Download - Family Case Analysis GROUP13
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ANGELES UNIVERSITY FOUNDATION
Angeles City
COLLEGE OF NURSING
COMMUNITY HEALTH NURSING:
FAMILY CASE ANALYSIS
An Assessment of Royale Family in Barangay Virgen Delos Remedios
Submitted by:
BSN II-3 GROUP 13A
Corpuz, Mary Ann Joyce I.
Esquejo, Charlaine Marie G.
Quiambao, Katherine Camille D.
Ramos, Quinn Gabriel Allen S.
Submitted to:
Mr. Sammy David, RN
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I. Introduction
In family life, love is the oil that eases friction, the cement that binds
closer together, and the music that brings harmony. Eva Burrows
Family is a network of people that provides love, support, advice, comforting,
their time, and friendship. It consists of a father, mother, children, grandparents, in-laws,
relatives, and friends. Within a family, there are times when conflicts cant be avoided.
The love of each family member is the oil that eases friction. When theres love for one
another, it solves conflicts. With love, the family is able to forgive, understand, and
reconcile. The cement represents the bonding and trials of the family. Even though the
parents are busy from work, they still need to have time for their children. When going
through trials, make sure to overcome it together. The music is the agreement in feeling,
action, ideas, and interests. It means a family that will always be there to listen to all your
problems and give you great advices, a family who accepts you for who you are, accepts
your similarities and differences, and trust. Love, bond, and trust are the most important
thing in a family. Family is the one who will always be there when others walk away,
will guide you through the right paths, will sacrifice anything for the sake of your
happiness and future, will never judge you, will be the first one to care for you when
youre sick, and most of all, family is the one who will love you unconditionally.
Nursing is a dynamic profession. Its scope covers a wide range of body of
knowledge which aims to promote optimum level of functioning and self reliance to
each individual, family, hence, the community. Therefore, nurses especially the
community help nurses have a big role in building a healthy family.
Family is the basic unit of the community, and they are the basic unit of care. It is
first initiated within the family, the care, and provision of our needs. Therefore, the
student nurses recognize that the quality of living of the family has close relationship to
the health of each family member.
Community Health Nursing is a vocational profession which is to give service to
the community with dedication to meet the health needs identified by the members of the
community and the members of the heath providers. It involves a complex process; the
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nurses must consider the resources of the family which would skillfully manipulate by
the nurse together with family to the advantage of each of the member of the family.
Family Case Analysis is a way for student nurses to reach out with the community
people to share knowledge and to alleviate their experienced problems. The student
nurses are given the opportunity to practice their nursing profession and share their
efforts to be an efficient nurse in the future. It is to upright the condition of the chosen
family resident in Barangay Virgen De Los Remedios is the main goal of the student
nurses. It is an opportunity for the student nurses to apply the learned concepts from the
academic to the reality of living depressed people.
They are residents of Barangay Virgen De Los Remedios, who are living in a
depressed area, comprises of not less than five family members, which needs
improvement with regards to their health and living condition. We chose this family
because they are the family willing to participate, chosen by the barangay health worker,
and fits in the criteria set by the group.
A. Objectives
a. Short Term: Student Centered
After 2 days of home visits to Barangay Virgen Delos Remedios, the student nurses will:
Familiarize themselves with the community.
Choose a family for their family case analysis.
Introduce themselves to the family and explain their purposes.
Gather information including demographic, socio-economic, cultural, and
environmental data.
Perform health assessment to each family member.
Identify the existing and potential problems that may affect the familys health
status.
b. Short Term: Client Centered
After 2 days of home visit to Barangay Virgen Delos Remedios, the family will:
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Participate regarding the purpose of home visits.
Provide complete and necessary information of each family member.
Identify health problems present in their family.
c. Long Term: Student Centered
After 6 weeks of home visit to Barangay Virgen Delos Remedios, the student nurses will:
Apply the therapeutic communication skills during the interview and gain the
cooperation of the family.
Understand the health planning and practices of the family.
Prioritize health problems jointly with the family.
Plan nursing interventions to solve identified problems.
Implement nursing interventions and health teachings.
Help the family realize the importance of availing health services.
d. Long Term: Client Centered
After 6 weeks of home visit to Barangay Virgen Delos Remedios, the family will:
Identify health problems present in their family.
Realize the importance of having a good health practices.
Comply with the health teachings rendered by the student nurses.
Maintain an environment that is conducive to health and environment.
B. Entry, Climate of acceptance, first few words
July 2, 2010 Friday
It was our first day to encounter with the family for our family case analysis. The
group rode the jeepney to the community with eager of knowing the family for their
FCA. The group, along with the community health worker, walked around the
community to find their family. Even though the student nurses were sweating, feeling
hot, and tired, they were still able to put a smile on their face. Although it took a while,
the group was able to find their family that fitted the criteria for the family case analysis.
