LICEO DE CAGAYAN UNIVERSITY

COLLEGE OF NURSING

FAMILY CARE STUDY

CARMEN, CAGAYAN DE ORO CITY CAGAYAN DE ORO CITY

In partial fulfillment of the Requirements in Related Learning Experience NCM 102 Submitted by: KRISHNA B. BALSARZA GROUP 3, BSN-2A

Submitted to: Mrs. REMEDIOS S. ROLE, RN, MAN

CLINICAL INSTRUCTOR

INTRODUCTION
Community is a body of people having common rights, privileges, or interests, or living in the same place under the same laws and regulations; a group of people sharing common geographic boundaries and common values and interest. Community literally means to give among each other. Community could be defined as a group of people who share gifts which they provide to all. The nature of community health nursing is comprehensive, directed towards the individual, families and the community at large. The community health nurse fulfills a unique role in the community, promoting and protecting the health of the community, whilst using a framework of sustainability. The objective of the study is to help the family to cope with discontinuities in health and threats in such a way to maximize their potential for high level wellness, as well as to promote supportive relationship between people and their physical and social environment. We choose the family of ______________ because their family passed the criteria and willing to participate for the said study. This study is being conducted in the family belong to ____________. The criteria to choose the right family for the study are the following, the family should belong to the poverty line with a salary not exceed 3,000-4,000/month, should have a 0-5 years old child for the application of IMCI and the family who have several health problems or no actual problems but lots of social problems. Every individual has the right to receive good care. To give good care, a nurse must plan to support familys needs, abilities, interests and preferences. Under the law, community health nurse and families are partners in this planning process. If clients get involved in the care planning process, it is almost certain that they will get better care and enjoy a higher quality of life

FAMILY PROFILE
FATHER Name: Position in the family: Birthday: Sex: Educational Attainment: Religion: Nationality:

MOTHER Name : Position in the family: Birth Date : Age : Sex: Civil Status: Address : Citizenship : Occupation : Income : Height : Weight : Religion : Educational Attainment : Immunization: Aida Nonasco Mother May 3, 1965 41 Years Old Female Widow Relocation, Zone 3, Canitoan, CDO Filipino Manicurista 600/month 52 46 kilogram Roman Catholic High School Level (2nd year) No Tetanus Toxoid received since first pregnancy .

SON (1) Name: Age: Birthday: Sex: Educational attainment: Position in the family: Civil status: Religion: Nationality: Occupation: Immunization: Income: SON (2) Name: Age: Birthday: Sex: Educational Attainment: Position in the family: Civil status: Religion: Nationality: Occupation: Immunization: Income: Jordan Nonasco 20 years old January 20, 1987 Male First Year High School 2nd child Single Roman Catholic Filipino Jeepney Drivers assistant Konduktor Incomplete immunization 1000/month Joel Nonasco Jr. 22 years old June 16, 1985 Male High School Graduate Eldest child Single Roman Catholic Filipino Jeepney Drivers assistant Konduktor incomplete immunization 1200/month

DAUGHTER (1) Name: Age: Birthday: Sex: Educational Attainment: Position in the family: Civil status: Religion: Nationality: Occupation: Immunization: DAUGHTER (2) Name: Age: Birthday: Sex: Educational Attainment: Position in the family: Civil status: Religion: Nationality: Occupation: Immunization: Jodame Nonasco 4 years old March 2, 2003 Female none Youngest Child Child Roman Catholic Filipino None Incomplete immunization Jorica Nonasco 12 years old December 10, 1995 Female Elementary level (Grade V) 3rd Child Child Roman Catholic Filipino None Incomplete immunization

There are only 5 members of the family living in one roof because the father is already died. During my visit most of the time, only the mother and the 4 years old child is in the house because her two sons (Jordan and Joel) are working as a konduktor , they usually came home late. The 12 years old child is not available all the time because shes in the school ( Calaanan elementary school) during my visit.

