediculosis. Nails are short and clean; no cyanosis & pallor noted.with capillary refill of 3sec. Head and Face Hito has a shape of oblong face, no presence of nodules & tenderness with symmetric facial expression noted Eyes Eyes were aligned and not deviated, eyebrows are thick, black and evenly distributed, eyelids are symmetrical with no tenderness & lesions noted, symmetric movement of eyes. Sclera is white; cornea is clear; bulbar and palpebral conjunctiva are pink in color, lacrimal apparatus are not swollen. Dark brown iris and equally round pupils are reactive to light and accommodation.
Ears auricle is brown in color, symmetry, firm, mobile, and aligned with the outer canthus. Pinna recoils when folded, no presence of nodules & tenderness. No presence of cerumen in both ears. Show a positive reaction in watch tick responses.
Nose External nose is symmetrical in shape & uniform in color, no presence of nodules, masses and tenderness. The nasal septum is intact & in the midline. No
lesions & ulcers present. Sinuses are not palpable and tender. Breathes normally through nares.
Lips and Teeth lips are symmetrical, dark brown in color. No presence of nodules or tenderness present. The mucosa is pinkish in color. Her teeth is incomplete. She has 26 teeth present. The gums are pinkish in color. Her teeth have a presence of plague with yellow color; has dental caries. The tongue is in the middle moving freely side to side. No presence of halitosis.
NECK Neck Muscle Head and neck are in the middle. The same color as the skin. There is no discomfort & no presence of lesions or masses. The trachea is in the midline. Thyroid is not visible & not swelling upon palpation. Equal strength in the muscles of sternocleidomastoid noted.
THORAX AND LUNGS Lungs The chest is symmetric; there is symmetric chest expansion with no tenderness or nodules present. Symmetric expiratory excursion & vocal fremitus. Breath sounds are clear. Spine is vertically aligned noted. Spiral column is straight. Breathing pattern is regular & normal rate & rhythm noted.
Heart
No bruits heard upon auscultating; pulsation are symmetrical & full. Normal heart sounds & no murmurs noted.
Abdomen No distention and presence of lesions and masses were observed. He has normoactive bowel sounds.
Extremities Peripheral pulses are in full pulsations. Limbs are not tender and no edema is present at extremities.
8.Squid PHYSICAL ASSESSMENT Vital signs: T- 35.9 C P- 126 bpm R- 34 bpm
General Appearance and Mental Status: Squid was seen playing outside the house with his cousin and some playmates before the final assessment and was running around. He was wearing whitw shirt with slippers on. Skin Dark Brown in color, moisten skin and warm to touch with good skin turgor.
Hair and Nails Dry, no presence of dandruff, color black hair. Fingernails and toenails are clean, no discoloration of the nail beds, pinkish in color, no clubbing of nails.
Head and Face Head is oblong, no presence of lesions or wounds.
Eyes Normal papillary constriction, bulbar and palpebral conjunctiva are slightly pale. Has normal visual field.
Ears Ears are symmetrical, color same as facial skin, no presence of lesions or wounds, presence of dirt.
Nose No presence of discharges. squid is able to breathe properly without difficulty.
Lips and Teeth Lips are pink in color and is evenly distributed, absence of dental caries and missing teeth.
NECK Neck Muscle Color is evenly distributed, presence of rashes at the back of the neck.
Lymph Nodes Lymph nodes are not palpable and there is absence of pain.
THORAX AND LUNGS Lungs Upon inspection, his chest wall rise and fall symmetrically. No deformities in the chest. Effortless respiration was also observed, can breath easily. Absence of abnormal breath sound when auscultated.
Heart
Regular rate and rhythm upon auscultation. No murmurs heard upon auscultation. Pulsations of precordium are not visible by mere inspection.
OBSTETRIC HISTORY
Mommy Shrimp Her Obstetric history is G13P13T7P3A3L10M0. She got pregnant for 13 times 7 of her children were termed and 3 of them are preterm and experienced miscarriage during her 2nd, 5th and 7th pregnancies. According to her the reason why she experience this is because she always lifts heavy objects when they sell fishes in the market she got hospitalized at Ospital ning Angeles. 10 of them are living but only the 6 children are living with them. Her children were born though Normal Spontaneous Delivery in Ospital ning Angeles and did not experience any complications.
PAST AND PRESENT ILLNESS
Mommy Shrimp
History of Past Illness According to Mother Shrimp when she was 13 years old she had measles that last for 1 week, she did not received all her immunizations when she was a kid. According to her she was hospitalized at Ospital ning Angeles due to Miscarriage. She didnt experience serious iillnesses, just common colds, cough, fever. She goes to the health centre for check up whenever she's sick.
Present Illness Mommy Shrimp doesnt have any illness at present. Upon the student nurses assessment, shes at good health.
Milk fish History of Past Illness According to Mommy Shrimp, milkfish had experienced cough and colds and fever in the past. She already experienced chickenpox when she was 11. Mommy shrimp gives bamboo leaves to manage chicken pox. If milkfish have coughs usually mommy Shrimp gives over the counter drugs like solmux. Usually Mommy shrimp goes to the health centre whenever Milk fish gets sick. Present Illness Milk fish doesnt have any illness at present. Upon the student nurses assessment, shes at good health.
Tilapia History of Past Illness Tilapia experienced fever and cough and colds before. Like his siblings, when He have fever, they used tepid sponge bath and over the counter drugs. Most of the times, they use Paracetamol. He already had his chicken pox when he was 9. Mommy Shrimp applies leaves of a bamboo to treat it. According to Mommy Shrimp, He had diarrhea also a month ago the group started the home visits.
Present Illness Tilapia doesnt have any illness at present. Upon the student nurses assessment, hes at good health.
Lobster History of Past Illness According to Mommy Shrimp, Lobster had not experience any serious illness. The common problem for him and his siblings is cough and colds. The treatment of Mommy Shrimp for that is giving over the counter drugs like solmux. Lobster has never been hospitalized. She had chicken pox before, when she was 7 years old. Mommy Shrimp Applies bamboo leaves on the affected area to treat it.
Present Illness Lobster doesnt have any illness at present. Upon the student nurses assessment, shes at good health.
Salmon History of Past Illness According to Mommy Shrimp, Salmon had experienced cough and colds and fever in the past. He never had serious illnesses. She already experienced chickenpox when he was 6 years old. Mommy shrimp gives bamboo leaves to manage chicken pox. If salmon have coughs usually mommy Shrimp gives over the counter drugs like solmux. Usually Mommy shrimp goes to the health centre whenever salmon gets sick
Present Illness Salmon doesnt have any illness at present. Upon the student nurses assessment, hes at good health.
Hito History of Past Illness Hito experienced fever and cough and colds before. Like her siblings, when she have fever, they used tepid sponge bath and over the counter drugs. Most of the times, they use Paracetamol. Mommy Shrimp brings Hito to the health centre whenever shes sick. She already had his chicken pox when he was 4years old. Mommy Shrimp applies leaves of a bamboo to treat it.
Present Illness Hito doesnt have any illness at present. Upon the student nurses assessment, shes at good health.
Squid
History of Past Illness Squid experienced fever and cough and colds before. Like his siblings, when he have fever, they used tepid sponge bath and over the counter drugs. Most of the times, they use Paracetamol. Mommy Shrimp brings squid to the health centre whenever hes sick. He is fully immunized. He had cough and colds a week ago the group started the home visits.
Present Illness Squid doesnt have any illness at present. Upon the student nurses assessment, hes at good health.