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Good morning po, Taga AUF po kami at naghahanap po kami ng family na
puwedeng ma-adapt para po sa FCA namin. Puwede po ba ang family niyo? the group
said. Ok lng. Halika pasok kayo, Lola replied. Lola grabbed chairs from the inside and
told us to sit down. Salamat po, group said with a smile on their faces. The first
question was Nay, ano po pangalan niyo? It was awkward at first but as time passed by,
the student nurses and Lola Deer got used it. She was very cooperative and willing to
participate in all the things we did.
First home visit:
July 2, 2010 Friday
It was the groups first time to visit their family. They established rapport by
greeting the family, introducing each of the members of the family, and explaining their
purposes for their home visits. The group was working as a team. Two student nurses
from the group were asking questions to Lola Beauty regarding the needed information
data including demographic, socio-cultural, and cultural data of the family. While two
student nurses from the group started to assess the children, Brother Prince and Sister
Princess. After the questions were done being asked, it was Lola Beautys turn to be
assessed by the student nurses. The group made an appropriate appointment for the
assessment of the father and mother.
Second home visit:
July 9, 2010 - Friday
The group conducted their second home visit, at around 8:00 in the morning.
Upon arriving at their house the mother stated pasok kayo., and the group goes inside
the house and started the things that should be done. The children are at the living room
as they play. Fortunately it was the time for us to interview and assess the vital signs and
physical assessment of each of the family members. Asked some questions to fill in some
datas that is essential in making of the family case analysis, also take the measurements
of their house which the group fond out that they have inadequate living space, for the
floor plan, their living room, the size of the windows which they have inadequate
ventilation and size of the bedroom at the same time documented them. The group
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noticed that Sister Princess have a swollen part near her left eye, we think that she is
beaten by a rat or a mosquito. Necessary information is gathered though an informal
interview or question and answer method. All the findings and information gathered were
document properly.
Third home visit:
July 16, 2010 - Friday
On the third home visit, the group was tasked to identify the problems that are
present in their chosen family. First of the problem was identified was the presence of
asthma, Sister Princess experienced attacks of asthma since she was 8 month old as
verbalized by Lola Beauty. The group noticed that the two children were thin and light as
they carry them. Hordeolum or stye was present on both children. The group assisted
Lola Beauty in bathing the children. After bathing them, the group decided to feed the
children of bread and cookies because they did not already have their breakfast that time.
One of the member let Sister Princess sleep after few minutes of taking a bath. Health
teachings where also given to the family about the problems identified by the group.
They discuss all of these problems, whether they are perceived by the family or not. The
group emphasizes that prevention is more important than cure. The family was given
necessary information to improve their health status and maintain their health.
Final home visit:
July 23, 2010 - Friday
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II. Family Constellation
LolaBeauty
49 yearsold
Grandmother Female 2nd Year Highschool
Upon the initialassessment, Lola Beauty
was cooperative,
coherent, and aware to
the place, time andperson. She was wearing
a white shirt and blueshorts, carrying Brother
Prince, and had her hair
tied up. She has presence
of dandruff and has dirtynails.
VS taken as follows:
Temp= 37.3CBP= 155/100 mmHg
PR= 90 bpmRR= 20 bpm
Papa
King
28 years
old
Father Male 1st Year High
school
Upon initial assessment,
Papa King was consciousand oriented as to date,
time and place. He was
wearing long maongshorts, has no top, and
with slippers. His mood
was appropriate to thesituation, he was
cooperative, and hascoordinated movements,straight posture and good
muscle tone.
VS taken as follows:
BP= 130/100 mmHgT= 37.2C/axilla
P= 98 bpm
R= 20 bpm
Mother
Queen
25 years
old
Mother Female High School
graduate
Upon initial assessment,
Mama Queen was
conscious and oriented asto date, time, and place.
She was wearing a t-shirt,
pants, and shoes ready togo to work. Her mood
was appropriate to the
situation, she wascooperative, and
Name AgePosition in
the familyGender
Educational
StatusPresent Health Status
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coordinated movements.
VS taken as follows:BP= 110/90 mmHg
T= 35.8 C/axilla
P= 70 bpm
R= 16 bpmBrotherPrince
4 yearsold
Eldest Child Male Never been toschool
Upon initial assessment,Brother Prince was
wearing a blue shirt and a
blue shorts and a pair of
slippers. He was unableto express himself
through speech. He has
presence of dandruff andhas long, dirty nails. He
is slightly thin.
VS taken as follows:Temp= 35.8C
PR= 103 bpm
RR=29 bpm
Sister
Princess
1 year
and 7
months
Youngest
daughter
Female Never been to
school
Upon initial assessment,
Sister Princess was
wearing a yellowsleeveless shirt and white
shorts and a pair of
slippers. She was unableto express herself through
speech. She is slightlythin and has presence ofdandruff, wound on the
right forehead, has rashes
on the left side of the
neck, and has long, dirtynails.