HEALTH HISTORY (ALL MEMBERS)

FATHER (DECEASED) Mr Joel Nonasco Sr. was born on July 22, 1964 through normal delivery but did not received the complete immunization. He only finished High school level, a Roman catholic and a Filipino citizen. He passed away last April 13, 2004 at the age of 40 because of Congestive Heart Failure. As the Mrs. Aida recalled of the incidence, Mr. Joel Nonasco had experienced fatigue but he ignored it because he thought it was just a result of his job (jeepney driver) not until he noticed that there is a swelling in his ankles and legs. Sometimes He experienced shortness of breath when he is doing strenuous activities and when lying flat in bed. He immediately rushed to the hospital and confined for 5 days but unfortunately it was too late since the fluid already accumulated the lungs and liver, even the doctors tried to give him medications bur still there was no changes. Mrs. Aida said that he got his disease from his father who also died due to heart failure. MOTHER Mrs. Aida Nonasco is 41 years old, born on May 3, 1965, weighs 46 kg with a height of 52, widow and a Filipino citizen. According to Aida, she never confined in the hospital because she had not encountered any major health problems aside from fever, cough, cold and fatigue. She gave birth to her four children through normal spontaneous vaginal delivery at home assisted by the trained hilot. During her pregnancies, she never had prenatal check-ups and she has never been injected with tetanus toxoid. When her husband died, she works harder to support her children because at that time her two sons have no work. Even the households are her responsibilities including her two daughters. Since then, she always experienced fatigue, headache, restless, back pain and sometimes difficulty of breathing. He visit the Barangay Health Center, it was found out that she had a hypertension

with a BP of 160/140 mmHg. She was then given with medication but she was not able to continue it because she cant afford to buy the said medication. According to her although it is a serious problem but she prefers to use the money to buy for their foods instead of buying those medications. She also mentioned that their food are always salted fish bagoong and dried fish bulad and also she always drink coffee and soft drinks. As she said, she got this disease from her mother because her mother is also hypertensive. SON (1) The eldest child of Mrs. Aida is named Joel Nonasco, 22 years old, born on January 20, 1987, single, male, Roman Catholic and a Filipino citizen. I was able to gathered data about Jordan only during my fourth visit because most of the time hes not in their house because his job is a jeepney drivers assistant (konduktor). As he mentioned, he never hospitalized before because he just ignored his health problem such as fatigue, cough, headache and difficulty sleeping and he did not receive a complete immunization when he was still young. He just asked his mother on what to do about his common health problems and sometimes their neighbors. If he experienced these symptoms, he just took a rest and drinks some herbal plants such as kalabo. Jordan has no known food and drug allergy and he has a regular pattern of elimination. Jordan is a cigarette smoker, according to him he consumed 1 pack of cigarette per day. He started smoking at the age of 18, he learned smoking from his friends. He also mentioned that if he has a problem he asked his friend to drink alcoholic beverages just to forget his problems financially and emotionally. SON (2) The second child of Mrs Aida Nonasco is named Jordan Nonasco Jr., 18 years old, male , single , born on June 16, 1985 and a Filipino citizen. I was not able to get data from him personally because most of the time his not around during my home visit. According to Mrs. Aida, he delivered Joel normally at home assisted by the trained hilot in the community. According to

her, Joel was not able to receive a complete immunization. Joel was never confined to the hospital since he hasnt encountered any health problems. He usually experiences cough, colds and an ordinary fever. Joel is not a smoker but drink beverages occasionally. He has no known food and drug allergies and has a normal pattern of elimination. DAUGHTER (1) The third child of Mrs. Aida named Jorica Nonasco, 12 years old, born last December 10, 1995, Female, Roman Catholic and Filipino citizen. Jorica was delivered through normal spontaneous delivery at home . During my visit Jorica was always not available because shes studying at Calaanan Elementary school (Grade V). I was able to gather data about her from his mother. According to Mrs. Anita, jorica was not able to receive a complete immunization because shes not particular about immunization because she doesnt know the importance of it. Jorica has no problems with regards to her health according to her mother. DAUGHTER (2) The youngest in the family named Jodame Nonasco, 4 years old, born on March 2, 2003, Female, Roman Catholic and a Filipino citizen. I was able to gather data from her mother since the child was too shy to respond to my questions. According to her mother, Jodame was not able to receive the complete immunization for the same reason. Jodame was born normally at home assisted by the trained hilot. According to her jodame was never confine in the hospital. The common problem that Jodame always complaint are stomach ache, head ache, cough, tootache and fever. She never bring Jodame to the health center because she just gave her with some remedies that would relieve her condition and hesitate to ask help from the health care providers.

