Fca Aufer

I.
INTRODUCTION:
“The devotion of such titans of spirit as Lenin to an Ideal must bear fruit.
The nobility of his selflessness will be an example through centuries to
come, and his Ideal will reach perfection”
-Mahatma Gandhi
Mahatma Gandhi’s quotation stated above means change should start within
you. Just like the great leader Lenin, his ideals were able to bear fruit. Likewise in the
field of Nursing, a nurse’s devotion and passion for change, particularly on disease
prevention and health promotion, will help her to achieve the change she wants. When
this happens, everything else follows- a fruit will bear eventually, and the ideals or
actions brought about by the initiation of nurse to change will serve as an inspiration
and example for others to imitate. Gradually, the fruit of the nurse’s ideals will reach
perfection which means, the change will manifest on others and on the community.
Community is considered as the recipient of service wherein it comprises a group

of people sharing common geographical boundaries, values, interest and
characteristics. It also refers to a limited geographic area in which the residents relate to
and interact among them, thus in Community Health Nursing, community is not the sole
central foundation in assessing the health status. In order to properly observe and
assess the community, its integral parts must be given attention. The family, which is
the basic unit that makes up the community, should be considered. No social group has
the potential to provide the same level of support and long lasting emotional ties as
one’s own family. Family is a factor in bringing the change necessary in promoting
wellness among people because it carries a common purpose which is to promote the
physical, mental, emotional, and social development of each of its members. With
same extent, every member of the family contributes to the wholeness of the
community. Since no one lives in isolation, the individual’s ability to maintain good
relationship with his/her family members and ability to be proactive for the welfare of the
whole community should be regarded in the study of Community Health Nursing.
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Hence, a healthy community is rooted from the participation of functional families that
of, through the assembly of active and productive individuals (Pillitteri, 2007).
Furthermore, community health nursing is a field of nursing that renders

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. Community health nursing indeed, has a breadth that is
beyond a medical model approach. Public Health Nurses work with many different client
groups, community settings and types of agencies, and they often possess additional
areas of specialty knowledge. They are the one who facilitates preventive measures
inside the community. (Keleher, 2007)
However, public health nurses and the other health care teams in the community
are being challenged because they are faced with barriers that stop them from
promoting health and preventing illness. One relatable example is the rising
unemployment and poverty in the Philippines. The official estimate for unemployment in
2008 was 7.4 percent or 2.7 million—an increase of 0.1 percent from 2007. The
government defines the unemployed as those who are simultaneously without work,
looking for work and immediately available for work. Added to this, in another survey,
Social Weather Station reported a record 23.7 percent increase in the number of
families experiencing hunger at least once in three months, to 4.3 million families or
more than 20 million people.
And with these situations, Family Case Analysis (FCA) tries to find out the
relationship of a certain family to the community at large; to find out risk problems and
find ways to alleviate these dilemmas that would benefit the family and the community.
It is a combined process of assessing, interacting, and interviewing a family. It is a
means by which the Nursing Practices is focused on the family as the recipient of care,
health as the goal and nursing as the medium for providing care.
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The group criteria in choosing their adopted family for the Family Case Analysis
are as follows:
• A family that will easily be identified to be depressed or deprived

• A family with 4 or more children, with at least 1 child who belongs to 0-6
age bracket.
• A family with visible poor environmental condition.
• A family that gives permission to be taken as case for the FCA project.
With these criteria established and met, the group chose the Fruit Family. Our
adopted family is deprived from adequate resources to sustain their health and lives in a
poor environmental condition in the Barangay Virgen delos Remedios. The family is
composed of eight family members, where the two of its members are the couple and
six of them are their children. The student nurses had three home visits all in all, from
December 3, 2009 to December 10, 2009. With the comprehensive physical
assessments done, the student nurses were able to determine some threats and deficits
that can affect the health of the Fruit Family. Thus, the group will try to determine health
related problems and solve them through planned actions.
A. Objectives
The Family Case Analysis (FCA) aims to examine and assess carefully the
general health status of the family, identify their health needs and problems and
intervene for the problems encountered. It also aims to promote changes and self-
reliance within the family.
Student- Centered:
a. Short-term:
After the initial home visits, the student nurses shall have:
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 Chosen the family for FCA as based from the set criteria.
 Introduced themselves with the family members.
 Established rapport with the family members.
 Explained the purpose of home visit and established contract about their
available time.
 Utilized therapeutic communication technique in dealing with the family.
 Familiarized each family member.
 Conducted a physical assessment on each member of the family.
 Described the family as to type, composition and structure.
 Determined different factors (environmental and socio-cultural factors) that
can affect their health.
 Identified needs and problems and eventually formulate a plan of action in
order to meet their needs with the family.
 Determined the strengths and weaknesses of the family.
 Guided the adopted family in eliminating actual and potential problem
which could affect achieving an optimum health.
 Formulated interventions for the problems identified considering also the
student nurses and family’s resources.
 Provided health teachings to rule out existing health conditions.
b. Long-term:
After the last day of home visit, the student nurses shall have:
 Gained the trust of the family regarding health.

 Assessed and explained to the adopted family the actual and potential
problems identified.
 Encouraged the family members in taking part in the implementation
process.
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 Coordinated and cooperated with the family in solving the identified
problems.
 Guided the family in recognizing their medical and health needs and given
health teachings appropriate to the situation.
 Provided information and assisted the adopted family in availing health
services from the Barangay Health Center.
 Evaluated the interventions made to solve the problems.
Client-centered
a. Short-term:
At the end of the first home visit, the family shall have:
 Established rapport with the students.

 Cooperated and coordinated well with the students.
 Identified the existing actual and potential problems within their family and
environment together with the group.
 Determined the factors that contribute to the existing problems of their
family.
 Discussed these problems with the group as well as with the rest of the
members of their family.
b. Long-term:
After the end of the last home visit the group shall have:
 Verbalized understanding of the rationale behind each intervention that

the student nurses have planned to implement.
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 Participated in the implementation phase of nursing interventions the
family members and student nurses agreed upon.
 Carried out planned interventions.
 Cooperated well with the student nurses in carrying out planned
interventions.
 Realized the sole significance of these interventions in achieving their full
health potential.
Research-Centered
This Family Case Analysis aims to answer the following questions:
1. How may the profile of each member of the family be described as to:
a. Sex
b. Age
c. Educational status
d. Position in the family
e. Present health status
2. How may the family be described as to:

a. Structure
b. Composition
c. Socioeconomic status
d. Cultural and religious beliefs
3. How the family may be graded in the family coping index regarding to:
a. Physical independence
b. Therapeutic Competence
c. Knowledge of health condition
d. Application of principles of general and personal hygiene
e. Health care attitudes
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f. Emotional competence
g. Family living patterns
h. Physical environment
i. Use of community facilities
4. How may the health of the family be assessed and described as to:
a. Physical assessment
b. Neurological assessment
c. History of past and present illness
d. Activity of daily living
e. Obstetrical history
f. Growth and development
g. Immunization status
5. How may the problems identified in the family be classifies as to:

a. Wellness condition
b. Health deficit
c. Health threat
d. Foreseeable crisis
6. How may the problems identified be prioritized and ranked as to:

a. Nature of the problem
b. Modifiability
c. Preventive potential
d. Salience
B. Entry, Climate of Acceptance, First Few Words, Number of Home Visits
The student nurses were tasked to find for a family that will be subjected for a
Family Case Analysis that was scheduled 3rd of December, 2009. After one rejection,
the group were finally able to find for a family, and they were tagged the Fruit Family.
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The family that group adopted is located at Sur Luisa Street of Barangay Virgen de los
Remedios. The following are the interaction of the student nurses with the Fruit Family
in three home visits:
First Home Visit (December 03, 2009)
The first exposure of the group on the community, Virgen Delos Remedios (VDR)
was on December 03, 2009 (Thursday). The group met in the main building of the AUF
in front of the bookstore at 7:30 in the morning. The group first had an orientation about
the community and they were divided into two subgroups. The group rides on a jeepney
going to the community. The group started to find the appropriate family after that the
group went to the health center for a brief introduction about VDR.
The group’s clinical instructor helped them to look for their designated family.
After the second try looking for a family, the subgroup A chose the Fruit family. The first
subgroup first met Mommy Orange and her three children who are tagged as Mango,
Banana, and Avocado. The group first saw Mango standing in front of their house while
Banana and Avocado are playing with their other playmates. The group first greeted
Mommy Orange by saying “Good morning po mommy…” and the group introduces their
selves one by one. The group asked the name of the mother and Mommy Orange
replied as well. The group established rapport with the family. The student nurses asked
Mommy Orange if the group can assess them, and Mommy Orange replied, “ok lang”.
The group started asking some questions beginning from their personal data took their
vital signs and assess their general condition. After the group completed their task for
that day, the group bid the Fruit Family goodbye and said, “Mommy salamat po. Babalik
na lang po kami bukas. Salamat po ulit”. Mommy Orange smiled back and said, “ok”.
Second Home Visit (December 04, 2009)
At the second home visit, the group was tasked to get the house measurements
of the family. The group only met Watermelon, Banana and Avocado. Watermelon said,
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“umalis po yung nanay ko, pero babalik din po siya mayamaya lang”. The student
nurses replied, “a, ganun ba, ok lang susukatin lang namin yung bahay nyo, ok lang
ba?, pero pagkauwi nya dun namin siya parang ch-check up” Watermelon said yes so
the group proceeded on their task. The student nurses took the measurements like total
floor area, total window opening. The group also assessed the family’s housing
condition and the member’s final assessments due to the groups’ shorten rotation. The
group decided to give the Fruit family a “lugaw” and bread as a token of appreciation for
welcoming us into their family wholeheartedly. The group helped the Fruit family in
preparing their breakfast. The group also helped the family to clean their dishes, and
their whole house. The group talked to Watermelon, “Sabihin mo sa mommy mo,
salamat ha, magbabalik pa rin kami next week”. Watermelon smiled backed and the
family and student nurses parted ways. Afterwards the group returned to check if
Mommy Orange is at their home already. When the group saw Mommy Orange, the
group performed final assessment to Mommy Orange and took her vital signs.
Third Home Visit (December 10, 2009)
On the third home visit, the group didn’t met Mommy Orange and Mango at first
few hours of interaction but the group already had their final assessment to these two
family members on the group’s second home visit. On the third home visit the group did
some of their interventions to the Fruit family, since Mommy Orange isn’t around the
group helped the Fruit family in cleaning their house like washing their dishes, sweeping
the floor and arranging the family’s furniture. As one of the group’s problem is poor
hygiene, the student nurses implemented their planned actions by bathing the children
especially Avocado and trimming their nails. The group had all of their needed
information so the group told the family that this can be their final home visit. The group
gave thanks to the family, their hospitality and their willingness to be part of our Family
Case Analysis. After some conversation, the group took pictures with the family and left
some tokens of appreciation and greeted, “Merry Christmas”. The family replied,
“salamat sa tulong nyo”. Then, the student nurses bid goodbye. After few hours,
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Mommy Orange and Mango went home so the group took the two family members’ final
assessment of their vital signs.
C. Family Constellation
Family Constellation includes the family profile of all the members of the family,
regarding with the given name of the member of the family, their age, ordinal position,
sex, educational status and their present health status. This chapter may aid the reader
in knowing all the necessary information about the family members.
POSITION PRESENT
EDUCATIONAL
NAME AGE IN THE SEX HEALTH
ATTAINMENT
FAMILY STATUS
Physical
assessment
was not done
because Mr.
49 years Apple was not
Vocational
old present during
Daddy APPLE Father M Graduate
July 21, the home visits
1960 because he
works as a
jeepney driver
from 5am to
9pm.
Mommy 44 years Mother F Elementary

ORANGE old Graduate Upon the initial
June 22, assessment,
1965 mother was
seen cleaning
the house. She
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has a large built
size which
shows that she
is
OVERWEIGHT.
She is
observantly
alert, with
coordinated
and steady gait.
She was
cooperative,
exhibited
thought
association and
has sense of
reality. Her
medium length
hair is dirty and
presence of
dandruff was
noted. Mommy
Orange has
also a knocked
upper tooth and
has dental
caries. She has
a trimmed neat
fingernails and
toenails. No
abnormal spine
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curvatures were
observed.
The following
vital signs were
noted:
T: 36.5°C
PR: 65bpm
RR: 19cpm
BP: 120/80
Height: 162 cm.
Weight: 62 kg
BMI: 23.66
m2/kg
Upon the final

assessment,
Mommy
Orange is
wearing white
shirt and black
shorts upon the
interaction. She
was seen
feeding her
children. It was
observed that
she is
conscious and
coherent. She
appears more
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clean and tidy.
She managed
to have a clean
and combed
hair. Still, she
has an intact
long term and
short term
memory.
However, she
still has a
knocked tooth
but reduced
tooth decay
was observed.
The following
vital signs were
noted:
T: 35.9°C
PR: 75bpm
RR: 20 cpm
BP: 110/90
Height: 162 cm
Weight: 62kg
BMI: 23.66
m2/kg
GRAPES 26 years First Child M Elementary

old Graduate He was not
February present during
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the initial and
final
assessment
13, 1983 because he
works everyday
from 7 am to 5
pm.
She was not

20 years assessed
old Second Elementary because she is
STRAWBERRY F
August 21, Child Graduate now living with
1989 her own family
in Manila.
14 years Third Child M Going to

old School Upon the initial
May 25, (Grade 5) home visit, He
1995 was seen
wearing a white
sleeveless shirt
and brown
short with no
MANGO slippers, he
was seen
playing with his
friends. After
performing
physical
assessment,
presence of
minimal scars
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on both hands
and feet were
observed and
dirty long nails
were noted. He
has also colds.
The following
vital signs were
noted:
T: 35.4°C
RR: 24 cpm
PR: 57 bpm
BP: 120/70
mmHg
Height: 149 cm
Weight: 41 kg
BMI: 18.47
kg/m2
Upon the final

home visit,
Mango, who is
14 years old,
was seen
wearing an
orange sando
shirt and black
short. Upon the
visit, he was
seen playing
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with his friends.
His speech,
reasoning, and
actions were
appropriate for
his age. After
performing the
final
assessment,
the scars on his
hands and feet
were lessened
and he has a
clean and
trimmed
fingernails and
toenails. His
colds
disappeared
already.
The following
vital signs were
noted:
T: 36.2°C
RR: 22 cpm
PR: 60 bpm
BP: 110/80
mmHg
Height: 149 cm
Weight: 41 kg
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BMI: 18.47
m2/kg
WATERMELON 12 years Fourth F Going to
old Child School Upon the initial
May 22, (Grade 5) home visit, she
1997 was seen
wearing a black
shirt and
maong short. It
was observed
that she is
cooperative
with the
examiner’s
instructions.
Her affect and
mood is
appropriate to
the situation.
Her speech is
understandable
and in
moderate pace.
The following
vital signs were
noted:
T: 35.7°C
RR: 19 cpm
PR: 73 bpm
BP: 110/60
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mmHg
Height: 150 cm
Weight: 47 kg
BMI: 20.89
kg/m2
Upon the final

assessment,
Watermelon
who is 12 years
old was seen
wearing a
sleeveless top
with blue
shorts. Her
speech,
actions, and
reasoning were
for his age. She
has a steady
gait and an
erect posture.
Short and clean
fingernails and
toenails were
noted.
The following
vital signs were
noted:
T: 36.2°C
RR: 17 cpm
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PR: 80 bpm
BP: 90/60
mmHg
Height: 150 cm
Weight: 47 kg
BMI: 20.89
kg/m2
BANANA 8 years old Fifth Child M Going to