VS taken as follows:
Temp= 36CPR= 51 bpm
RR= 44 bpm
III. Health Assessment
1. Lola Beauty (Grandmother)
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Initial Assessment (July 2, 2010---Friday)
General Appearance
Upon the initial assessment, Lola Beauty was cooperative, coherent, and aware tothe place, time and person. She was wearing a white shirt and blue shorts, carrying
Brother Prince, and had her hair tied up. She has presence of dandruff and has dirty nails.
Vital Signs
BP= 155/100 mmHgTemp= 37.3C
PR= 90 bpm
RR= 20 bpm
Physical Assessment
Skin
Lola Beauty has fair complexion. She has a good skin turgor as evidenced by
when the skin was pinched at the arm; the skin goes back to its previous state. No edema
and no lesions noted upon inspection.
Hair and Scalp
Lola Beauty has a short black hair and it is evenly distributed upon inspection.
Has presence of dandruff and the scalp is rough upon palpation.
Nails
Nails are pinkish, convex curve with 160 angle, long and dirty. Has a normal
capillary refill time which is 2 seconds.
Skull
Skull is round and symmetrical in size and has no nodules or masses noted upon
palpation.
Face
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Facial movement has coordination and has balanced facial features. There is absence
of edema.
Eyes and Vision
Eyebrows evenly distributed, eyelids close symmetrically approximately 16 blinks
per minute, white sclera, pink palpebral conjunctiva and transparent bulbar conjunctiva,
pupils are well rounded and reactive to light and accommodation, absence of abnormal
secretions. During the Corneal Sensitivity Test, client blinks when cornea is touched
indicating that he has intact cranial nerve no. 5 (trigeminal). She can see and read
newsprint clearly.
Ears and Hearing
No abnormal discharges noted, ears are on the level of outer canthus of the eye, has
dark pinna and recoil after it is folded, with minimal cerumen. During the Whisper test,
the client is able to hear normal voice tone at a distance of 1-2 inches.
Nose
Air moves freely as Lola Beauty breaths through her nares, nasal septum intact and
in midline, no swellings and lesions, absence of abnormal discharges.
Lips
Dark pink in color, moist and smooth, able to purse lips, symmetry of contour.
Tongue
Central position, pink, moist, slightly rough, no lesions, with raised papillae, moves
freely, not tender, no palpable nodules.
Neck muscles
Lola Beautys sternocleidomastoid and trapezius muscles are equal in size, head
centered, coordinated smooth movements with no discomforts, equal muscle strength, is
able to turn the head to one side against the resistance of our hands, able to shrug
shoulders against the resistance of our hands, no palpable lymph nodes, trachea is on the
midline of the neck upon inspection, thyroid gland not visible on inspection, full
pulsation and symmetric pulse volume of the carotid artery, jugular vein not distended,
no enlargement of lymph nodes.
Lungs and Thorax
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Spine vertically aligned, spinal column is straight, full and symmetric chest
expansion, with normal breath sounds, no tenderness or masses noted upon palpation.
Heart
Normal heart sound (lub-dub upon auscultation), has a normal heart rate of
98 beats per minute and has regular rhythm and has a BP of 155/100 mmHg, no murmurs
heard upon auscultation.
NEUROLOGICAL ASSESSMENT
Mental Status - conscious, awake; knows his name; where he is currently and
who he is at the moment; answers questions asked to him accordingly; uses
Kapampangan whenever he answers the questions asked.
Sensory Function - able to distinguish a light touch using tip of cotton; able to
distinguish hot from cold water; pointed the place where the pricking pain was
pointed; can readily determine the position of fingers and toes.
Motor Function- has upright position and gait steady with opposing arm
swinging; walks unaided maintaining balance; can alternately supinate and
pronate at rapid pace; moves smoothly and coordinately.
Cranial Nerves
CRANIAL NERVE ASSESSMENT
TECHNIQUE
EXPECTED
OUTCOME
ACTUAL
FINDINGS
I: Olfactory
Type: Sensory
Function: Smell
Ask the client to
identify aromas
like cologne,
alcohol and
vinegar, with each
nostril separately
with eyes close.
The client will be
able to identify
different aromas
like cologne,
alcohol and
vinegar, unless
such condition
like cold is
present.
Lola Beauty was able
to identify the
aromas of cologne,
alcohol and vinegar.
II: Optic Ask the client to The client will be Lola Beauty was able
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Type: Sensory
Function: Vision
read words on a
piece of paper with
each eye first then
both eyes at 12-14
inches.
able to read the
words at 12-14
inches.
to read the articles in
the newspaper at 12-
14 inches.
III: Oculomotor
Type: Motor
Function: Upward and
downward movement of pupils
Ask client to look
straight ahead then
approach the pupil
with a penlight and
observe for pupil
constriction.