ACTUAL IMPLEMENTATION
1ST Visit My first visit with my chosen family was on January 17, 2006. I was able to greet the family and introduced my self, what school I came from and ask them if they will allow me to choose their family for my care study. Mrs. Aida gave me a permission to conduct the said study and explained to her what are the purpose and objective of the said study to establish rapport to them. I also informed them the duration of the study which is every Wednesday, Thursday and Friday. Since they allowed me to choose their family for the study I already gathered some data related to the profile and common problems encountered by each member of the family. I also took the vital signs of Mrs. Aida and her 4 years old child since the other two members were not there. Mrs. Aida Nonasco Blood Pressure: Respiratory Rate: Jodame Nonasco Pulse Rate: 62 beats/minute Respiratory Rate: 19 breaths/minute 2nd Visit The second visit with the family was on January 18, 2007. When I reached the house I saw Mrs. Aida washing their clothes, I greet them and ask if it is okay to disturb her for 30 minutes. She smile and said yes and I let her take a rest for a minute and took her vital signs. Mrs. Aida always ate foods that would trigger her condition such as salted and dried fish, and most of the time drink coffee and soft drinks. I instructed her to avoid those foods but instead she must eat green leafy vegetables that can be found in their backyard such as malunggay, alugbati and camote tops. I also encouraged her to visit the health center for monitoring of her condition. During my second visit her two sons were not there. temperature: 36.8C 140/120 mmHg 21 breaths/minute Pulse Rate: 86 beats/minute temperature: 36.9C

Mrs. Aida Nonasco Blood Pressure: Respiratory Rate: Jodame Nonasco Pulse Rate: 69 beats/minute Respiratory Rate: 20 breaths/minute 3rd Visit The third home visit was on January 19, 2007. I greet the family and they welcome me in their house and have a conversation and took their vital sign. I have observed that they have an open drainage in front of their house and have many container and galloons for their water. The water in the containers are used for their clothes and bathing while the water in the galloons are used for their drinking. I instructed the family to clean their open drainage everyday and to cover their container. Since they just throw their garbage at the back of their house I encouraged them to burn it or have it segregated from biodegradable and non-biodegradable. I also instructed the family to maintain the cleanliness of their kitchen, table and their bedrooms and have it organize. Mrs. Aida Nonasco Blood Pressure: Respiratory Rate: Jordan Nonasco Blood Pressure: Pulse Rate: breaths/minute Jodame Nonasco Pulse Rate: Respiratory Rate: 67 beats/minute 22 breaths/minute temperature: 36.8C 120/80 mmHg 86 beats/minute temperature: 37.1C Respiratory Rate: 22 130/100 mmHg 20 breaths/minute Pulse Rate: 87 beats/minute temperature: 37.3C temperature: 36.5C 150/120 mmHg 22 breaths/minute Pulse Rate: 80 beats/minute temperature: 37C

4th Visit My fourth visit was on January 26, 2007. I greet the family and took their vital signs. My purpose in this visit is to inform the family about the different health services available in the community rendered by the Department of Health. These services are given to the people in the community for free and I told them also how they can avail for that services. Mrs. Aida doesnt know about it and shes happy that I gave them information about the services. I also teach them what are those basic procedure and its purposes that would help them to manage their health problems that are commonly experience by the family. These procedures such as how to do tepid sponge bath properly and the proper preparation of ORESOL for dehydration/diarrhea and the importance of herbal plants. These procedures are very basic yet this can help to save peoples lives. Mrs. Aida Nonasco Blood Pressure: Respiratory Rate: Joel Nonasco Blood Pressure: Respiratory Rate: Jodame Nonasco Pulse Rate: Respiratory Rate: 5th Visit During my fifth visit last January 31, 2007 the family was not there and their house is close. When I asked their neighbor, they told me that they went to their relatives in Carmen. 72 beats/minute 18 breaths/minute temperature: 36.8C 110/90 mmHg 19 breaths/minute Pulse Rate: 80 beats/minute temperature: 37C 140/120 mmHg 22 breaths/minute Pulse Rate: 85 beats/minute temperature: 38.9C