IV. SOCIO ECONOMIC, CULTURAL AND ENVIRONMENTAL ASSESSMENT
A. Family Structure The Seafood family is a nuclear type of family, composed of father, mother and children. Although the family is not lucky enough to have a wealthy and comfortable living, they still manage to surpass every challenging situation that they encounter by having positive outlook.
B. Dominant Family members in terms of Decision Making especially to Health care It is important to determine the dominant family members in terms of decision making and to whom to consult when the family encounters problems especially to health.Mommy shrimp and Daddy Crab both make decision for their family in terms of budgeting and decision making. C. Source of Income, Expenditures Daddy Crab and Mommy shrimp sells fish in the market, they earn around 500 php per day. A total gross income of 15,000 per month was computed. Mommy shrimp is aware that their income is not enough to support the physiologic needs of the family. If divided into 8 members of the family, each will be receiving 1,875 php. This is considered insufficient as compared to NEDAs required 2,768.60/month per individual. Below shows the breakdown of expenses: EXPENSES Gas Bigas, Can goods, foods Allowance Electric bill Total PHP 650.00 PHP 7,500 (250/day) PHP 6,000(200/day) PHP 850 PHP 15,000 AMOUNT
PHP 15,000 / 8 MEMBERS OF THE HOUSEKEEPER FAMILY= PHP 1,875 per member *this shows that they have inadequate income for each member because according to NEDA it should be PHP 2,768.60 per member each month.
D. Working Hours Mommy shrimp and Daddy Crab wake up at 5:30 in the morning to sell fish in the market. Mommy shrimp goes home at around 1:00 in the afternoon. While daddy Crab still sells fish until evening.
E. Ethnic background and religious affiliation Daddy Crab is from Visayas while Mommy shrimp originated from Pampanga. The family s religion is Roman Catholic, they attend Holy Mass every Sunday and prays every night before going to bed.
F. Significant Others Roles in the Family Life Being a member of poor family is not really an easy life as verbalized by the mother (Mommy Shrimp). Although they can still pay their expenses, they are still times that they need to ask help from their relatives.
G. Health habits and Beliefs The assessment of the health beliefs of family would help student nurses to recognize the familys method on how they handle health problems. The family resorts to herbal alternatives as they have shortage for financial aspects. Some may include guava leaves, lagundi, katakataka and oregano. They also visit the Barangay Health Center to
be able to be included in the free vitamins being given for children. They are also visiting Health Center for immunization.
H. Familys involvement in community activities According to Mommy shrimp she participates in seminars being sponsored by the Health center. They also make use of the Resources for minor health complaints.
Family Utilization of Community Resources
The Seafood family utilizes community resources such as check-ups from the health center, elementary school and chapel. Utilization of these resources can greatly affect the health status of the family members. Mommy shrimp brings her children to the health center regularly for check-ups. The family goes to church during Sundays to attend the mass.
J. Housing Condition Housing condition plays a major role in affecting the health and functioning of the family. It should be properly assessed as shelter is one of the basic human needs and provides safety and security to the members of the family. The house should be safe, conducive for growth and health and hazard-free in order for the family to achieve their optimum level of functioning. The Seafood family is of concrete type. The floor is cemented with a kitchen, a dining area, one bedroom..
The house has a length of 4.7 meters and a width of 3.12 meters. The total floor area is 14.67 square meters. The Seafood family has 2 adult members and 6 children. An adult requires 3 m2 of living space and 1.5 m2 requirement for a child. The total floor
area when divided among the members is equal to 3.13 indicating the adequacy of space for each member. The total space needed is 15 m2. The family didnt meet the average space needed for each member.
Total Space Requirement of the Family
Adult Children
3 square meters x 2 1.5 square meters x 6
= 6 m2 = 9 m2 Total=15 m2
TFA < TSR 14.67 square meters 15 square meters
The total floor area is lesser than the total space requirement of the seafoodFamily. The Seafood family residence is overcrowded.
The house has one door and no window. The Seafood family is a candidate for inadequate ventilation. It was also observed that there is inadequate or poor lighting as evidenced by a total of one light bulb inside house, it is located in the living room. Furnitures include the bed, chairs and a table. As for sleeping arrangement, the family sleeps together in the bedroom.
Accident hazards noted include the presence of sharp object such as knives and scissors within the reach of the children. There were also vectors noted such as flies, rodents and cockroaches.
K. Food Sources, Storage and Cooking Facilities The family buys their food from a nearby market situated inside the community. Because of the absence of a refrigerator, the family stores their leftover foods at the table and covers them with plates. Their meals are cooked using the gas stove in the kitchen.
L. Water Supply (Source, Ownership, Potability and Storage) The potability and safety of water supply must be assessed as many diseases can be harbored from contaminated water. They fetch water from a relative to use from drinking. While they use Nawasa for washing clothes and dishes. M. Toilet Facility (Type, Ownership, Sanitary Condition) The condition of the toilet facility determines the familys hygienic status. The toilet is located inside the bathroom. The bathroom is small and dirty. Water is poured into the toilet to facilitate the disposal of waste materials into the septic tank. The bathroom is located outside the house.
N. Drainage System (Type, Sanitary Condition) Assessment of the drainage system is important to determine the presence of stagnation which could serve as a breeding site for vectors of diseases. The drainage is located in the side of the house. It is an open type, stagnant but it doesnt emit foul odor.
O. Social and Health Facilities Available The family utilizes the different facilities in the community. The family maximizes the services offered by the health center. Mommy Shrimp brings her children there especially if they have cough and colds, fever, etc.
P. Communication and Transportation Facilities The main dialect of the family is Tagalog. The family doesnt have a cellular phone that they use to communicate with friends and relatives. The family usually walks to go to different facilities inside the community. They use tricycles or utility jeepneys when going to farther places.
V. Problem Identification List of Problems Score
Problem no. 1: Accident Hazards: Pointed/ sharp objects improperly kept 3.84
Problem no. 2: Health Threat: Unhealthy Lifestyle Habit: Poor Personal Hygiene
3.34
Problem no. 3 Poor home condition: Inadequate
3.34
ventilation as a Health threat
Problem no. 4: Poor Environmental Conditions: Presence of Breeding Sites for Vectors as a Health Threat
3.01
Problem no. 5: Presence of Health Deficit:
2.83
Pediculosis Capitis
Problem no. 6: Poor Toilet Facility as a Health Threat
Problem no. 7 : Health Threat: Improper Garbage Disposal
Problem # 1: Health Threat: Accident Hazards: Pointed/ sharp objects improperly kept
CRITERIA
COMPUTATION
SCORE
JUSTIFICATION
Nature problem
of
the
2/3x1
0.67
The health
presence threat. which
of The may
accident hazards is a presence of pointed
Health Deficit
objects
accidentally Health Threat a health
cause threat
cuts and wounds, as because these may cause or increase the Foreseeable Crisis incidence.
Modifiability of the Problem
2/2x2
Current Knowledge and Management The family is aware of
Easily Modifiable Partially Modifiable Not Modifiable
the problem and the consequences the problem may bring. The family members are willing to put things in order and to prevent the occurrence of any accidents. But they are having a hard time to maintain orderliness because