The clients eyes
will have a normal
reaction for
PERRLA.
Lola Beauty had a
normal reaction to
PERRLA.
IV: Trochlear
Type: Motor
Function: Extra-ocular
movement of eyes in oblique
movement
Ask client to hold
the head still and
follow the
thermometer as it
moves in the six
cardinal eye
movements.
The client will be
able to follow the
movement of the
thermometer.
Lola Beauty has
good coordination of
eye movements and
able to follow the
movement of the
thermometer.
V: Trigeminal
Type: Motor and Sensory
Function: Sensation of cornea,
skin of face and jaw movement
Ask the client to
make chewing
movements, open
the mouth against
resistance, move
jaw from side to
side and open
mouth widely.
Cotton is wisp at
the side of the
clients eyes.
The client will be
able to make
chewing
movements, open
the mouth against
resistance, move
jaw from side to
side and open
mouth widely.
Blinking Reflex
was noted.
Lola Beauty was able
to make chewing
movements, open the
mouth against
resistance, move jaw
from side to side and
open mouth widely.
Blinking Reflex was
noted to Lola Beauty
VI: Abducens
Type: Motor
Have the client to
hold his head
The client will be
able to follow the
Lola Beauty has
good coordination of
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IX: Glossopharyngeal
Type: Motor and Sensory
Function: Swallowing, gag
reflex, pharyngeal movement
and sense of taste of the
posterior one-third of the
tongue
Ask the client to
swallow then open
mouth widely and
say Ah. Ask the
client to identify
the taste (sugar)
placed on posterior
tongue.
Client will elicit
gag reflex. The
client will be able
to identify the
taste of sugar
placed on
posterior tongue.
Lola Beauty was able
to elicit gag reflex.
And the uvula moved
upward upon saying
Ah.
X: Vagus
Type: Motor
Function: Swallowing and
Speaking
Ask client to cough
and say its name.
The client will be
able to state his
name without
hoarseness of
voice.
Lola Beauty had an
effective coughing
and was able to state
her name without
hoarseness of voice.
XI: Accessory
Type: Motor
Function: Movement of
shoulder muscles
Ask client to
elevate shoulders
against the gravity
and turn head from
side to side.
The client will be
able to elevate
shoulders against
the gravity and
turn head from
side to side.
Lola Beauty was able
to elevate shoulders
against the gravity
and turn head from
side to side.
XII: Hypoglossal
Type: Motor
Function: Movement and
strength of tongue
Ask the client to
protrude the tongue
and move in
different directions.
The client will be
able to protrude
his tongue and
move in different
directions.
Lola Beauty was able
to protrude her
tongue and move in
different directions.
HISTORY OF PAST AND PRESENT ILLNESS
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Currently, Lola Beauty is not experiencing any illness. He often acquired some
colds, cough and even fever. There are times when her blood pressure is high, but has
medicines to lower it down.
ACTIVITIES OF DAILY LIVING
TIME ACTIVITIES
7:00 am Wakes up
7:00-8:00 am Cleans the house and cooks breakfast
8:00-11:00 am Takes care of her grandchildren
11:00-12:00pm Prepares lunch
12:00-1:00 pm Eats lunch
1:00-5:30 pm Takes care of her grandchildren
5:30-6:30pm Prepares dinner
6:30-7:00 Eats dinner 7:00-9:00pm Watching TV with family
9:00 pm Rest and Goes to sleep
Eating pattern
Lola Beauty eats thrice daily. She eats whatever is available.
Sleeping pattern
Lola Beauty wakes up at 7:00 am and sleeps at 9:00 pm. She sleeps in the livingroom by herself. She sleeps 10 hours a day.
Leisure time activities
When Lola Beauty has leisure time, she utilizes it for watching TV, listening to
the radio, cleaning the house or chatting with neighbors.
2. Papa King (Father)
Initial Assessment (July 9, 2010---Friday)
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Eyes and Vision
Eyebrows evenly distributed, eyelids close symmetrically approximately 16
blinks per minute, white sclera, pink palpebral conjunctiva and transparent bulbar
conjunctiva, pupils are well rounded and reactive to light and accommodation, absence of
abnormal secretions. During the Corneal Sensitivity Test, client blinks when cornea is
touched indicating that he has intact cranial nerve no. 5 (trigeminal). He can see and read
newsprint clearly.
Ears and Hearing
No abnormal discharges noted, ears are on the level of outer canthus of the eye,
has dark pinna and recoil after it is folded, with minimal cerumen. During the Whisper
test, the client is able to hear normal voice tone at a distance of 1-2 inches.
Nose
Air moves freely as Daddy Jon breaths through his nares, nasal septum intact and
in midline, no swellings and lesions, absence of abnormal discharges.
Lips
Dark pink in color, moist and smooth, able to purse lips, symmetry of contour.