September, School Upon initial
18 2001 (Grade 2) home visit,
Banana who is
8 years old was
seen wearing a
Spiderman shirt
and gray soiled
short without
slippers. He
has dry
cerumen on
both ears and
has long, dirty
fingernails and
toenails. When
physical
assessment
was done, it
was observed
that he has
discharges
coming from
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the nose which
shows that he
has colds.
There were
also rashes
noted on his
eye brows. He
has an obvious
wound on his
left thumb and
minimal scars
were observed
on his hands
and feet.
There is also
presence of
tooth decay.
More so, body
odor was noted.
He has a poor
hygiene.
The following
vital signs were
noted:
T: 35.9 °C
RR: 20 cpm
PR: 85 bpm
Height: 113 cm
Weight: 16 kg
BMI: 12.5 kg/m2
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Upon the final
home visit,
Banana who is
8 years old was
seen wearing a
green shirt and
white shorts
with slippers.
He has dry
cerumen on
both ears and
clean, trimmed
fingernails and
toenails were
noted. When
physical
assessment
was done, it
was observed
that his colds
were managed.
The rashes
noted on his
eye brows
lessened. The
wound on his
left thumb is
already healed.
Over-all, his
hygiene shows
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improvement.
The following
vital signs were
noted:
T: 36.2 °C
RR: 18 cpm
PR: 80 bpm
Height: 113 cm
Weight: 16 kg
BMI: 12.5 kg/m2
Upon the initial

home visit,
Avocado was
AVOCADO 6 years old Sixth Child F Going to seen wearing a
November School green shirt and
26, 2003 (Preparatory) red short.
During the
observation,
she was seen
having erected
and relaxed
body posture.
She has no
abnormal spine
curvatures. She
has rhythmic
and
coordinated
movements.
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She has a dry
hair and lice
infestations
were seen. Her
teeth have
dental caries.
Observantly,
she has a thin
psyche. Dirty,
long fingernails
and toenails
were also
noted. She also
has a cough
and colds.
The following
vital signs were
noted:
T: 36.5°C
PR: 72 bpm
RR: 28 cpm
Height: 107 cm
Weight: 15 kg
BMI: 13.16
kg/m2
Upon the final

home visit,
Avocado was
seen wearing a
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pink shirt and
brown shorts.
She has an
erected and
relaxed body
posture. She
has no
abnormal spine
curvatures. She
has rhythmic
and
coordinated
movements.
Her hair is
neatly combed
and clean
fingernails and
toenails were
noted.
The following
vital signs were
noted:
T: 36.3°C
PR: 78 bpm
RR: 25 cpm
Height: 107 cm
Weight: 15 kg
BMI: 13.16
kg/m2
II. HEALTH ASSESSMENT
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Health Assessment or Physical Assessment is a systematic and efficient manner
of evaluating the body and its functions. Some purpose of this includes obtaining
baseline data about the family’s functional abilities and to identify areas of health
promotion and disease prevention. Listed below are the health assessments of the
family members:
A. INITIAL ASSESSMENT
Daddy Apple
The student nurses haven’t met Daddy Apple throughout the home visits
because he is getting out for work as early as 5 am.
Mommy Orange
General Appearance
Mommy Orange is 44 years old. He has long, black hair with some grayish and
white discoloration. She is chubby and small. She is conscious and coherent while the
group interviews her. At our initial home visit, she was wearing blouse and short jeans
with slippers on. Her nails are trimmed and clean. She has steady gait and posture and
no signs of distress observed. She stands 162 cm. and weighs 62 kg.
Mommy Orange’s vital signs were taken and recorded as follows:
Vital Signs 1st home visit 2nd home visit 3rd home visit
Blood Pressure 120/80 mmHg 120/90 mmHg 110/90 mmHg
Temperature 36.5 ˚C 36.9 ˚C 35.9 ˚C
Respiratory Rate 19 cpm 20 cpm 21 cpm
Pulse Rate 65 bpm 72 bpm 75 bpm
SKIN, HAIR AND NAIL ASSESSMENT
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Skin:
 Light brown in color.
 Warm, and dry to touch.
 No signs of dehydration noted.
 Skin folded over the forearm returned after 2 seconds.
 No redness or edema noted.
 Has no presence of scars noted.
Hair:
 Hair is in medium length.
 Hair is black in color with some grayish and white strands.
 There is the presence of dandruff noted.
Nails:
 Pinkish nail beds.
 Capillary refill return after 2 seconds.
 No inflammation noted.
 No clubbing or abnormal curvature of the nails.
 Nails are trimmed and neat.
HEAD AND NECK ASSESSMENT
Head:
 Round in shape and symmetrical on sides.
 No tenderness noted.
 No lumps noted upon palpation
 There are no fractures noted.
Neck:
 There are no lumps palpated.
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 Lymph nodes are non-palpable.
 Trachea is on the midline position.
 Range of Movement is appropriate.
EYE ASSESSMENT
 Hair on eyebrow, eyelashes, and eyelids are evenly distributed.

 No discharge on the eyelids upon inspection.
 Sclera appears white.
 Bulbar and Palpebral conjunctivas are light brown to pinkish in color.
 No edema and lumps observed on nasolacrimal duct upon palpation.
 Pupils are equal in size.
 PERRLA (Pupils equally round and reactive to light and accommodation.)
 Both irises are brown in color.
 Mommy Orange was able to read newsprint 14 inches far.
 Has a coordinated eye movement.
EAR ASSESSMENT
 No lumps palpated on both ears.

 No lesions or signs of inflammation noted.
 Ear folded return after 1 second.
 The ear contains yellowish cerumen but not dry.
 Both ears are responsive to whisper test.
 Mastoid process is non-tender.
 Color of the ear is same with the facial skin.
 There is mild swaying upon Romberg’s test.
NOSE AND SINUS ASSESSMENT
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 No presence of colds or nasal discharges.
 Nasal septum is in midline position.
 No tenderness noted upon palpation.
 Can distinguish different smell.
 No lumps palpated.
 No obstruction observed upon deep inhalation.
MOUTH AND PHARYNX ASSESSMENT
 The lips have small cracks but no lesion noted.

 The lips are light to pinkish in color.
 Buccal mucosa is pink in color and moist without discoloration or increased
pigmentation.
 No presence of aphthous stomatitis.
 No ulcers or nodules observed.
 Frontal teeth are evulsed.
 Mommy Orange has 28 teeth with the absence of frontal teeth and some
premolars.
 No bleeding observed on the buccal mucosa and the gums.
 Gums are light brown in color but no lesions observed.
 There is no presence of lesions on the tongue.
 Mommy Orange can distinguish different taste.
 Uvula is in midline position and elevates upon saying “ah”.
 There is no inflammation of the tonsils observed.
CARDIAC ASSESSMENT
 No irregular sounds heard upon auscultation.

 Apical pulse is in normal rate.
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 There are no palpitations observed.
PERIPHERAL AND VASCULAR ASSESSMENT
Arms:
 Equal in size and symmetrical in shape.
 No presence of edema, lesions and redness noted.
 Skin complexion is brown, warm to touch.
 Radial pulse is in normal value.
 There are no lumps noted upon palpation.
Legs:
 Legs large in size but symmetrical.
 Skin on legs and thigh is intact.
 Skin is light brown in color.
 Skin on legs and thigh is warm and dry to touch without edema noted.
 Tibial pulse can slightly be palpated.
 There are no presence of lesions, lumps and bruising noted.
 Legs have smooth coordinated movements.
THORAX AND LUNG ASSESSMENT
 There is presence of rales on exhalation upon auscultation.

 Chest expansion is symmetrical.
 There is no presence of lesions, redness or edema.
 Respirations are quite labored because of smoking.
BREAST ASSESSMENT
Upon the permission of Mommy Orange, one girl from the group palpated Mommy’s
breast and the results are as follows:
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 Breast moderate in size, round in shape, and symmetrical bilaterally.
 There are no lumps palpated on both breast.
 There is no tenderness felt upon movement.
 There are no peau d’ orange or abnormal skin appearance upon interview to
Mommy Orange.
 Upon interview to Mommy Orange, she stated that she hasn’t observed any dark
spots.
ABDOMINAL ASSESSMENT
 Umbilicus is in midline position.

 Number of bowel sounds is normal at the rate of 10 sounds per minute.
 There is no tenderness felt on all quadrants.
 There is no presence of abdominal hair.
GENITOURINARY-REPRODUCTIVE ASSESSMENT
Upon interview to Mommy Orange, she stated that:

 There is no pain upon urination and fecal excretion.
 There is the presence of episiorrhaphy or “tahi” as verbalized by Mommy
Orange.
MUSCULOSKELEAL ASSESMENT
 Posture and Gait is steady, stable, coordinated and smooth.