Current Knowledge, technology, and intervention
to manage the problem Resources of the family physical, financial and manpower Resources of the Nurse knowledge, skills, time Community Resources
some of the members keep on messing up the things inside the house and due to lack of time.
Family resources The members of the family can work hand in hand to put things in order to assure safety in their house.
Student Nurses Resources The student nurses can work with the family and help them identify ways on how to intervene with the problem and minimize or eradicate the occurrence of the problem.
Community Resources The Barangay
Council of Claro M Recto is always willing to reach out to its member needing help or assistance especially when it comes to the safety and health of its members. It can conduct a group discussion to prevent the occurrence of accident in the community to ensure safety to every household.
Preventive Potential
2/3x1
0.67
Severity If not properly kept or
High Moderate Low
positioned, the knives and other sharp objects are within the childrens reach that can lead to accidents and injuries to the family members especially to the children.
Gravity or severity of
the problem Duration of the problem Current Management Exposure of any high risk group Current Knowledge and Management The family is aware of the problem and the consequences the problem may bring. The family members are willing to put things in order. But they are having a hard time to maintain orderliness because some of the members keep on messing up the things inside the house. Duration The mother said that this has been the usual setup of their house with things placed everywhere.
High Risk Group
The children will be the victims if the problem is not solve immediately. And it can be due to the elders carelessness.
Salience
2/2x1
0.5
The family considered it as a problem needing immediate
A serious problem. Attention needed.
attention as evidenced by utilizing ways to put those sharp object in their proper places to avoid accident.
A problem but not needing immediate attention.
Not a problem
Total
3.84
Problem # 2: Health Threat: Unhealthy Lifestyle Habit: Poor Personal Hygiene
Criteria Nature of the problem Wellness potential-3 Health deficit-3 Health threat-2 Foreseeable crisis-1
Computation Score 2 1 /3x 0.67
Justification The problem is a threat to the health of the family because poor personal hygiene increases the risk that microorganisms may invade the body and thus result to various illnesses.
Modifiability of the problem Current knowledge Family resources Resources of the nurse Community resources 2 2 /2 x 2
The problem is easily modifiable.
Current Knowledge: The family knows the importance of bathing.
Family Resources: The family has resources, they allotted money in their monthly budget in purchasing soap shampoo and other toiletries and also,
the mother regularly washes the clothes of the family.
Resources of the nurse: The student nurses provide some health teaching on how to prevent infection or even other complications through proper hygiene. They also demonstrated proper bathing and hand washing, tooth brushing etc.
Community Resources: The Healthy Lifestyle campaign of the community advocates the practice of good general and personal hygiene.
Preventive potential
Gravity/Severity: The problem is severe, given the fact that it is a
23x1 Gravity or severity of the problem Duration of the problem Current Management Exposure of any high risk group
0.67
contributing to multiple health problems such as the presence of dental caries furungolosis, pediculosis capitis, and other diseases.
Duration of the problem: The problem is experienced by the family even before the initial home visit because of its long duration.
Current Management: The family is taking a bath during the morning but it is not enough especially proper hand washing and other proper hygiene practices are not being practiced.
Exposure to high risk groups: All members of the family manifest signs of poor personal hygiene, making
them all affected.
Salience
02x1
The family does not recognize the existence of the problem.
TOTAL
3.34
Problem # 3 Poor home condition: Inadequate ventilation as a Health threat
Criteria Nature of the problem Wellness potential-3 Health deficit-3 Health threat-2 Foreseeable crisis-1
Computation 2
Score Justification 0.67 This problem is considered as a Health threat. The house is concrete type; it has insufficient windows and air cannot move freely since there is only one door opening the house for air circulation.
Modifiability of the problem Current knowledge Family resources X Nurses resources Community resources X
The problem is partially modifiable.
1 1
CURRENT KNOWLEDGE -the family still have the knowledge and aware
about the existing problem; they can also still find a way to improve their condition.
FAMILY RESOURCES -to fully eradicate the problem, making of window/s should be done which entails not only effort but also financial resources.
NURSES RESOURCES -Health teachings such as advising the family to make a window and maintaining effective air circulation were discussed.
COMMUNITY RESOURCES -this problem is out of the communitys control and limits.
Preventive Potential Gravity/severity of the problem Duration 2
0.67
The problem has a moderate preventive potential.
Current management Exposure of high risk groups
SEVERITY -this problem had long existed; all members especially the children are at risk for easy transmission of contagious diseases.
DURATION -this issue had been existing ever since the family resided in the house.
CURRENT MANAGEMENT -there are some actions done to improve the ventilation of the house such as by rearranging the cabinets, keeping the door open at daytime and advised to make a window to promote natural flow of air inside.
EXPOSURE OF HIGH RISK GROUPS -all members are definitely affected especially when there
are cases of communicable diseases.
1 Salience 2 The problem is felt by the family and interventions are done to improve their condition about inadequate ventilation. 3.34
TOTAL SCORE
Problem # 4 : Health Threat: Poor Environmental Condition: Presence of Breeding Sites for Vectors CRITERIA Nature of the Problem Health Deficit Health Threat Foreseeable Crisis COMPUTATION 2/3 x 1 SCORE 0.67 JUSTIFICATION The problem is a health threat because of the presence of breeding sites of insects like cockroaches and flies can cause different diseases.
Modifiability of the Problem Current Knowledge, Resources of the family. X
1/3 x 2
0.67
Knowledge: The family is not aware of the poor environmental conditions. Family: The family can clean their surroundings sweeping by the frequently
floor, throwing garbage in proper disposal, take away stagnant water, and using mosquito sleeping. Nurse: The student nurse can impart their knowledge, time and skills by teaching the family to always clean their surroundings the and maintaining drainage nets when
Resources of the nurse,
clean and free from stagnant water. Community: The community does not appear to be concern about the problem of the family.
Community Resources
Preventive Potential High Moderate Low Gravity or severity of the problem
2/3 x 1
0.67
Severity: Problem is not yet severe, since the family has not yet experienced any illness caused by the poor environmental conditions. Duration: The problem exists about 8 years already.
Current Management: The family uses mosquito nets at night and use slippers to manually kill cockroaches Risk groups: The family is considered a high risk group since they are living near a Duration of the problem poor environment that may cause diseases.
Current management Exposure of any high risk group
Salience A Serious problem Attention needed A problem but not needing immediate attention Not a problem
2/2 x 1
The
family
knows the
and
recognizes at stake
immediate
attention since their health is
TOTAL
3.01
Problem# 5 Presence of Health Deficit: Pediculosis Capitis
Criteria
Computation
Actual score
Justification Pediculosis is considered to be a health deficit brought about by the
1. Nature of the problem