Tongue
Central position, pink, moist, slightly rough, no lesions, with raised papillae,
moves freely, not tender, no palpable nodules.
Neck
Papa Kings sternocleidomastoid and trapezius muscles are equal in size, head
centered, coordinated smooth movements with no discomforts, equal muscle strength, is
able to turn the head to one side against the resistance of our hands, able to shrug
shoulders against the resistance of our hands, no palpable lymph nodes, trachea is on the
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midline of the neck upon inspection, thyroid gland not visible on inspection, full
pulsation and symmetric pulse volume of the carotid artery, jugular vein not distended,
no enlargement of lymph nodes.
Lungs and Thorax
Spine vertically aligned, spinal column is straight, full and symmetric chest
expansion, with normal breath sounds, no tenderness or masses noted upon palpation.
Heart
Normal heart sound (lub-dub upon auscultation), has a normal heart rate of 98
beats per minute and has regular rhythm and has a BP of 130/100 mmHg, no murmursheard upon auscultation.
NEUROLOGICAL ASSESSMENT
Mental Status - conscious, awake; knows his name; where he is currently and
who he is at the moment; answers questions asked to him accordingly; uses
Kapampangan whenever he answers the questions asked.
Sensory Function - able to distinguish a light touch using tip of cotton; able to
distinguish hot from cold water; pointed the place where the pricking pain was
pointed; can readily determine the position of fingers and toes.
Motor Function- has upright position and gait steady with opposing arm
swinging; walks unaided maintaining balance; can alternately supinate and
pronate at rapid pace; moves smoothly and coordinately.
Cranial Nerves
CRANIAL NERVE ASSESSMENT
TECHNIQUE
EXPECTED
OUTCOME
ACTUAL
FINDINGS
I: Olfactory
Type: Sensory
Ask the client to
identify aromas
The client will be
able to identify
Papa King was able
to identify the
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Function: Smell like cologne,
alcohol and
vinegar, with each
nostril separately
with eyes close.
different aromas
like cologne,
alcohol snd
vinegar, unless
such condition
like cold is
present.
aromas of cologne,
alcohol and vinegar.
II: Optic
Type: Sensory
Function: Vision
Ask the client to
read words on a
piece of paper with
each eye first then
both eyes at 12-14
inches.
The client will be
able to read the
words at 12-14
inches.
Papa King was able
to read the articles in
the newspaper at 12-
14 inches.
III: Oculomotor
Type: Motor
Function: Upward and
downward movement of pupils
Ask client to look
straight ahead then
approach the pupil
with a penlight and
observe for pupil
constriction.
The clients eyes
will have a
normal reaction
for PERRLA.
Papa King had a
normal reaction to
PERRLA.
IV: Trochlear
Type: Motor
Function: Extra-ocular
movement of eyes in oblique
movement
Ask client to hold
the head still and
follow the
thermometer as it
moves in the six
cardinal eye
movements.
The client will be
able to follow the
movement of the
thermometer.
Papa King has good
coordination of eye
movements and able
to follow the
movement of the
thermometer.
V: Trigeminal
Type: Motor and Sensory
Function: Sensation of cornea,
skin of face and jaw movement
Ask the client to
make chewing
movements, open
the mouth against
resistance, move
jaw from side to
The client will be
able to make
chewing
movements, open
the mouth against
resistance, move
Papa King was able
to make chewing
movements, open the
mouth against
resistance, move jaw
from side to side and
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side and open
mouth widely.
Cotton is wisp at
the side of the
clients eyes.
jaw from side to
side and open
mouth widely.
Blinking Reflex
was noted.
open mouth widely.
Blinking Reflex was
noted to Papa King.
VI: Abducens
Type: Motor
Function: Extra-ocular
movement of eyes in a lateral
movement
Have the client to
hold his head
steady and follow
the thermometer
direction.
The client will be
able to follow the
movement of the
thermometer.
Papa King has good
coordination of eye
movements and able
to follow the
movement of the
thermometer.VII: Facial
Type: Motor and Sensory
Function: Movement of facial
muscles and sense of taste on
the anterior two thirds of the
tongue
Ask the client to
smile, frown, raise
eyebrow, puff the
cheeks and show
teeth. Ask the
client to identify
the different tastes
(sugar) placed on
the anterior 2/3 of
the tongue.
The client will be
able to smile,
frown, raise
eyebrow, puff the
cheeks and show
teeth. The client
will be able to
identify the sugar
placed on the
anterior 2/3 of the
tongue.
Papa King was able
to smile, frown, raise
eyebrow, puff the
cheeks and show
teeth. He was also
able to identify the
taste of sugar on the
anterior 2/3 of his
tongue.
VIII: Vestibulocochlear/
Acoustics
Type: Sensory
Function: Hearing and
Equilibrium
Have the client to
walk with both
eyes close and
repeat the
whispered few
words at the
clients back.