 Shrugs shoulders and moves head to right and left against resistance.
 Upper and lower extremities have full ROM.
 Muscles moderately firm bilaterally.
 No deviations, inflammations, or bony deformities.
 Moves upper and lower extremities freely against gravity and resistance.
30 | P a g e
NEUROLOGIC ASSESSMENT
Mental status:
 Mommy Orange is conscious and coherent.
 Facial expressions symmetrically and correlate with mood and topic discussed.
 Speech is clear and intonation is appropriate.
 Follows assessment instructions.
 Oriented to person, place, time, and events.
 Enjoys joking.
Cerebellar and motor function:

 There are no involuntary movements.
 Alternates finger to nose with eyes closed, occasionally tends to hit opposite side
of nose.
Sensory status:
 Superficial light and deep- touch sensation intact on arms, legs, neck, chest, and
back.
 Identifies point localization correctly.
Motor status:
 Muscle tone firm at rest.
 Muscles are not a bit prominent because of fat deposition.
 No involuntary movements noted.
 Muscle strength moderately strong and equal bilaterally.
CRANIAL NERVES ASSESSMENT
Cranial Nerve Assessment Normal Actual Finding
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Technique Finding
I. Olfactory Ask the client to Client is able to Mommy Orange
smell and identify identify the was able to
the scent presented different scents identify different
with each nostril with each nostril scents
separately and with separately and presented to
the eyes closed. with eyes her.
closed unless
such conditions
like colds is
present.
II. Optic Provide adequate The client Mommy Orange

lighting and ask should be able was able to read
client to read from a to read with with each eye
reading material each eye and and both eyes.
held at a distance of both eyes.
36cm (14 in.)
III. Oculomotor Reaction to light: Illuminated and Mommy Orange

Using a penlight non-illuminated pupils
and approaching pupil should (Both the
from the side, shine constrict. illuminated and
a light on the pupil. non- illuminated)
Observe the constricted.
response of the
illuminated pupil.
Shine the light on
the pupil again and
observe the
response of the
other pupil.
Her pupils
Reaction to Pupils constrict constricted
accommodation: when looking at when looking at
Ask client to look at a near object, a near object
a near object and dilate when and dilated
then at a distant looking at a when looking at
object. Alternate the distant object, a far object.
gaze from the near converge when
to the far object. near object is
Next, move an moved towards
object towards the the nose.
client’s nose.
IV. Trochlear Hold a penlight 1 ft. Client’s eyes Mommy
32 | P a g e
in front of the should be able Orange’s eyes
client’s eyes, ask to follow the were able to
the client to follow penlight as it follow the
the movements of moves. penlight upward,
the penlight with the downward,
eyes only. Move the sideward and
penlight upward, diagonally.
downward,
sideward and
diagonally.
V. Trigeminal While client looks Client should Mommy Orange

upward, lightly have a positive was able to elicit
touch lateral sclera corneal reflex, corneal reflex,
of eye to elicit blink able to respond responded to
reflex. To test light to light and sharp and dull
sensation, have deep sensation objects and was
client close eyes, and able to able to
wipe a wisp of differentiate hot differentiate hot
cotton over client’s from cold. from cold.
forehead.
To test deep
sensation, use
alternating blunt and
sharp ends of an
object. Determine
sensation to warm
and cold object by
asking client to
identify warmth and
coldness.
VI. Abducens Hold a penlight 1 ft. Both eyes Both eyes move
in front of the coordinated, in coordination.
client’s eyes only. move in unison
Move the penlight with parallel
through the six alignment.
cardinal fields of
gaze.
VII. Facial Ask client to smile, Client should be She was able to
raise the eyebrows, able to smile, demonstrate
frown, puff out raise eyebrows, various facial
cheeks, and close puff out cheeks, expressions,
eyes tightly. Ask and close eyes and was able to
client to identify without any differentiate
33 | P a g e
various tastes difficulty. The between the
placed on tip and client should taste of sweet
sides of tongue. also be able to and sour.
distinguish
different tastes.
VIII. Vestibulocochlear Have a client Client should be Mommy Orange
occlude one ear. able to hear the was able to hear
Out of the client’s ticking of the ticking in both
sight, place a ticking watch in both ears.
watch 2 to 3 cm, ears.
ask what the client
can hear and repeat
with the other ear.
Ask the client to The client She was able to

walk across the should have stand and walk
room and back and upright posture in an upright
assess the client’s and steady gait position and
gait. and able to able to maintain
maintain balance.
balance.
IX. Glossopharyngeal Ask the client to say Client should be Mommy Orange
“ah” and observe able to elicit was able to elicit
upward movement gag reflex and gag reflex and
of the uvula. swallow without was able to
Elicit gag reflex. any difficulty swallow without
Note ability to and the uvula any difficulty.
swallow. must elevate The uvula
when the client elevated when
says “ah”. she said “ah”.
X. Vagus Ask the patient to The client Mommy Orange

swallow and speak should be able can swallow
(note hoarseness) to swallow without difficulty
without difficulty and can speak
and speak audibly.
audibly.
XI. Accessory Ask client to shrug Client should be Mommy Orange

shoulders against able to shrug was able to
resistance from your shoulders and shrug her
hand (repeat for turn head from shoulders and
other side). side to side. turn her head
from side to
side.
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XII. Hypoglossal Ask client to Client should be Mommy Orange
protrude tongue at able to move was able to
midline and then tongue without move her
move it side to side. any difficulty. tongue in
different
directions.
Nutritional Status
Mommy Orange, age 44, has a height of 162 cm and weighs 62 kilograms.
BMI = Weight in kilograms__ _
Height in square meters
= 62 kilograms__ _
(1.62 meters) 2
= 62 kg__ _
Asia-Pacific Obesity Guidelines
BMI Interpretation
<18.5 Underweight
18.6 – 22.9 Healthy Weight
> 23.0 Overweight
23.0 – 24.9 At risk
25.0 – 29.9 Obese I
> 30.0 Obese II
2.62 m2
= 23.66 kg/m2
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Therefore, Mommy Orange is said to be within overweight range based on Asia-
Pacific Obesity Guidelines.
CLINICAL THRESHOLDS
MEN < 90 cm (35 inches)

WOMEN < 80 cm (31.5 inches)
Waist Circumference: 75 cm. (NORMAL)
WHR INTERPRETATIONS
WHR MEN WOMEN
NORMAL < 1.0 <0.85
CENTRAL OBESITY ≥ 1.0 ≥ 0.85
WHR= waist circumference

hip circumference
= 29.25 inches
31 inches
= 0.94 (CENTRAL OBESITY)
Obstetrical History:
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Mommy Orange started a family when she was 18 years old. She has six
children. She had her menarche when she was 12. She has a regular menstrual cycle
of 28 days. She delivered all her children via normal spontaneous delivery (NSD).
According to her, she never experienced any complication in all her children.
She regularly follows prenatal check-up when she was pregnant and had a
complete vaccination of Tetanus Toxoid. She has some superstition like the pregnant
should sleep in straight posture and she must not take a bath in the evening to prevent
neurologic disorders. She is nearing the menopausal age but according to her, she
does not want to have further children. Her obstetric history is G6P6T6P0A0L6M0.
History of Past and Present Illness
Mommy Orange has no serious diseases experience except for cough and colds,
fever and headache.
Activities of Daily Living
Mommy Orange’s day starts at 6:00 a.m. she prepares breakfast for Daddy
Apple and their children. From the whole day, Mommy Orange is mostly at home except
for some leisure hours at 3:00 p.m. to 4:00 p.m.; she is playing Bingo and she is
smoking near their neighbor. After dinner commonly at 7:00 p.m. Mommy Orange watch
television up to 10:00 p.m. and sleeps afterwards.
Grapes
Due to his work from 7:00 a.m. to 6:00 p.m., the group wasn’t able to assess
Grapes.
Strawberry
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Strawberry has already build a family in Manila and she is not staying anymore in
the family’s house so the group was not able to assess her.
Mango
General Appearance
Client is alert and cooperative. Smiling but with mild anxiety. Dress is slightly dirty.
Walks steadily with posture slightly stooped.
Mango’s vital signs were taken and recorded as follows:
SKIN, HAIR AND NAILS ASSESSMENT
Skin:
 Skin is dark brown in color.
 Skin is also warm, and dry to touch.
 Skin fold return to place after 1 second when lifted over arm.
 Minimal scars and lesions on upper and lower extremities were noted.
 There is no presence of edema observed.
 No redness observed.
Hair:
 Mango has short-length hair.
38 | P a g e
 Hair is black in color, straight, clean, medium textured.
 Hair is evenly distributed on head.
 No scalp lesions or flaking.
 There is the presence of dandruff.
Nails:
 Fingernails are long and not trimmed.
 Fingernails are dirty and in medium thickness.
 No clubbing or abnormal curving of the nails.
Head:
 Head is symmetrically rounded.
 No edema, lumps noted upon palpation.
 Skull is intact and no presence of head fractures observed.
Neck:
 Neck is non-tender with full Range of Movement.
 Neck is symmetrical without masses, scars, and lesions.
 Trachea is in midline position.
 Thyroid gland or Adam’s apple is not quite prominent.
EYE ASSESSMENT
 Hair on eyebrow, eyelashes are intact and equally distributed.