infestations of parasites 3/3 x 1 1 wherein the ecological relationship is parasitism from the host. In the Seafood familys case, Mommy Shrimp and the children were
affected by the problem. The problem is highly modifiable as evidenced by the following criteria observed:
2.Modifiability of the problem
Current knowledge Family Resources SN Resources Community Resources
P P
> The family has a current knowledge of the problem as during the interview of Mommy Shrimp was able to verbalize the presence of the problem "ay oo may mga kuto nga sila"(oh yes they have the presence of lice.)
1/2 x 2
> The family's manpower and physical resources are available as evident by the family's willingness to cooperate and comply with the Student Nurses health teachings and as verbalized by Mmommy shrimp that she minimize the presence of lice by using a specialized comb.
> The Student Nurses are well informed and knowledgeable about pediculosis and the management to be done to prevent the occurrence of these diseases and on how to eradicate those lice, thus making them enable to impart this knowledge to the family. Another thing is the Student Nurses is very enthusiastic in helping the family to diminish if not to eradicate the problem.
> The Barangay Health Center did not give the mother a specific treatment or health teachings to the family.
3. Preventive Potential
The Seafood Familys problem regarding Pediculosis has a high modifiability status as reflected by the following criteria below. > The problem is severe since all but one have the presence of the said health deficit
Severity Duration Current Management High -risk Group 1/3 x 1 0.33
>The problem has existed for a long time ago, this has already existed since the second eldest is still young as verbalized by Mommy Shrimp
>The family has a current management on the problem this is through physical means, "ginagamitan ko sila ng suyod" (I used a specialized comb as treatment) as verbalized by Mommy Shrimp upon interview.
> The children and even Mommy Shrimp were already been affected by the condition. The family has already viewed this as a problem, but perceived as not needing immediate action as verbalized by the mother: pagka-may oras lang ako, sinusuyudan ko sila(when I only have
4. Salience of the problem
1/2 x 1
.5
the luxury of time, I tend to their problem by using a specialized comb for the lice.) Total Score 2.83
Problem # 6: Health Threat: Poor Home Condition: Poor Toilet Facility
CRITERIA 1. Nature of the Problem Health deficit3 Health threat2 Foreseeable Crisis 1
COMPUTATION SCORE 2/3 x 1 0.67 The
JUSTIFICATION problem is
characterized by health threat because the toilet facility exposes the family in acquiring different infectious diseases. Dirty toilet can attract flies that can transfer pathogenic microorganisms food of the family. to the
2. Modifiability of the condition/problem Easily modifiable-2 Partiallymodifiable-1 Not modifiable-0
1/2 x2
The problem is partially modifiable because: Current Knowledge: the family on lacks the
knowledge
importance of having a clean toilet facility.
-Current Knowledge(x) -Family resources (x) -Resouces of the nurse () -Community Resources () Resources nurses: the student nurse are available to share their knowledge related to this problem, ways and techniques in improving their toilet facility and give health teachings about the importance of having a clean toilet. of the family resources: due not toilet. to have financial enough constraints, the family do materials for cleaning the
Resources Community: health Health midwife to the center
of in
the the and provide of
community is present. workers can
health teachings related importance having a clean toilet and the ways and technique about this said problem
Therefore, the problem is partially modifiable because the family dont have enough knowledge on the risk of not having a clean toilet facility. In of they buy in addition, financial cannot complete because problem, afford to materials
cleaning the toilet. But student nurse and health center is present and available to give health teachings.
3. Preventive Potential
1/3 x 1
0.33
The problem has a Low preventive because: Gravity/ severity of the potential
Gravity or seve ity of the problem Duration of the problem Current Management
problem: - the problem is severe doesnt have a clean toilet
Duration of the problem -the problem has been existing for along time
Exposure of any high risk group
current management: the family or lessen to has no the intervention done action
problem because of not having enough materials and lack of time.
Exposure of any high risk group: -The whole family the is affected in the problem especially ones. Therefore, has a the problem preventive young
low
potential because of its severity and duration, the problem existed a slightly long time and yet no management is done because materials. exposure group of is of lack of
knowledge and lack of Moreover, high risk present,
especially the children.
4) Salience A condition or a problem needing immediate attention:2 0/2 x1 0 The family is used to have an improper toilet facility thus, do not existence of the problem. As a result, A condition or a problem not needing immediate attention:1 Not perceived as a problem:0 the family doesnt realize the need for an immediate attention.
TOTAL
Health Threat: IMPROPER GARBAGE DISPOSAL Criteria Nature of the Problem 3 = Health deficit Computation 2/3 x 1 Score 0.67 Justification Improper garbage disposal is a health threat to the family as it predisposes a good breeding ground for vectors of disease such as rodents and insects
2 = Health threat 1 = Foreseeable crisis
which could bring about diseases such as leptospirosis, dengue and the like.
Modifiability of the problem
1/2 x 2
1 FAMILY RESOURCES. The family has physical
Family Resources Community Resources Student Resources Knowledge, Technology and Interventions to manage the problem
resources such as brooms and broomstick. Family members have the capability to clean their house and environment. COMMUNITY RESOURCES. The community has a garbage truck which collects the garbage of the barangay. NURSING RESOURCES. The Student nurses could give the family health teachings regarding proper garbage disposal such as segregating their trash to biodegradable and non-biodegradable. KNOWLEDGE OF THE FAMILY. The family does not have any
current management of the problem as evidenced by the scattered dirt and garbage both outside and inside the house. Preventive Potential 1/3 x 1 0.33 SEVERITY. The problem is severe as Gravity Duration Current Management Presence of High risk groups The problem approximately exists for about more than a year, as mother has verbalized it during the interview. CURRENT MANAGEMENT. The family does not have any current management on the problem. EXPOSURE TO HIGH RISK GROUP. All family members, especially the children, being the high risk group, are exposed to the health problem. evidenced by the scattered dirt and garbage both outside and inside the house. DURATION.
Salience 2 = A serious problem needing immediate attention 1 = A problem not needing immediate attention 0 = Not perceived as a problem
0/2 x 1
0 The family does not perceive Improper garbage disposal facilities as a problem.
Total
Problem # 1: Accident hazards: Pointed / sharp objects improperly kept as a Health Threat
Cues
Analysi s of the problem
Objecti ves
Nursing intervent ions
Rationa le
Method of the family Contact
Resource s Required
Expecte d Outcom e
S> 0
Inability to provide
Short Term: After 23 days of home visits, the family will be able to apply necess ary ways of prevent ing possibl e
1. Discuss with the importan ce of accident hazard s.
1. to avoid any injuries brought about by
Home Visit
Time, effort, knowledg e and
Short Term: After 2-3 days of home visits, the family shall have demonstr ated necessar y ways of preventin g possible accidents and perform
O>
a home environ ment
family the possible Intervie w
skills of the student nurses
> things conducti are seen placed unorgan ized around and even outside the house ve health mainten ance due to failure to benefits investme nt home improve in to
awarenes ignoran ce.
Observ ation Time, cooperatio n,