Allow client to
stand with feet
The client will be
able to walk with
both eyes close
and repeat the
whispered few
words at the
clients back. The
client will be able
to perform
Papa King was able
to walk with both
eyes close and repeat
the whispered few
words whispered to
him. He was also
able to perform
Rombergs Test with
equilibrium.
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HISTORY OF PAST AND PRESENT ILLNESS
Currently, Papa King is not experiencing any illness. He often acquired some
colds, cough and even fever.
ACTIVITIES OF DAILY LIVING
TIME ACTIVITIES
6:30 am Wakes up
7:00-9:00 am Works as a street sweeper
9:00-12nn Rest and goes to sleep
12:00-1:00 pm Eats Lunch
1:00-2:00pm Get ready for work
2:30-10:00 pm Works as a Guard Vendor
10:30 pm Goes home11:00 pm Rest and goes to sleep
Eating pattern
Papa King eats thrice daily. He eats whatever is available.
Sleeping pattern
Papa King wakes up at 6:30 am and sleeps at 11:00 pm. He sleeps with his wife and 2
children. He sleeps 7 hrs a day.
Leisure time activities
When Papa King has leisure time, he utilizes it for sleep, rest, watching TV, listening
to the radio, playing basketball or with the kids.
3. Mama Queen (Mother)
Initial Assessment (July 9, 2010---Friday)
General Apperance
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Upon initial assessment, Mama Queen was conscious and oriented as to date,
time, and place. She was wearing a t-shirt, pants, and shoes ready to go to work. Her
mood was appropriate to the situation, she was cooperative, and coordinated movements.
Vital Signs
BP= 110/90 mmHg
T= 35.8 C/axilla
P= 70 bpm
R= 16 bpm
Skin
Mama Queen has brown complexion, with evenly distributed body hair consistent
from head, neck, arms down to the legs and with other parts upon inspection. No edema
and no lesions noted upon inspection. Herskin is moist with the same temperature on
upper and lower extremities upon palpation. She has a good skin turgor as evidenced by
when the skin was pinched at the arm, the skin goes back to its previous state.
Hair and Scalp
Mama Queen has a straight long dark brown hair and it is evenly distributed upon
inspection. Has no dandruff and infestations of lice, no evidence of flaking and no areas
of hair loss. The scalp is smooth upon palpation.
Nails
Nails are pinkish, convex curve with 160 angle, short and clean. Has a normal
capillary refill time which is 2 seconds.
Skull
Skull is round and there are no presence of nodules and masses.
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Face
Facial movement has coordination and has balanced facial features. There is
absence of edema.
Eyes and Vision
Eyebrows evenly distributed, eyelids close symmetrically approximately 17
blinks per minute, white sclera, pink palpebral conjunctiva and transparent bulbar
conjunctiva, pupils are well rounded and reactive to light and accommodation, absence of
abnormal secretions. During the Corneal Sensitivity Test, client blinks when cornea is
touched indicating that she has intact cranial nerve no. 5 (trigeminal). She can see and
read newsprint clearly.
Ears and Hearing
No abnormal discharges noted, ears are on the level of outer canthus of the eye,
has brown pinna and recoil after it is folded, with minimal cerumen. During the Whisper
test, the client is able to hear normal voice tone at a distance of 1-2 inches.
Nose
Air moves freely as Mommy Mariel breaths through her nares, nasal septum
intact and in midline, no swellings and lesions, absence of abnormal discharges.
Lips
Pink in color, moist and smooth, able to purse lips, symmetry of contour.
Tongue
Central position, pink, moist, slightly rough, no lesions, with raised papillae,
moves freely, not tender, no palpable nodules.
Neck
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Mama Queens sternocleidomastoid and trapezius muscles are equal in size, head
centered, coordinated smooth movements with no discomforts, equal muscle strength, is
able to turn the head to one side against the resistance of our hands, able to shrug
shoulders against the resistance of our hands, no palpable lymph nodes, trachea is on the
midline of the neck upon inspection, thyroid gland not visible on inspection, full
pulsation and symmetric pulse volume of the carotid artery, jugular vein not distended,
no enlargement of lymph nodes.
Lungs and Thorax
Spine vertically aligned, spinal column is straight, full and symmetric chest
expansion, with normal breath sounds, no tenderness or masses noted upon palpation.
Heart
Normal heart sound (lub-dub upon auscultation), has a normal heart rate of 80
beats per minute and has regular rhythm and has a BP of 110/90 mmHg, no murmurs
heard upon auscultation.
NEUROLOGICAL ASSESSMENT
Mental Status - conscious, awake; knows her name; where she is currently and
who she is at the moment; answers questions asked to her accordingly; uses
Kapampangan whenever she answers the questions asked.