6th Visit Last February 2, 2007, I had my sixth visit with the family. I greet them and ask why they are not available yesterday and she said they went to their relatives to borrow some money. She said that their income is not enough to support their needs. I gave them some instructions on how to find enough resources that could sustain family needs. I encouraged the family to prioritize needs, to minimize unnecessary spending and to use available resources such as vegetables (malunggay, camote tops and alugbati) in their backyards to minimize budget for foods. During this visit, I informed the family about the schedule of our culminating and microteaching for them to be prepared. Mrs. Aida Nonasco Blood Pressure: Respiratory Rate: Jodame Nonasco Pulse Rate: Respiratory Rate: 7th Visit February 08, 2007 was my 7th and last visit to the family. I informed them that this is my last visit but we still have to see each other during the microteaching and culminating activity. I was able to extend my gratitude to the family for allowing me to choose their family for my case study and for being participative. Im so happy because they said that they learned a lot from me And they will practice all the things that they have learned. Im planning to give something to them as a thanks giving but I decided to give it during the culminating activity. This study has a two way process, they learned something from me and I also learned something from them. Mrs. Aida Nonasco Blood Pressure: Respiratory Rate: 130/110 mmHg 20 breaths/minute Pulse Rate: 86 beats/minute temperature: 38.7C 68 beats/minute 20 breaths/minute temperature: 37C 130/100 mmHg 22 breaths/minute Pulse Rate: 79 beats/minute temperature: 38.9C

FAMILY COPING INDEX

Area 1. Physical Independence ability to move about, get of bed and perform daily activities. 2. Therapeutic Independence includes procedure or treatment prescribed knowledge to condition 3. Knowledge of health condition 4. Application of Principles of General hygiene family nutrition and 6 adequate rest and relaxation. 1 No appropriate medical treatment on her condition. Poor hygiene, faulty eating habits, garbage not properly thrown in right place. (scattered at the back of their house ) Unclean kitchen and unwashed plates that leads to the presence of flies all over their area. Inadequate living space, house unclean, poor ventilation. Incomplete immunization of the children. 1 1 3 Rate Justification The family partially provides needs to its members. Mother fails to give sufficient care to herself and other members of the family Prefers to use unrecognized herbal medication to treat existing disease instead of consulting to physician. Listen to hearsay instead of consulting professional medical help. Knowledge deficit on the nature, signs and symptoms, preventive and therapeutic measures of the disease (Hypertension)

5. Health attitude the way the family feels about heath care in general. 6. Emotional Competence 1

Has no confidence in doctors. Superstitious rites and belief in illnesses. Inappropriate assumptions pertaining to health condition. Does not give priority for immediate of her

 maturity and integrity with which the members of the family are able to meet usual stresses and problems of life and to plan for a happy and fruitful living . 7. Family Living how well the family members get along with another in an interpersonal relationship. 8. Physical Environment home, community and the work environment. 9. Use of Community Facilities degree of the family use and awareness of available community facilities for health education and welfare to physician Legend: 5 Complete competence 3 Moderate Competence 1 No competence 1 Resist health care management. Use of unrecognized herbal medication upon encouragement of neighbor 1 Poor ventilation, open drainage, scattered garbage at the back of their house, disorganized and dirty kitchen. 3 The family can get along with but sometimes there are problems that they need to talk about. medical condition. Shes lack of emotional support since her husband was died.