2. Instruct and demonstr ate with the family the proper 2. For the safety measur es and to
the floor see
complianc e, participati on and understan ding of the
such as ment
knives, cooking utensils, bottles, wires things.
and lack acciden handling of knowled ge preventi measure s. ts and of measur es in prevent ing ts and of the knives or any pointed perform keeping
prevent the injuries such as cuts.
family
measure s in preventin
Health teachings
g accidents wounds such as
and old ve
acciden object in safe wounds place. such as keeping pointed objects out of reach of and removi ng t hazard both outside and inside the house. 4. Encourag 3. Remove the possible accident such as the scattered inside and outside the house. 3. to prevent occurre nce of injury and promote safety.
Therapeut ic communic
keeping pointed objects reach of the children and removing accident hazard both inside and outside the house.
> presenc e knives and wires near the reach of the children. of
ation skills out of
children hazard
acciden things
Long Term: After 2 weeks of
e family Long term: After 2 weeks of home visits the family will maintai n the things in proper order as evidenc e by the knives and es properl y kept. 6. Instruct to keep objects not within the childrens reach. 5. Provide health teachings on the possible effect of the problem. members interventi ons to solve the problem.
4. To encoura
home visits the family shall have maintain ed things in proper order as evidence d by knives and
to identify ge Particip ation of the family member s.
5. To encoura ge the family to adhere the propose d solution identifie d problem .
medicine s are properly kept.
the family for the
medicin sharp
6. To help the
children 7. Encourag e to keep sharp objects in drawer. 7. For 8. Advise to fix those wires in their proper places. 8. To avoid 9. Encourag e keeping sharp objects out of reach of the children. 9. To help 10. them avoid accident s like cuts on each family member s. them not to get the sharp objects. to prevent any accident s.
Advice not to place sharp objects near the edge.
looking sharp objects.
the family for the
10. To avoid sharp objects from falling leading to cuts.
Problem #2: Poor personal hygiene: Health threat ANALY SIS OF THE PROBL EM > inability to recogniz e the METH OD OF FAMIL Y CONT ACT > Home visit RESOU RCES REQUIR ED EXPECT ED OUTCO ME
CUE S
OBJECT IVES
NURSING INTERVEN TIONS
RATIONA LE
s> o> child ren
> short term: After 3hours of
>assess the > serves hygienic practices of the family as a basis for planning and
> cooperati on of the family
> short term: After 3hours
were seen with long and dirty finge r nails and toe nails >we ars dirty ng
presenc e of a problem due to: a. ignoranc e of facts or lack of knowled ge
nursing interventi ons the family will be able to show knowledg e and understa nd the importan ce of healthy lifestyle and appreciat e the importan ce of good personal hygiene as evidence by ability to perform and ate the > explain the importance > ask the client to take a bath on a regular basis and demonstrat e proper bathing > encourage the family to wash hands frequently and teach proper hand washing
implement ing nursing interventio ns > time, effort and persever ance of the > to minimize or prevent the occurrenc e of possible illness > knowledg e about good personal hygiene student nurses
of nursing interventi ons the family shall have showed knowled ge and understo od the importan ce of healthy lifestyle and apprecia ted the importan
> inability decision s with respect to taking appropri ate health action due to: a. lack of knowled ge
clothi to make
> this is to keep their skin clean and to promote comfort
ce of good personal hygiene as evidence d by ability to performe d and demonst
demonstr of wearing
health > inability to provide a home environ ment which is conduci ve to health mainten ance and develop ment due to: a. lack of knowled ge of importa nce of hygiene and sanitatio n >long term: After 3 home visits the family will be demonstr ate lifestyle changes in their personal hygiene as evidence by having short clean nails, teaching s and interventi ons to be provided
slippers
> to prevent transmissi on of pathogeni c
rated the health teaching s provided
> teach and explain to the family the importance and how to maintain short clean nails
microorga nisms >long term: > to prevent inhabitatio n of microorga nism thereby preventing the occurrenc e of disease After 3 home visits the family shall have demonst rated lifestyle changes in their personal hygiene as evidence d by having short clean nails, wearing of clean clothes,
personal able to
wearing of clean clothes,
Problem #3 Inadequate ventilation as a health threat.
Assess ment
Analysis of the Problem
Objective s
Nursing Intervent ions
Rationa le
Method of Family Contact
Resource s Required Family Resource s: >Time and effort of the family.
Expected Outcome /s Short Term: The family shall have verbalize d understan ding on the importan
S>
Inability to provide
Short Term: After 1 home visit, the family will verbalize understan ding on the importan ce of having adequat e ventilatio n and
1. Assess the familys total window area
1. To have baselin e data and determi ne how much work is neede d in order to solve or reduce the proble
>Home visit
O>
a home environm ent
>With provision s of health teaching s.
> >There is no window which is blocke d by hangin g clothes
conduciv e to health mainten ance and personal develop ment due to lack of skill in
>Familys >Observ ation full coopera tion and active participa tion.
ce of having adequat e ventilatio n and lighting
carrying out
lighting inside 2. Educate the family Long Term: After 4 home visits, the family will exhibit behaviors and practices that promote adequat e ventilatio n inside their home. 3. Encoura ge family to keep door open. regardin g the importa nce of having adequa te ventilati on inside their home.
m. >Openn ess of family for change. 2. The family will have an idea on the benefit s of having adequ ate lighting and ventilati on. StudentNurse Resource s: >Knowle dge regardin g the importan ce of having 3. Will help increas e and improv e the circulat >Knowle proper lighting and ventilatio n. >Willingn ess to comply.
inside their house.
measures their to improve home environm ent and inadequ ate family resources , specifical ly financial constrain ts or limited financial resources . house.
Long Term: The family shall have exhibited behaviors and practices that promoted adequat e ventilatio n inside their home.
ion of air inside the house. At the same time, this will also 4. Educate the family regardin g the risks involving not having adequa te lighting and ventilati on in their home. 4. The family will increas e lighting during dayligh t so sunlight can pass through , therefor e illumina ting the house.
dge regardin g the risk factors involved in having inadequ ate ventilatio n and lighting.
>Knowle dge regardin g the ideal size of windows to promote adequat e ventilatio n.
Commu nity Resource
know the risk factors involvin g not having adequ ate lighting and ventilati on inside the house.
s: >Health teaching s from the health center regardin g the importan ce of maintaini ng a healthy home environm ent.
Problem # 4: Presence of breeding place of insects and rodents ANALY SIS OF THE PROBL EM > inability to METH OD OF RESOU FAMIL RCES Y REQUIR ED CONT ACT > home visit > cooperat ion of EXPECT ED OUTCO ME > short term: After
CUES
OBJECT IVES
NURSING INTERVEN TIONS
RATIO NALE
s> -
> short term: After
> provide health teachings
> to prevent occurre
o> the familys house shows: > presenc e of contami nated water in the area which serves as a breedin g site for insects which may pose threat to the family > presenc e of insects, rodents and mosquit
provide a home environ ment which is conduci ve to health mainten ance and l develop ment due to: a. lack of knowled ge of importa nce of hygiene and sanitati on
1hour of nursing interventi ons, the family will be able to demonstr ate understa nding of ences of having rodents and
regarding diseases brought about by insects and rodents
nce of disease s brought
the family
1hour of nursing interventi ons, the