 There are no secretions felt on eyelids.
 There are no tenderness, edema and lesions noted on the eyelids.
39 | P a g e
 There is no edema noted on nasolacrimal duct upon palpation.
 Sclera is white in color without dark spots.
 Palpebral and bulbar conjunctivas are pinkish in color but without lesions noted.
 PERRLA (Pupil is equally rounded and reactive to light and accommodation.
EAR ASSESSMENT
 Auricles are without deformities, lumps, or lesions noted and palpated.

 Auditory canals contain moderate amount of dark-brown cerumen.
 Ear color is same with facial skin.
 Ear folded returned after 1 second.
 No edema and redness noted on both ears.
 Mango is responsive to watch tick test.
NOSE AND SINUSES ASSESSMENT
 There is no presence of lumps, edema lesions noted upon palpation.

 Presence of nasal discharges was observed.
 Sense of smell was quite affected by nasal discharges.
 Sinuses are non-palpable
 Lips are moist with no lesions or ulcerations observed.

pigmentation.
40 | P a g e
 There is no presence of aphthous stomatitis, lesions on buccal mucosa upon
inspection.
 Upper and lower teeth are secured.
 There is the presence of dental carries.
 Gums are pink in color and moist without inflammation, bleeding, or
discoloration.
 Hard and soft palates smooth without lesions or masses.
 Tongue is in midline position and has a full range of motion.
 Gag reflex is present intact.
 Uvula is in midline position and elevated upon speaking.
 Mango identified different taste presented.
 Tonsils are not inflamed or enlarged.
CARDIAC ASSESSMENT
 No abnormal sounds heard upon auscultation

 Apical pulse is in normal value.
Arms:
 Equal in size and symmetrical bilaterally.
 Skin on arms is dark brown in color.
 Skin is warm and dry to touch.
 There is no presence of edema, bruising noted.
 Minimal lesions and marks of chickenpox were observed.
 Radial pulses normal in rate, and strong.
Legs:
 Legs’ size is appropriate for Mango’s weight.
41 | P a g e
 Legs are symmetrical in size and shape.
 Skin on legs and thigh is intact, light brown in color.
 Skin on legs is warm and dry to touch without edema.
 Tibial pulse can be slightly palpated.
 Toenails are dirty and not trimmed.
 Feet are dirty.
 Thorax’ skin is light brown in color with mark of chickenpox noted.

 There is no chest hair observed.
 There are no abnormal sounds heard upon auscultation except for some sounds
of cough.
 There is the presence of cough.
 No edema, lesion, bulging or retraction observed on the skin.
 Breathing is not labored.

 No abdominal hair observed.
 There is no edema, lesions noted.
 There is no tenderness on all abdominal quadrants upon palpation.
 Bowel sounds are in normal value of 15 sounds per minute.
GENITO-URINARY AND REPRODUCTIVE ASSESSMENT
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Upon interview to Mango, he verbalized that he doesn’t feel any pain upon
urination and fecal excretion.
MUSCULOSKELETAL ASSESSMENT
 Posture is slightly stooped.

 Gait steady, smooth, and has coordinated movements.
 Upper and lower extremities have full Range of Motion (ROM).
Mental status:
 Moody and short-tempered.
 Vocabulary suitable to educational level.
 Gives semiabstract answers but are appropriate.

 Touches nose with fingers with eyes closed.
 Alternates supination, pronation, adduction and abduction properly.
Sensory status:
 Superficial light and deep- touch sensation are clearly identified on arms, legs,
neck, chest, and back.
43 | P a g e
Motor status:
 Muscle size adequate for age.
 No fasciculation or involuntary movements noted.
CRANIAL TYPE AND ASSESSMENT EXPECTED ACTUAL

NERVE FUNCTION PROCEDURE RESULT RESULT
I. Olfactory >Sensory >Asked her to >The client >Mango
*Carries smell the should identify correctly
smell vinegar while the vinegar and identified the
impulses her eyes were soy sauce scent of vinegar,
from natural closed presented soy sauce even
mucous correctly with presence of
membrane nasal
to brain discharges.
.
II. Optic >Sensory >She was asked >The client > Mango read
*Visual to read a print should read the the print properly
impulses for about 14 print properly with no difficulty
from eyes to inches away with no difficulty
brain
III. Oculomotor >Motor > The client is > The client’s >Mango’s pupils
*Contracts seated, using a pupil should constricted
the eye penlight, the constrict
muscle to examiner will
control eye check for the
44 | P a g e
movements, eye/pupil
constricts constriction
pupils and
elevates
eyelid
IV. Trochlear >Motor >Instruct client >The client’s >Mango’s eye

*Contracts to follow the eye should have followed H-
eye muscle penlight coordinated pattern with
to control movements/moti coordinated eye
inferomedial on in all movement
eye direction
movement
V. Trigeminal >Sensory >the client was > The client >Mango’s
*Sensory instructed to should identify correctly
impulses of close her eyes & correctly the part identified the
touch, pain identify which where she felt part being
and part of her face touched touched
temperature is being touched correctly
from face to
the brain
>Motor > The client was >Contraction of >Mango’s

*Influences asked to bite, to masseter and muscle
clenching palpate temporal muscle contracted
and lateral masseter and
jaw temporal lobes.
movements
VI. Abducens >Motor >Instructed her > The client’s > Mango’s eye
*Controls to move eyes eye should moved laterally
lateral eye laterally move laterally with no difficulty
45 | P a g e
movements
VII. Facial >Sensory > The client is > The client >Mango was
*Contains instructed to should identify able to identify
sensory taste and vinegar and salt the salt and
fibers for identify vinegar correctly vinegar
taste of and salt
anterior two- correctly
thirds of
tongue and
stimulated
secretions
from salivary
glands
>Motor >The client >Mango was

*Supplies > The client is should be able able to perform
the facial asked to smile, to perform the the instructions
muscles and frown, show instructions with with no signs of
affects facial teeth, raise no difficulty difficulty
expressions eyebrows and
blow her cheeks
VIII. Acoustic >Sensory >Asked the >The client >Mango was

*Contains client to repeat should be able able to repeat
fiber for the whispered to repeat the the whispered
hearing and words and after whispered words correctly
balance that, asked the words correctly and slight
client to stand and perform swaying resulted
straight and balance while while she was
close her eyes standing with standing with
closed eyes eyes closed.
46 | P a g e
IX. >Sensory >The client is > The client >Mango
Glossopharyng *Contains instructed to should be able correctly
eal fibers for identify taste to identify taste identified taste
taste of introduced like and gag reflex presented with
posterior salt and should be gag reflex
third of calamansi juice present present
tongue &
sensory
fibers of the
pharynx that
result in the
gag reflex
when
stimulated
X. Vagus >Sensory >The client is >The client’s > Mango’s soft
*Carries instructed to say soft palate and palate and uvula
sensation “ah”, swallow uvula should be symmetrically
from the and a tongue symmetrical in rise, she
throat, depressor is rising and swallowed with
larynx, introduced for should have no no difficulty and
heart, lungs, gag reflex difficulty in she was able to
bronchi, swallowing and elicit gag reflex
gastrointesti elicit gag reflex
nal tract and
abdominal
viscera
XI.Spinal >Motor >Palpate >The client’s >Mango have
accessory *Innervates strength of trapezius symmetrical
neck muscle sternocleidomas muscle should trapezius muscle
that toid and be symmetrical with slight
promotes trapezius and with strong contraction,
47 | P a g e
movement muscles. Ask contraction of same results
of the the client to turn sternocleidomas with her
shoulders head against the toid muscles on sternocleidomas
and head examiner’s hand opposite side toid muscle
rotations & ask the client the head was
to shrug turned
shoulders
XII. >Motor >Instructed her > The client >Mango was
Hypoglossal *Innervates to protrude her should be able able to move her
tongue tongue and to move her tongue in
muscle that move it on tongue on different
promotes different different directions with
the directions directions with no difficulty
movement no difficulty
of food and
talking.
Growth and Development
(Adolescents, 13 to 19 years)
Erik Erikson’s Psychosocial Stages