HOME AND ENVIRONMENT

HOUSING Family Nonasco recently residing at Relocation Zone 3, Canitoan Cagayan de Oro City. There are could be considered as a squatter area because they just

relocate for some reasons. The house is owned by the government and they have pay 1 peso daily and there house is made of wood. They only have 1 room used for sleeping. They used firewood as their cooking facility and located at the inside their house. Kitchen is cluttered, usually with the presence of unwashed dishes. Foods are placed on the dinning table, left over are not covered and not properly kept. As to their lighting facilities they used lampara. As I have assessed, their home is not organized and the space is inadequate for the member of the family at the same time, rest is inadequate due to confining space. WATER SYSTEM The only problem in their area is the water supply. They have poor water supply because they still need to fetch water in a far area that is why the Nonasco family is using clean covered tanks as a container for their drinking water. As I have assessed, most of the people living in that area are utilizing the same water supply as to the Nonasco family. Theyre only fortunate enough when it rain because they will have extra water supply to be used. TOILET When I assessed their toilet, I have noticed that they are using the pouring system in which they will just pour water after using the bowel. It is located outside their house at a distance of 5 meters. It is a public CR but they dont need to pay every time they used it.

SANITARY CONDITION They disposed their garbage at the back of their house and they did not practicing proper waste segregation. They also have an open drainage in front of

their house and according to Mrs. Aida, they clean it just once a week. They dont have a pet inside their house and they dont have any domestic animals. KIND OF NEIGHBORHOOD The neighborhood is composed mostly of low- income families. A few of these families are friendly and show concern for one another especially when there is a problem among them.

EVALUATION
The family Nonasco needs to cooperate with therapeutic changes to help the condition of the entire family. Understanding the disease condition

(hypertension) and the importance of proper management should be one of the priorities the family must continually maintain and must be on guard of. Since environmental factor is one of the problem in the family, extra measures should be practiced like cleaning the house and its surroundings. . it is advisable that the surrounding should be kept clean, proper waste disposal should observed not just for the family but, as well, for the whole community. Diet should be strictly monitored also like avoiding salted and dried fish and avoid drinking soft drinks and coffee. It is very important for them to eat green leafy vegetables since they can get this in there small garden. Self discipline would help Mrs. Aida to control her blood pressure such as diet control, medications and the importance of visiting the health centers for monitoring of her condition.

NAME: MRS. AIDA NONASCO Vital signs: Pulse: 105 bpm BP: 100/60 mmHg Temp: 37.6C Resp. 25cpm

DATE: JANUARY 17, 2007

INSTRUCTIONS: Place an [X] in the area of abnormality. Comment at the space provided. Indicate the location of the problem in the figure using [X].

EENT: [ ] pain [ ] reddened [ ] impaired vision [ ] drainage [ ] gums [ ] hard of hearing [ ] deaf [ ] burning [ ] edema [ ] assess eyes, ears, nose [ ] throat for abnormality [ ] no problem RESPIRATION [ ] asymmetric [ ] tachypnea [ ] barrel chest [ ] apnea [ ] rales [ ] cough [ ] bradypnea [ ] sputum [ ] orthopnea [ ] pain [ ] shallow [ ] labored [ ] cyanotic [ ] ronchi [ ] wheezing [ ] diminished [ ] dyspnea [ ] lesion of teeth

_______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ ______________

[ ] asses resp. rate, rhythm, pulse blood [ ] breath sounds, comfort [ ] no problem GASTROINTESTINAL TRACT [ ] Obese [ ] dysphagia [ ] distention [ ] mass [ ] rigidity [ ] pain [ ] no problem

[ ] assess abdomen, bowel habits, swallowing [ ] bowel sounds, comfort GENITO-URINARY AND GYNE [ ] pain [ ] Urine [ ] color [ ] vaginal bleeding [ ] hematuria [ ] discharge [ ] nocturia [ ] assess urine frequency, control, color, odor, [ ] comfort, gyne bleeding [ ] discharge [ ] no problem NEURO [ ] paralysis [ ] stuporous [ ] unsteady [ ] seizures [ ] lethargic [ ] comatose [ ] vertigo [ ] confused [ ] vision [ ] grip [ ] tremors