presence of about the presenc e of insects > demonstrat e to the family ways on how to maintain clean > to effective ly e the presenc rodents and insects > remove or mobilize > breedin g places must be evaluate d so as and rodents
>knowle dge, time, effort and motivatio n of the student nurses
family shall have demonstr ated understa nding of consequ ences of having rodents and insects in environm ent as evidence d by having covered water storage facility
persona consequ
insects in environmen minimiz environm t like ent as evidence by covering storage of water always kitchen clean
keeping the e of
>long
stagnant water and places of possible breeding
b. lack term: of skills After 4 in carrying home out
> long term:
oes in their house > open spaces for possible entry of rodents
measur es to improve home environ ment
visits, the places of family will be able to demonstr ate ways on how to minimize or eradicate the presence of rodents and insects by maintaini ng a clean ngs > use sprays to reduce and eliminate presence of insects and > plug open spaces for possible entry of rodents insects and rodents
to prevent multiplic ation
After 4 home visits, the family shall have demonstr ated ways on how minimize or eradicate the presence of rodents and insects by maintaini ng a clean surroundi ngs
> to prevent the entry of insects and rodents inside the house
> to prevent growth and multiplic ation of rodents and insects
surroundi rodents > always keep water storage covered
> to eliminat e breedin g site for the growth of insects and rodents
PROBLEM #5: PRESENCE OF PEDICULOSIS AS A HEALTH DEFICIT CUES ANALYSI S OF THE PROBLE M OBJEC TIVES NURSING INTERVE NTIONS METH RESOU OD RCES OF FAMI LY CONT ACT >To >Hom >The make e Visit familys the cooperat family ion. aware of >The the knowled nature of ge and the skills of problem, the its student existenc nurses. e and its >The probable time and cause. effort of the >To student RATION ALE EXPEC TED OUTCO ME
S> alam ko my kuto sila kaso ayaw naman nilang paalis masaki t daw O>pres ence of nits
>Inability to make decisions with respect to taking appropriat e health action due to lack or inadequat e knowledge /insight as to alternative
Short Term: After 4 hours of home visit, the family will be able to verbaliz e understa nding regardin g the nature
>Discuss to the family regarding the existence of the health deficit.
>Discuss about the possible
Short Term: After 4 hours of home visit, the family verbaliz ed understa nding regardin g the nature of the problem
and lice on some membe rs of the family.
courses of action open to them.
of the problem and methods , different ways to manage and resolve the problem or conditio n. Long Term: After 4 days of home visits, the family will be able to apply the proper measure s to be free from pediculo sis.
effects of having pediculosis .
>Discuss about the different ways and alternative s on how to manage and resolve the presence of pediculosis .
make the family aware of the probable consequ ences of having pediculo sis and increase their interest to manage the problem. >To make the family aware of the different measure s they can practice, apply and follow to manage the condition especiall y about the possible alternati ves.
nurses.
and methods , different ways to manage and resolve the problem or conditio n. Long Term: After 4 days of home visits, the family applied the proper measure s to be free from pediculo sis.
Problem #6: Health Threat: Poor Home Condition: Poor Toilet facility
METO HDS CUE S ANALYS IS OBJECTI VES NURSING INTERVEN TION RATION ALE OF FAMIL Y CONTA CT S > Inability to O> -the toilet bowl is dirty insid e and outsi de. -the is seen dirty -it has slight provide home environ ment, which is conduciv e to health mainten ance and personal ment due to inadequ ate resource s Long Short term: After 1 day of home visit, the family will understa nd the e of having a good toilet in terms of sanitation . teach and show to the family the For the family to have an Provide with health teachings on how to improve condition. For the family to identify ways on how to improve their sanity condition accepta nce and ce of the family regardin g keeping Long Term: importanc the family explain to the family the importance of having a good toilet facility to facilitate complian ce of the family Home Visit Health teaching s from the student nurses regardin g how to keep the toilet clean Short term: The family shall have known the importanc e of having a good toilet facility especially of sanitation RESOU RCE REQUIR ED EVALUA TION
place develop
especially their sanity
complian in terms
ly foul odor -the floor is wet
specifica lly financial problem and lack of knowled ge about the importan ce of having a clean toilet facility.
term: After 23days of home visits, the family will be able to keep the toilet facility clean.
proper way idea on to clean the toilet how to keep their toilet clean
the toilet facility clean
The family shall have kept the toilet
Material s needed in cleaning the toilet like brush, soap,
clean.
Problem #7 : Improper garbage disposal as a health threat
Assess ment
Analysi s of the Proble m
Objecti ves
Nursing Interven tions
Rational e
Method of Family Contact
Resourc es Required
Expecte d Outcom e/s
S: Manugs e basura keng kilwal ampong keng kilub kasi deng anak kun ating basurah parati lang mamyal kilwala as verbaliz ed Mommy Shrimp
Inability to a home environ ment which is e to ali health ance and a personal develop ment failure to see benefits investm ent in home ment improve ment and lack by environ kami provide
Short Term: After a full day of home visit, the family verbaliz e importa nce of clean surroun ding and effects of poor environ ment sanitatio n to health.
1. Assess home condition of the family.
1. To have a baseline data and to know focus of interventi ons. 2. To
>Home visits with provisio n of health teaching s
Family Resourc es: >Openne ss to new n familys trust and involvem ent in nursing interventi ons.
ShortTerm: The family shall verbalize d importan ce of having a clean surround ing and effect of poor environ ment sanitatio n to health. LongTerm: The family shall have demonst rated
informatio have
conduciv will 2. Assess familys ge on the existenc e of the problem.
determin e appropria te manage ment and level of competen ce both for communi cation and intervenin g skills. >Observ ation >Intervie w
da balu mainten
having a knowled
>Time, effort, and cooperati on of the family. >Willingn ess to comply. >Manpow
an tsaka due to
ung king of
3. Discuss Long Term: After the 4 home the importan ce of good 3. To stimulate the initiative of the
er. StudentNurse Resourc es:
O: >Trash
of/inade quate
environm family to
inside and outside of the home > Presenc e of flies inside and outside the house.
knowled ge of importan ce of hygiene and sanitatio n.
visits, the family will demons trate in behavio r such as their surroun dings regularl y, ing a good environ ment conduci ve for living.
ental condition s as well as the
take action in order to modify
>Proficie ncy in >Good communi cation skills and patience. >Time and effort of the studentnurses. >Teachin gs on the importanc e, effects of proper garbage disposal. Commun ity Resourc es: >There is a communit y garbage
changes in behavior such as cleaning the surround ings regularly , maintaini ng a good environ ment conduciv e for living.
effects of unsatisfyi an untidy ng ent. ental condition. 4. ge member s of the family to 4. To minimize dirt from being scattered which are source of infection and to keep an environm ental condition conduciv e for health of family. 5. To 5. promote
changes environm environm
cleaning Encoura
clean the possible ings and dispose garbage properly.
maintain surround
Encoura ge member s of the family to separate the biodegrada ble form non biodegrada ble trash
proper waste disposal and to implemen t segregati on that will help the family both in garbage disposal and lessening of clutter. 6. To
truck that routinely collects garbage of the communit y househol ds.
6. Instruct the family to use properly.
help in maintaini ng a cleaner and wider work and recreatio n.
dumpsite area for
7. Encoura ge the family to 7. To prevent formation
cover the of garbage pit. breeding place for flies, mosquito es, rats and other pests.