Fidelity: Identity vs. Role Confusion (Adolescents, 13 to 19 years)
Ego Quality: Fidelity
Related elements in Society: Ideology
The adolescent is newly concerned with how they appear to others. Superego
identity is the accrued confidence that the outer sameness and continuity prepared in
the future are matched by the sameness and continuity of one's meaning for oneself, as
evidenced in the promise of a career. The ability to settle on a school or occupational
identity is pleasant. In later stages of Adolescence, the child develops a sense of sexual
identity.
48 | P a g e
As they make the transition from childhood to adulthood, adolescents ponder the
roles they will play in the adult world. Initially, He is apt to experience some role
confusion- mixed ideas and feelings about the specific ways in which they will fit into
society- and may experiment with a variety of behaviors and activities. Most
adolescents achieve a sense of identity regarding whom they are and where their lives
are headed.
Mango at this age is becoming more aware of his identity. Makes transition from
childhood to adulthood as he verbalized “dapat mas maging mature nako ngayon na
tumatanda na ko”. Ponder out the roles that he will play in the adult world. He is apt to
experience some role confusion- mixed ideas and feelings about the specific ways in
which they will fit into society- and may experiment with a variety of behaviors and
activities. Most likely Mango is already achieving a sense of identity regarding who he is
and where his life is headed.
Sigmund Freud’s Psychosexual Stages
Genital Phase
The genital phase lasts from puberty, about the twelfth year of age, and onwards.
It actually continues until development stops; which is ideally in the eighteenth year of
age when adulthood starts. This phase represents the major portion of life, and the
basic task for the individual is the detachment from the parents. In this phase the focus
is again on the genitals but this time the energy is expressed with adult sexuality. The
ego in the genital phase is well-developed, and so uses secondary process thinking,
which allows symbolic gratification. The symbolic gratification may include the formation
of love relationships and families, or acceptance of responsibilities associated with
adulthood.
Now, Mango’s pleasure is mostly related to secondary process thinking. Her

drive energy is redirected to symbolic gratification, mainly related to love relationships
and families, or acceptance of responsibilities associated with adulthood. Mango can
49 | P a g e
think independently and makes choices based on his priority and not of his parents.
Problems however might occur during this phase because it is also the time when the
individual tries to come in terms with unresolved residues of the early childhood.
Nutrition Status by Age, Weight and Height
Mango, age 13, has a height of 149 cm and weighs 41 kilograms.

= 41 kilograms__ _
(2.22 meters) 2
= 41 kg.__ _
2.22 m2
= 18.47 kg/m2
BMI Interpretation
<18.5 Underweight
> 23.0 Overweight
23.0 – 24.9 At risk
25.0 – 29.9 Obese I
> 30.0 Obese II
Therefore, Mango is said to be within underweight range based on Asia-Pacific

Obesity Guidelines.
History of Past Illness
According to Mommy Orange, Mango has already experienced minor illnesses

such as headache, fever, colds, cough and diarrhea due to infection or decreased
immunity. Mommy orange used Oregano to relieve the cough of Mango. For treating
fever and colds, sometimes Mommy orange gave him Bioflu and Biogesic without
doctor’s prescription while for stopping diarrhea, Mommy orange sometimes gave him
50 | P a g e
Diatabs or Lomotil even if he did not consult her physician or barangay health center.
But most often, he does not take any medication. He has never been hospitalized. He
was also exposed to chickenpox.
History of Present Illness
Upon the assessment to Mango, he experiences cough and colds that occurs
intermittently. The only medication he uses is Oregano.
Mango’s day starts at 6:00 AM he takes a bath and goes to Remedian School
(Grade 6) at 7:00AM At 12:00 noon, he would take his lunch with his family. Around
1:00 PM, he would go back to school. At 4:30 PM, he would go home. When he is
already at home he would take a nap and afterwards do all his assignments, after that
he will go and spend time with their neighbor and peers, which has the same age, like
his. At 7:00PM up to 9:00PM he and his family would have their dinner. After having
their dinner Mango would usually watch TV together with his family. After watching TV
he will go to sleep.
Watermelon
General Appearance
Client is alert and cooperative with the student nurses. She is smiling with mild
anxiety towards the physical assessment done to her by the group. Dress is dirty and
soiled. Watermelon walks steadily. Her posture and gait is firm.
Watermelon’s vital signs were taken and recorded as follows:
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Skin:
 Skin is warm, and dry to touch.
 Skin fold return to place after 1 second when lifted over forearm.
 Some scars on upper and lower extremities.
 No signs of dehydration noted upon inspection.
 No edema and redness observed.
 There is no presence of lumps palpated.
Hair:
 Hair is shoulder-length, black in color, straight, clean, medium textured.
 No patches of hair loss observed.
 No dandruff noted upon inspection.
Nails:
 Fingernails are short, neat and properly trimmed.
 There is no presence of clubbing or abnormal curving of the nails.
 Capillary refill return after 2 seconds upon Blanch’s test.
Head:
 No tenderness palpated on the head.
 No lumps or irregular masses and lesions noted.
52 | P a g e
 Skull has no fractures upon inspection.
Neck:
 Neck is non-tender upon palpation with full Range of Motion.
 Neck is symmetrical.
 No lumps, abnormal masses observed upon palpation.
 No lesions noted.
 Trachea is in midline position
 Thyroid gland is non-palpable.
EYE ASSESSMENT
 Hair on eyebrows, eyelashes is evenly distributed.

 No lesions or secretions noted on eyelids.
 No edema or lumps palpated on the nasolacrimal duct.
 The color of bulbar and palpebral conjunctivas is light brown to pinkish.
 Color of the sclera appears white.
 Pupil is equally round and reactive to light and accommodation.
 No lesions observed around the eye.
 Eyes have coordinated movement.
 Watermelon can read newsprint 14 inches far.
EAR ASSESMENT
 Color of the ear is same with facial skin.

 No tenderness, lumps or irregular masses palpated.
 Auditory canal contains yellowish cerumen.
53 | P a g e
 Watermelon was responsive to watch tick test.
 Mild swaying upon Romberg’s test.
 No presence of tinnitus or tingling sound in the ears.
 Watermelon can hear and repeat whispered word.
 External structure of the nose is without deformity.

 Nose symmetrical.
 No nodules, lumps and edema observed upon palpation.
 No nasal discharges observed
 Watermelon can clearly identify different scents.
 There was no obstruction heard upon deep inhalation.
 Lips are moist and free from cracks or any sign of dehydration.
 No lesions or ulcerations observed on the lips.
 Buccal mucosa is pinkish in color and moist without discoloration or increased
pigmentation.
 No ulcers or nodules observed on the buccal mucosa.
 Watermelon has a complete 28 teeth for her age.
 No dental caries noted upon inspection.
 Gums are pinkish in color.
 Hard and soft palates are free from lumps, lesions or ulcerations.
 Tongue has a full range of motion.
54 | P a g e
 Watermelon can distinguish different flavor.
 Gag reflex is present upon inspection.
CARDIAC ASSESSMENT
 Apical pulse is in normal range.