Sensory Function - able to distinguish a light touch using tip of cotton; able to
distinguish hot from cold water; pointed the place where the pricking pain was
pointed; can readily determine the position of fingers and toes.
Motor Function- has upright position and gait steady with opposing arm
swinging; walks unaided maintaining balance; can alternately supinate and
pronate at rapid pace; moves smoothly and coordinately.
Cranial Nerves
CRANIAL NERVE ASSESSMENT EXPECTED ACTUAL
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TECHNIQUE OUTCOME FINDINGS
I: Olfactory
Type: Sensory
Function: Smell
Ask the client to
identify aromas
like cologne,
alcohol and
vinegar, with each
nostril separately
with eyes close.
The client will be
able to identify
different aromas
like cologne,
alcohol and
vinegar, unless
such condition
like cold is
present.
Mama Queen was
able to identify the
aromas of cologne,
alcohol and vinegar.
II: Optic
Type: Sensory
Function: Vision
Ask the client to
read words on a
piece of paper with
each eye first then
both eyes at 12-14
inches.
The client will be
able to read the
words at 12-14
inches.
Mama Queen was
able to read the
articles in the
newspaper at 12-14
inches.
III: Oculomotor
Type: Motor
Function: Upward and
downward movement of pupils
Ask client to look
straight ahead then
approach the pupil
with a penlight and
observe for pupil
constriction.
The clients eyes
will have a
normal reaction
for PERRLA.
Mama Queen had a
normal reaction to
PERRLA.
IV: Trochlear
Type: Motor
Function: Extra-ocular
movement of eyes in oblique
movement
Ask client to hold
the head still and
follow the
thermometer as it
moves in the six
cardinal eye
movements.
The client will be
able to follow the
movement of the
thermometer.
Mama Queen has
good coordination of
eye movements and
able to follow the
movement of the
thermometer.
V: Trigeminal
Type: Motor and Sensory
Function: Sensation of cornea,
Ask the client to
make chewing
movements, open
The client will be
able to make
chewing
Mama Queen was
able to make
chewing movements,
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skin of face and jaw movement the mouth against
resistance, move
jaw from side to
side and open
mouth widely.
Cotton is wisp at
the side of the
clients eyes.
movements, open
the mouth against
resistance, move
jaw from side to
side and open
mouth widely.
Blinking Reflex
was noted.
open the mouth
against resistance,
move jaw from side
to side and open
mouth widely.
Blinking Reflex was
noted to Mama
Queen.
VI: Abducens
Type: Motor
Function: Extra-ocular
movement of eyes in a lateral
movement
Have the client to
hold his head
steady and follow
the thermometer
direction.
The client will be
able to follow the
movement of the
thermometer.
Mama Queen has
good coordination of
eye movements and
able to follow the
movement of the
thermometer.
VII: Facial
Type: Motor and Sensory
Function: Movement of facial
muscles and sense of taste on
the anterior two thirds of the
tongue
Ask the client to
smile, frown, raise
eyebrow, puff the
cheeks and show
teeth. Ask the
client to identify
the different tastes
(sugar) placed on
the anterior 2/3 of
the tongue.
The client will be
able to smile,
frown, raise
eyebrow, puff the
cheeks and show
teeth. The client
will be able to
identify the sugar
placed on the
anterior 2/3 of the
tongue.
Mama Queen was
able to smile, frown,
raise eyebrow, puff
the cheeks and show
teeth. She was also
able to identify the
taste of sugar on the
anterior 2/3 of her
tongue.
VIII: Vestibulocochlear/
Acoustics
Type: Sensory
Function: Hearing and
Have the client to
walk with both
eyes close and
repeat the
The client will be
able to walk with
both eyes close
and repeat the
Mama Queen was
able to walk with
both eyes close and
repeat the whispered
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Equilibrium whispered few
words at the
clients back.
Allow client to
stand with feet
together and arms
resting at the sides,
first with eyes
open and then
closed (Rombergs
Test).
whispered few
words at the
clients back. The
client will be able
to perform
Rombergs Test
with equilibrium.
few words whispered
to her. She was also
able to perform
Rombergs Test with
equilibrium.
IX: Glossopharyngeal
Type: Motor and Sensory
Function: Swallowing, gag
reflex, pharyngeal movement
and sense of taste of the
posterior one-third of the
tongue
Ask the client to
swallow then open
mouth widely and
say Ah. Ask the
client to identify
the taste (sugar)
placed on posterior
tongue.
Client will elicit
gag reflex. The
client will be able
to identify the
taste of sugar
placed on
posterior tongue.
Mama Queen was
able to elicit gag
reflex. And the uvula
moved upward upon
saying Ah. She
was also able to
identify the taste of
sugar placed on her
posterior tongue.
X: Vagus
Type: Motor
Function: Swallowing and
Speaking
Ask client to
cough and say its
name.
The client will be
able to state his
name without
hoarseness of
voice.