SOCIO-GRAPH
Legend:
Student Nurses
Family
Two way relationship
(Group) Interaction : family-nurse
Health teachings
Problems
Success / improvement
Documentation
Socio Graph
Day 1:
During the first visit, the group introduced themselves to the family by greeting, Good Afternoon po The family responded back with a smile and greeted the group without any hesitation. The group introduced themselves. It is also in this day that they asked the approval of the family and if they can do the assessment. The group also gathered the demographic data of the family, includes full name of each member of the family, the age, birth date, etc. The group also gathered other data like family beliefs and lifestyle.
The group monitored the vital signs of each member of the family who were present during the first home visit. For the mother, the group provided her health teachings related to her high blood pressure. While interviewing, the group observed the vicinity of the house. They measured the house, the windows, and doors. Data in accomplishing the family coping index are also gathered.
Day 2:
During the second day of visit, the group did the physical assessment of the members of the family, including the cranial nerves. They also gathered data about the past and present illnesses of each member of the family and how they manage it. They also observed the environment condition. The group also asked some information: source of food, water supply, transportations, and other socio-economic, cultural, and environmental factors. Problems were also identified by the group. They also did their documentation during the day.
Day 3:
On the third visit, the group monitored the problems in the family, the group observed the vicinity of house. They observed that there are problem in their sanitation. This includes their toilet facility. The group provided health teachings related to the identified problems of the family. They also assessed if there is an improvement on the problems that were identified during the 2nd home visits and they had observed the improvements on the family.
Day 4: During the fourth day of visit, the group did their final physical assessment of the members of the family. The group provided health teachings related to the identified problems of the family. And reminded the family to continue what they taught during the
previous home visits. The group also gathered data for their final Family coping index. They also observed more improvements.
VII. FAMILY COPING INDEX
INITIAL CATEGORY 1 3
FINAL EVALUATION 5
5 1 3
Initial: 1. Physical Independence. Some members of the family has poor hygiene. The mother takes good care of each family member
Final: After the Groups Final Home visits, >Concerned with the ability to move about, to get out of bed, to take care of daily grooming, walking, etc. the familys physical independence has progressed through the health Teachings of the Student Nurses. The familys capabilities to handle the problem have improved. The family was able to provide partially the needed attention of their children. Initial: 2. Therapeutic Competence. The Family is taking Vitamin C daily, and tempra for the fever of Maggie.But when the group asked them the purpose of the vitamins, >Includes all of the procedures and treatments prescribed for the care of illnesses such as giving medications using appliances, Final: The Family now is able to demonstrate that they can carry they dont really know it.
dressings, relaxations, etc.
out the prescribed procedures with basic understanding at the medication usually taken through the efforts of the student nurses in Health Teachings.
3. Knowledge of health condition.
Initial: They are familiarizing to some diseases but they dont have any information on what that diseases is all about.
>Concerned with the particular health condition there is the occasion of care.
Final: The family knows some facts and scientific based home medication to apply when a family member has for example cough and colds. The mother would increase the fluid intake of the sick family member. And also the mother will
do the cleanliness if the environment.
4. Application of Principles of Personal Hygiene.
Initial: Some of the Family member lacks of sleep, especially Mommy spongebob. He only sleep 5 hours. The Family eats 5 time a day: 3 meals and 2 snacks. They usually eats fish, fried foods, and less vegetable.
>Concerned with family action in relation to maintaining family nutrition, securing adequate rest and relaxation for family members, carrying out accepted preventive measures.
Final: After giving the various Teachings, encouragement of sleeping early, taking lots of vegetables and also increasing water intake. The families started eating vegetables and minimized eating of fried foods.
5. Health Attitudes.
Initial: At the groups initial visit, the
>Concerned with the
familys health attitude was poor
way the family feels about health care in general, including preventive service, care of illnesses, and public health measures.
because they seldom visit the Heath center for the check-ups. With regards to their environment, it is considered as poor due to presence of breeding places for rodents and insect which is one of the major source or carrier of disease.
Final: After explaining to Mommy Spongebob and Mommy Marj some health information, the family recognized some of the important points the group has given when giving care each family member. the group provided health teachings that could possible enhance the familys health attitudes.
Initial: 6. Emotional Competence. The family can handle their problems, when Mommy SpongeBob and Daddy Patrick has >Something to do with the maturity and an argument they give space and time for each other to think and to
integrity, which the members of the family are able to meet the usual stresses and problem of life.
be Calm. Final: Family members still have a harmonious relationship with each other. Mommy SpongeBob and Mommy Marj was able to finish their job and chores in time and yet she still attend the needs of her children. Initial:
7. Family Living.
At the groups initial visit, Mommy spongebob is the one who took good care of the children of Mommy Marj. She has a close
>Concerned with the interpersonal relationship between family members. The degree of respect an affection they show for one another, the ways is which they manage the budget.
relationship with her son and children of her sister, Mommy Marj slightly lacks time for her children because she is always at work. Mommy Spongebob and Mommy marj are the ones who decide and do the budgeting for the household. The relationship of the families was usually good. The families are at most happy and enjoy their house as a home.
Final:
After providing some Health teachings to the Family especially to the health of the family regarding the proper discipline of their children. The family also learned how to maximize their time and use it wisely. 8. Physical Environment
Initial: The place they settled to live in has poor environment. The house
>Concerned with the home, the community and work environment as it affects family health.
is disorganized; materials are not in their proper places. There are lots of breeding places for rodents and roaches. The garbage is exposed, and the drainage system is not functioning as water is stagnant. They do have their own toilet facility for their household but it is rather unsanitary.
The family did minimal changes with their environment, it was not sufficient to meet a satisfying result because of their lack of resources or they cannot really do anything or enough about the said problem.
9. Use of Community Resources.
Initial: The family has a mobile phone to call some help when needed and also the community has a Health center.
>Includes degree of the familys use and awareness of the available community facilities for health education and welfare.
Final: Health Teachings were given at the final visits, it is more better to utilize what the community has to offer. Especially for just simple cough and colds and also fever. The student nurses told the family that they can avail free medicines in the health center.