 No abnormal sounds heard upon auscultation.
 No pulsations are visible.
Arms:
 Arms are equal in size and symmetrical.
 Watermelon has light brown complexion.
 Skin on the arm is warm and dry to touch.
 No edema, bruising, or lesions noted upon inspection.
 Radial pulse is palpable and in normal rate.
 Brachial pulse can be slightly palpated.
Legs:
 Legs’ size is appropriate and symmetrical with Watermelon’s weight.
 Skin is intact with no lesions, ulceration, redness or lumps inspected.
 Skin on legs is light brown to white in color.
 Skin over the legs is warm and dry to touch.
 Tibial pulse can be slightly felt.
 Toenails are thick but not dirty.
55 | P a g e
 Skin on chest is pale pink in color but without any lesions, lumps or birth mark
observed.
 No hair noted on the chest.
 No abnormal bulging or retractions on skin above the ribcage.
 No coughs and colds observed.
 Respirations are in normal range.
 Respirations are not labored.
 Bilateral chest expansion is symmetrical.
 Bowel sounds heard upon auscultation in normal value of 12 sounds per minute.
 Abdomen is free from hair, bruising, and lumps.
 No tenderness felt on all abdominal quadrants upon palpation.
 There is no skin discoloration noted.
Upon interview to Watermelon she verbalized that she doesn’t feel any pain upon
 Posture and gait is steady and coordinated.

 Upper and lower extremities have full Range of Motion.
 No deviations, inflammations, or bony deformities observed.
56 | P a g e
NEUROLOGICAL ASSESSMENT
Mental status:
 Pleasant and friendly.
 Slightly and appropriately dressed for weather with matching colors and patterns.
Speech clear and appropriate.
 Carefully chooses words to convey feelings and ideas.

 Alternates finger to nose with eyes closed,
 Watermelon’s pronation, supination abduction and adduction of hands are in
coordination and without difficulty.
Sensory status:
back.
Motor status:
57 | P a g e

I. Olfactory >Sensory >Asked her to >The client >Watermelon
smell vinegar while the vinegar identified the
impulses her eyes were presented scent of vinegar.
from natural closed. correctly.
mucous
membrane
to brain.
II. Optic >Sensory >She was asked >The client >Watermelon
*Visual to read a print should read the read the print
impulses for about 14 print properly properly with no
from eyes to inches away. with no difficulty. difficulty.
brain.
III. Oculomotor >Motor > The client is > The client’s >Watermelon’s
*Contracts seated, using a pupil should pupils
the eye penlight, the constrict. constricted.
constricts constriction.
pupils and
elevates
eyelid.
IV. Trochlear >Motor >Instruct client >The client’s >Watermelon’s

*Contracts to follow the eye should have eye followed H-
eye muscle penlight. coordinated pattern with
58 | P a g e
inferomedial on in all movement.
eye direction.
movement.
V. Trigeminal >Sensory >the client was > The client >Watermelon

and part of her face touched touched.
temperature is being correctly.
from face to touched.
the brain.
>Motor >Contraction of >Watermelon’s

*Influences > The client was masseter and muscle
clenching asked to bite, to temporal contracted.
and lateral palpate muscle.
jaw masseter and
movements. temporal lobes.
VI. Abducens >Motor >Instructed her > The client’s >Watermelon’s

*Controls to move eyes eye should eyes moved
lateral eye laterally. move laterally. laterally with no
movements. difficulty.
VII. Facial >Sensory > The client is > The client >Watermelon
*Contains instructed to should identify was able to
sensory taste and vinegar and salt identify the salt
fibers for identify vinegar correctly. and vinegar.
taste of and salt
anterior two- correctly.
59 | P a g e
thirds of
tongue and
stimulated
secretions
from salivary
glands.
>Motor >The client >Watermelon

*Supplies > The client is should be able was able to
the facial asked to smile, to perform the perform the
muscles and frown, show instructions with instructions with
affects facial teeth, raise no difficulty. no signs of
expressions. eyebrows and difficulty.
blow her
cheeks.
VIII. Acoustic >Sensory >Asked the >The client >Watermelon
*Contains client to repeat should be able was able to
fiber for the whispered to repeat the repeat the
hearing and words and after whispered whispered words
balance. that, asked the words correctly correctly and
client to stand and perform slight swaying
straight and balance while resulted while
close her eyes. standing with she was
closed eyes. standing with
eyes closed.
IX. >Sensory >The client is > The client >Watermelon

third of calamansi juice. present. present.
60 | P a g e
tongue &
sensory
fibers of the
pharynx that
result in the
gag reflex
when
stimulated
X. Vagus >Sensory >The client is >The client’s >Watermelon’s

*Carries instructed to say soft palate and soft palate and
sensation “ah”, swallow uvula should be uvula
from the and a tongue symmetrical in symmetrically
throat, depressor is rising and rise, she
larynx, introduced for should have no swallowed with
heart, lungs, gag reflex. difficulty in no difficulty and
bronchi, swallowing and she was able to
gastrointesti elicit gag reflex. elicit gag reflex.
nal tract and
abdominal
viscera.
XI.Spinal >Motor >Palpate >The client’s >Watermelon

accessory *Innervates strength of trapezius have
neck muscle sternocleidomas muscle should symmetrical
that toid and be symmetrical trapezius muscle
promotes trapezius and with strong with slight
movement muscles. Ask contraction of contraction,
of the the client to turn sternocleidomas same results
shoulders head against the toid muscles on with her
and head examiner’s hand opposite side sternocleidomas
rotations. & ask the client the head was toid muscle.
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to shrug turned.
shoulders.
XII. >Motor >Instructed her > The client >Watermelon

Hypoglossal *Innervates to protrude her should be able was able to
tongue tongue and to move her move her tongue
muscle that move it on tongue on in different
the directions. directions with no difficulty.
movement no difficulty.
of food and
talking.
School Age (6 years to 12)

Psychosocial Crisis: Industry vs. Inferiority
Ego Quality: Competence
Related Elements in Society: Division of labor
To bring a productive situation to completion is an aim which gradually

supersedes the whims and wishes of play. The fundamentals of technology are
developed. To lose the hope of such “industrious” association may pull the child back to
the more isolated, less conscious familial rivalry of the oedipal time.
Watermelon at this age is becoming more aware of herself as an individual. She

works hard at being responsible, being good and doing it right. She is now more
reasonable to share and cooperate. Some perceptual cognitive developmental traits
specific for this age group: Watermelon understands the concepts of space and time, in
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more logical, practical ways, beginning to grasp, eager to learn and accomplish more
skills; reading, writing, telling time. She also gets to form moral values, recognize
cultural and individual differences and is able to manage most of her personal need and
grooming with minimal assistance. At her age, Watermelon might express her
independence by being disobedient, using back talk and being rebellious.
Learns to include values and skills of school, neighborhood, and peers. Peer
relationships important. Focuses more on reality, less on fantasy. Family is main base
of security and identity. Sensitive to reactions of others. Seeks approval and
recognition. Enthusiastic, noisy, imaginative, desires to explore. Likes to complete a
task. Enjoys helping others.
Latency Phase
The latency phase is typified by a solidifying of the habits that the child
developed in the earlier stages. Whether the Oedipal conflict is successfully resolved or
not, the drives of the id are not accessible to the ego during this stage of development,
since they have been repressed during the phallic stage. Hence the drives are seen as
dormant and hidden (latent) and the gratification the child receives is not as immediate
as it was during the three previous stages.
Now, Watermelon’s pleasure is mostly related to secondary process thinking. Her

drive energy is redirected to new activities, mainly related to schooling, hobbies and
friends. Problems however might occur during this stage, and this is attributed to
inadequate repression of the Oedipal conflict, or to the inability of the ego to redirect the
drive energy to activities accepted by the social environment.
63 | P a g e
Watermelon, age 12, has a height of 150 cm and weighs 47 kilograms.