Mama Queen had an
effective coughing
and was able to state
her name without
hoarseness of voice.
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XI: Accessory
Type: Motor
Function: Movement of
shoulder muscles
Ask client to
elevate shoulders
against the gravity
and turn head from
side to side.
The client will be
able to elevate
shoulders against
the gravity and
turn head from
side to side.
Mama Queen was
able to elevate
shoulders against the
gravity and turn head
from side to side.
XII: Hypoglossal
Type: Motor
Function: Movement and
strength of tongue
Ask the client to
protrude the
tongue and move
in different
directions.
The client will be
able to protrude
his tongue and
move in different
directions.
Mama Queen was
able to protrude her
tongue and move in
different directions.
MOTHERS OBSTETRICAL HISTORY
Mama Queen has been living with Papa King for 4 years now. Her Obstetric
History is G4P4 (4004). She started having her menstrual cycle when she was 12 years
old. All of her children were born via normal delivery and they were all delivered at the
hospital. According to her, she had completed her tetanus toxoid vaccine.
HISTORY OF PAST AND PRESENT ILLNESS
Currently, Mama Queen is not experiencing any illness. She often acquired some
colds, cough and even fever several times due to some factors that are still unknown over
the past years according to her; she just acquired it sometimes when her other family
members have it.
Eating pattern
Mama Queen eats thrice daily. She eats whatever is available.
Sleeping pattern
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Mama Queen wakes up at 6:00 am and sleeps at 11:00 pm. She sleeps with her
husband and 2 children. She sleeps 7 hours every a day.
Leisure time activities
She utilizes it for sleep, rest, watching TV, listening to the radio, or chatting
with neighbors.
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IV. Socio-Economic, Cultural, and Environmental Assessment
A. Type of Family Structure
The Royale Family is an extended type of family, composed of parents: Papa
King and Mama Queen, children: 4-year old Brother Prince and 1-year old SisterPrincess, and Lola Beauty living with them. When Papa Prince and Mama Princess are at
work, Lola Beauty is the one taking care of their kids. 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 a positive outlook in life.
B. Dominant family members in terms of decision making especially to health care
In terms of decision making, whether related to health care or not, Papa King and
Mama Queen are the decision makers in the family.
C. Source of Income, Expenditures
The familys source of income is Papa Kings wage from being a street sweeper
and a barangay tanod in their community and Mama Queens wage from being a
saleslady at LCN Enterprises. The family has adequate financial for the basic needs of the
family. In case of emergency, they use the money that the mother had kept/saved.
D. Working hours
Papa Prince works from 7 am to 9 am as a street sweeper, 2 hours a day, 2pm-
10pm as a guard vendor, and 10 pm to 6 am as a barangay tanod while Mama Queen
works from 8 am to 5 pm as a saleslady at LNC Enterprises.
E. Ethnic background and Religious Affiliation
The familys religion is Roman Catholic, so very few restrictions are being
implemented. They dont attend the Holy Mass often.
F. Significant others role in the family life
Lola Beauty is taking care of the kids whenever Papa King and Mama Queen are
not around.
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cabinet for medicines, plates, and glasses. At the back of their house is where the kitchen
and bathroom are located. There are presence of ants, spiders, and cockroaches. For the
lighting conditions, the family use incandescent bulbs as their source of light during
evenings. However, inadequacy in daytime lighting is very evident, as there is only one
window.
K. Food sources, storage, and cooking facilities
The family usually buys cooked food at the carinderia while Lola Beauty prepares
the rice. They seldom cook for their own food. When they ran out of gas for their stove,
Lola Beauty prepares rice in the front porch where the pile of charcoal is used. Food
storage comprises of food covered in plates.
L. Water Supply (source, ownership, portability, storage)
The family has a level 3 water system. They own such water supply facility. For
the kids, they boil the water first before they let the kids drink it while the adults in the
family drink the water from the household tap. The type of water storage is pitchers or
jars with cover.
M. Toilet facility (type, ownership, sanitary condition)
Their toilet facility is at the back of the house. The family has a septic tank
without water carriage so it has to be mechanically flushed by pouring water in it. It is in
good condition because the surrounding area of the bowl is clean and no discoloration or
foul odor is evident.
N. Drainage system (type, sanitary, condition)
Their drainage system is located on the front yard of the house. Its type is of open
and flowing nature. The garbage disposal container is sack and it is uncovered.
O. Social and health facilities available
The community where the family resides has various social and health facilities.
They have a basketball court wherein certain activities such as sports fest are being
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carried out and the Barangay San Remedios Health Center which offers an array of
services such as immunization, family planning programs, and prenatal care.
P. Communication and transportation facilities
In the family, Papa King and Mama Queen have cell phones for communication.
The family commutes by riding a tricycle or public utility jeepney to go to places. They
can also walk if the destination is just considerably near.