[ ] assess motor, function, sensation, LOC, strength [ ] grip, gait, coordination, speech [ ] no problem MUSCULOSKELETAL AND SKIN [ ] appliance [ ] stiffness [ ] itching [ ] petechiae [ ] hot [ ] drainage [ ] prosthesis [ ] swelling [ ] lesion [ ] poor turgor [ ] cool [ ] flushed [ ] atrophy [ ] pain [ ] ecchymosis [ ] diaphoretic moist [ ] assess mobility, motion gait, alignment, joint function [ ] skin color, texture, turgor, integrity [ ] no problem

NAME: JODAME NONASCO Vital signs: Pulse: 105 bpm BP: 100/60 mmHg Temp: 37.6C Resp. 25cpm

DATE: JANUARY 17, 2007

INSTRUCTIONS: Place an [X] in the area of abnormality. Comment at the space provided. Indicate the location of the problem in the figure using [X].

EENT: [ ] pain [ ] reddened [ ] impaired vision [ ] drainage [ ] gums [ ] hard of hearing [ ] deaf [ ] burning [ ] edema [ ] assess eyes, ears, nose [ ] throat for abnormality [ ] no problem RESPIRATION [ ] asymmetric [ ] tachypnea [ ] barrel chest [ ] apnea [ ] rales [ ] cough [ ] bradypnea [ ] sputum [ ] orthopnea [ ] pain [ ] shallow [ ] labored [ ] cyanotic [ ] ronchi [ ] wheezing [ ] diminished [ ] dyspnea [ ] lesion of teeth

_______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________
DATE: JANUARY 19, 2007

[ ] asses resp. rate, rhythm, pulse blood [ ] breath sounds, comfort [ ] no problem GASTROINTESTINAL TRACT [ ] Obese [ ] dysphagia [ ] distention [ ] mass [ ] rigidity [ ] pain [ ] no problem

[ ] assess abdomen, bowel habits, swallowing [ ] bowel sounds, comfort GENITO-URINARY AND GYNE [ ] pain [ ] Urine [ ] color [ ] vaginal bleeding [ ] hematuria [ ] discharge [ ] nocturia [ ] assess urine frequency, control, color, odor, [ ] comfort, gyne bleeding [ ] discharge [ ] no problem NEURO [ ] paralysis [ ] stuporous [ ] unsteady [ ] seizures [ ] lethargic [ ] comatose [ ] vertigo [ ] confused [ ] vision [ ] grip [ ] tremors

[ ] assess motor, function, sensation, LOC, strength [ ] grip, gait, coordination, speech [ ] no problem MUSCULOSKELETAL AND SKIN [ ] appliance [ ] stiffness [ ] itching [ ] petechiae [ ] hot [ ] drainage [ ] prosthesis [ ] swelling [ ] lesion [ ] poor turgor [ ] cool [ ] flushed [ ] atrophy [ ] pain [ ] ecchymosis [ ] diaphoretic moist [ ] assess mobility, motion gait, alignment, joint function [ ] skin color, texture, turgor, integrity [ ] no problem

NAME: JORDAN NONASCO Vital signs: Pulse: 105 bpm BP: 100/60 mmHg Temp: 37.6C Resp. 25cpm

INSTRUCTIONS: Place an [X] in the area of abnormality. Comment at the space provided. Indicate the location of the problem in the figure using [X]. EENT:

[ ] pain [ ] reddened [ ] impaired vision [ ] drainage [ ] gums [ ] hard of hearing [ ] deaf [ ] burning [ ] edema [ ] assess eyes, ears, nose [ ] throat for abnormality [ ] no problem RESPIRATION [ ] asymmetric [ ] tachypnea [ ] barrel chest [ ] apnea [ ] rales [ ] cough [ ] bradypnea [ ] sputum [ ] orthopnea [ ] pain [ ] shallow [ ] labored [ ] cyanotic [ ] ronchi [ ] wheezing [ ] diminished [ ] dyspnea [ ] lesion of teeth