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Develop self-reliance in managing good health.

Activities of daily living Nutritional status

Vital signs: T- 36.8 C P- 78 bpm R- 21 cpm BP- 110/80 mmHg

Heart Regular rhythm of apical pulse was noted upon auscultation.

CN III Oculomotor Motor

Function: Extraocular movements, moves eyeball

whispered words. Client must be able to maintain upright posture.

CN IX Glossopharyngeal Sensory and Motor

Function: swallowing and gag reflex

Function: Sensory of pharynx and larynx, swallowing,

to speak clearly and without difficulty. Client must

vocal cord movement and for speaking

the client to swallow.

be able to swallow without difficulty.

able to swallow without difficulty.

Function: head movement, shrugging of shoulders

Body Mass Index (BMI) =

ACTIVITES OF DAILY LIVING

PHYSICAL ASSESSMENT Vital signs: T- 36.6 C P- 75 bpm R- 17 bpm

CN II Optic Sensory Function: Visual and Visual Fields

To assess clients Oculomotor Nerve

The clients eye must

CN III Oculomotor Motor

eyeball downward, and laterally

penlight with his/her eyes without moving its head.

the object used with coordination. The client

of the object used with coordination.

Function: Sensation of cornea, skin of face, and nasal mucosa

Function: Extraocular movements, moves

fingers without strain or difficulty.

CN VIII Vestibulocochlear Sensory

Function: Hearing and Balance

CN IX Glossopharyngeal Sensory and Motor

Function: swallowing and gag reflex

and shoulders as instructed, with coordination and without difficulty.

and shoulders as instructed, with coordination and without difficulty.

CN XII Hypoglossal Motor

The client must be able to move the tongue without difficulty.

The client was able to move the tongue without difficulty

Body Mass Index (BMI) =

5.Lobster PHYSICAL ASSESSMENT

(Books) at a distance of 14 inches.

CN III Oculomotor Motor

Extraocular movement, specifically moves eyeball downward, and laterally

Function: Sensation of cornea, skin of face, and nasal mucosa

The client must be able to follow The client was

Abducens Nerve instruct the client

Extraocular movements, moves eyeball.

to follow the examiners finger as it moves from side to side.

examiners fingers without strain or difficulty.

able to follow examiners fingers.

CN VIII Vestibulocochlear Sensory

Function: Hearing and Balance

CN IX Glossopharyngeal Sensory and Motor

Function: swallowing and gag reflex

Function: head movement, shrugging of shoulders

The client was able to move head and shoulders as instructed,

instructed, with coordination and without difficulty.

with coordination and without difficulty.

CN XII Hypoglossal Motor

The client must be able to move the tongue without difficulty.