_______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ ______________
DATE: JANUARY 26, 2007

[ ] asses resp. rate, rhythm, pulse blood [ ] breath sounds, comfort [ ] no problem GASTROINTESTINAL TRACT [ ] Obese [ ] dysphagia [ ] distention [ ] mass [ ] rigidity [ ] pain [ ] no problem

[ ] assess abdomen, bowel habits, swallowing [ ] bowel sounds, comfort GENITO-URINARY AND GYNE [ ] pain [ ] Urine [ ] color [ ] vaginal bleeding [ ] hematuria [ ] discharge [ ] nocturia [ ] assess urine frequency, control, color, odor, [ ] comfort, gyne bleeding [ ] discharge [ ] no problem NEURO [ ] paralysis [ ] stuporous [ ] unsteady [ ] seizures [ ] lethargic [ ] comatose [ ] vertigo [ ] confused [ ] vision [ ] grip [ ] tremors

[ ] assess motor, function, sensation, LOC, strength [ ] grip, gait, coordination, speech [ ] no problem MUSCULOSKELETAL AND SKIN [ ] appliance [ ] stiffness [ ] itching [ ] petechiae [ ] hot [ ] drainage [ ] prosthesis [ ] swelling [ ] lesion [ ] poor turgor [ ] cool [ ] flushed [ ] atrophy [ ] pain [ ] ecchymosis [ ] diaphoretic moist [ ] assess mobility, motion gait, alignment, joint function [ ] skin color, texture, turgor, integrity [ ] no problem NAME: JOEL NONASCO Vital signs: Pulse: 105 bpm BP: 100/60 mmHg Temp: 37.6C Resp. 25cpm INSTRUCTIONS: Place an [X] in the area of abnormality. Comment at the space provided. Indicate the location of the problem in the figure using [X]. EENT: [ ] pain [ ] reddened [ ] impaired vision [ ] drainage [ ] gums [ ] hard of hearing [ ] deaf

_______________

[ ] burning [ ] edema [ ] assess eyes, ears, nose

[ ] lesion of teeth

_______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ ______________

[ ] throat for abnormality [ ] no problem RESPIRATION [ ] asymmetric [ ] tachypnea [ ] barrel chest [ ] apnea [ ] rales [ ] cough [ ] bradypnea [ ] sputum [ ] orthopnea [ ] pain [ ] shallow [ ] labored [ ] cyanotic [ ] ronchi [ ] wheezing [ ] diminished [ ] dyspnea

[ ] asses resp. rate, rhythm, pulse blood [ ] breath sounds, comfort [ ] no problem GASTROINTESTINAL TRACT [ ] Obese [ ] dysphagia [ ] distention [ ] mass [ ] rigidity [ ] pain [ ] no problem

[ ] assess abdomen, bowel habits, swallowing [ ] bowel sounds, comfort GENITO-URINARY AND GYNE [ ] pain [ ] Urine [ ] color [ ] vaginal bleeding [ ] hematuria [ ] discharge [ ] nocturia [ ] assess urine frequency, control, color, odor, [ ] comfort, gyne bleeding [ ] discharge [ ] no problem NEURO [ ] paralysis [ ] stuporous [ ] unsteady [ ] seizures [ ] lethargic [ ] comatose [ ] vertigo [ ] confused [ ] vision [ ] grip [ ] tremors

[ ] assess motor, function, sensation, LOC, strength [ ] grip, gait, coordination, speech [ ] no problem MUSCULOSKELETAL AND SKIN [ ] appliance [ ] stiffness [ ] itching [ ] petechiae [ ] hot [ ] drainage [ ] prosthesis [ ] swelling [ ] lesion [ ] poor turgor [ ] cool [ ] flushed [ ] atrophy [ ] pain [ ] ecchymosis [ ] diaphoretic moist [ ] assess mobility, motion gait, alignment, joint function [ ] skin color, texture, turgor, integrity [ ] no problem