= 47 kilograms__ _
(2.25 meters) 2
= 47 kg__ _
2.25 m2
= 20.89 kg/m2

BMI Interpretation
<18.5 Underweight
> 23.0 Overweight
23.0 – 24.9 At risk
25.0 – 29.9 Obese I
> 30.0 Obese II
Therefore, Watermelon is said to be within health weight range based on Asia-

Pacific Obesity Guidelines.
According to Mommy Orange, Watermelon has already experienced minor

illnesses such as headache, fever, colds, cough and diarrhea but hasn’t experience any
serious illness. Mommy Orange used Oregano to relieve cough of Watermelon. For
treating fever and colds, sometimes Mommy Orange gave her Bioflu and Biogesic
without doctor’s prescription.
Upon the assessment to Watermelon, she doesn’t experience cough and colds
unlike her siblings. She does not take any medications like vitamin supplements.
64 | P a g e
Watermelon’s day starts at 6:00 AM she takes a bath and goes to Remedian
School (Grade 6) at 7:00AM At 12:00 noon, she would take her lunch with her family.
Around 1:00 PM, he would go back to school. At 4:30 PM, she would go home. When
she is already at home she would take a nap and afterwards do all her assignments and
study her lessons after that she will go and spend time to their neighbor, which has the
same age, like her. At 7:00PM up to 9:00PM she and his family would have their dinner.
After having their dinner Watermelon would usually watch TV together with her family.
After watching TV she will go to sleep together with the rest of the family.
Banana
General Appearance
Client is alert and cooperative but has no idea what the student nurses are doing.
Smiling but with mild anxiety towards the student nurses. Dress is dirty and soiled.
Banana walks steadily but with posture slightly stooped.
Banana’s vital signs were taken and recorded as follows:
Skin:
 Skin is dark to light brown in color.
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 Minimal wounds were noted on upper extremities.
Hair:
 Banana has short-length hair.
 Hair is black in color, straight, clean.
 There is the presence of dandruff upon inspection.
Nails:
 Fingernails are long and not trimmed.
 Fingernails are dirty and in medium thickness.
Head:
 Skull is intact.
 No presence of head fractures observed.
Neck:
 Neck is non-tender upon palpation with full Range of Movement.
 Neck is symmetrical without lumps, scars, and lesions.
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EYE ASSESSMENT

 There is no edema or any obstruction noted on nasolacrimal duct upon palpation.
 Sclera is white in color and without dark spots.
EAR ASSESSMENT

 Auditory canals contain moderate amount of light brown color of cerumen.
 Banana is responsive to watch tick test.

 Sense of smell is affected by nasal discharges but can slightly detect
different scents.
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inspection.
pigmentation.
 Malocclusion of the upper frontal teeth was observed.
 Banana has dental stains but without dental carries.
 Gums are pink in color and moist without inflammation, bleeding, or discoloration.
CARDIAC ASSESSMENT
 No feeling of chest pain.

Arms:
 Skin on arms is dark to light brown in color.
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 Arms are equal in size and symmetrical bilaterally.
 Radial pulses are normal in rate, and strong.
Legs:
 Legs’ size is appropriate for Banana’s weight.
 Toenails are noted dirty and not trimmed.
 Feet of Banana are dirty as well.

 There is the presence of cough and colds.
of cough.

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Mental status:
 Facial expressions are subjective to Banana’s feelings towards the entry of the
student nurses.
 Banana is not quite oriented to person, place, time, and events.
 Banana cannot verbalized own feelings due to his young age and state of mind.

Sensory status:
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Motor status:

I. Olfactory >Sensory >Asked her to >The client >Banana
mucous
membrane
to brain.
II. Optic >Sensory >She was asked >The client >Banana can
*Visual to read a print should read the see the
impulses for about 14 print properly newsprint but
from eyes to inches away with no difficulty. doesn’t slightly
brain. know how to
read.
III. Oculomotor >Motor > The client is > The client’s >Banana’s
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pupils and
elevates
eyelid.
IV. Trochlear >Motor >Instruct client >The client’s >Banana’s eye

eye direction.
movement.
V. Trigeminal >Sensory >the client was >The client >Banana

and part of her face touched touched
temperature is being touched correctly
from face to
the brain
>Motor > The client was >Contraction of >Banana’s

*Influences asked to bite, to masseter and masseter and
clenching palpate temporal temporal muscle
and lateral masseter and muscle. contracted.
jaw temporal lobes.
movements
VI. Abducens >Motor >Instructed her > The client’s >Banana’s eyes
72 | P a g e
lateral eye laterally. move laterally. with no difficulty.
movements.
VII. Facial >Sensory > The client is > The client >Banana was
fibers for identify vinegar correctly. vinegar.
taste of and salt
thirds of
tongue and
stimulated
secretions
from salivary
glands.
*Supplies >The client >Banana was

the facial > The client is should be able able to perform
muscles and asked to smile, to perform the the instructions
affects facial frown, show instructions with with no signs of
expressions. teeth, raise no difficulty. difficulty.
eyebrows and
blow her
cheeks.
VIII. Acoustic >Sensory >Asked the >The client >Banana was

balance. that, asked the words correctly and slight
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close her eyes. standing with standing with
closed eyes. eyes closed.
IX. >Sensory >The client is > The client >Banana
tongue &
sensory
fibers of the
pharynx that
result in the
gag reflex
when
stimulated.
X. Vagus >Sensory >The client is >The client’s >Banana’s soft

heart, lungs, gag reflex. difficulty in she was able to
bronchi, swallowing and elicit gag reflex.
gastrointesti elicit gag reflex.
nal tract and
abdominal
viscera.
XI.Spinal >Motor >Palpate >The client’s >Banana has
74 | P a g e
and head examiner’s hand opposite side toid muscle.
rotations. & ask the client the head was
to shrug turned.
shoulders.
XII. >Motor >Instructed her > The client >Banana was

the directions. directions with no difficulty.
movement no difficulty.
of food and
talking.

75 | P a g e
Banana at this age works hard at being responsible, being good and doing it
right. Banana can follow some command from her mother. He is now more reasonable
to share and cooperate. Some perceptual cognitive developmental traits specific for this
age group: Banana understands the concepts of space and time, in more logical,
practical ways, beginning to grasp, eager to learn and accomplish more skills; reading,
writing, telling time. He also gets to form moral values, recognize cultural and individual
differences and is able to manage most of his personal need and grooming with minimal
assistance.
Banana can independently walk, think and act on his own. The group has seen
him play whenever he wants. He can also think logically about simple issues like if he
will take a bath or not.

Latency Phase
The latency phase is typified by a solidifying of the habits that the child
developed in the earlier stages. Whether the Oedipal conflict is successfully resolved or
not, the drives of the id are not accessible to the ego during this stage of development,
since they have been repressed during the phallic stage. Hence the drives are seen as
dormant and hidden (latent) and the gratification the child receives is not as immediate
as it was during the three previous stages.
Now, Banana’s pleasure is mostly related to secondary process thinking. His

drive energy is redirected to new activities, mainly related to schooling, hobbies and
friends. Problems however might occur during this stage, and this is attributed to
76 | P a g e
inadequate repression of the oedipal conflict, or to the inability of the ego to redirect the
drive energy to activities accepted by the social environment.
Banana, age 8, has a height of 113 cm and weighs 16 kilograms.

= 16 kilograms__ _
(1.28 meters) 2
= 16 kgs__ _
1.28 m2
= 12.5 kg/m2

BMI Interpretation
<18.5 Underweight
> 23.0 Overweight
23.0 – 24.9 At risk
25.0 – 29.9 Obese I
> 30.0 Obese II
Therefore, Banana is said to be within underweight range based on Asia-Pacific

Obesity Guidelines.
According to Mommy Orange, Banana had not experience any serious illness.
The common problem for him and his siblings is cough and colds. The treatment of
Mommy Orange for that is via boiling of Oregano. Banana has never been hospitalized.
He has exposed to mumps virus earlier in his life.
77 | P a g e
Upon the assessment to Banana, He experiences cough and colds. He does not
take any medications.
Banana wakes up at around 6:00 AM and takes a bath and goes to Remedian
School at 7:00AM. When the clock reads at 12:00 noon, he would take his lunch with
his family. Around 1:00 PM, he would go back to school. At 4:00 PM, He would go
home. At 5:00 PM he will go outside and play with his playmates. Afterwards, he would
do his assignments. And at 7:00PM to 9:00PM he and his family would have their
dinner. After having their dinner Banana would usually watch TV together with his
family. After watching TV he will go to sleep.
Avocado
General Appearance
Client is alert but sometimes uncooperative towards the student nurses but is
understandable because of his young age. Avocado sometimes feels scared towards
the student nurses’ action. Different expressions of smiling and frowning were observed.
Dress is dirty and soiled. Posture and gait is steady.
Avocado’s vital signs were taken and recorded as follows:
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Skin:
 Skin is light brown in complexion.
Hair:
 Hair is shoulder-length, black in color, straight but not properly groomed.
 Presence of dandruff was noted.
Nails:
 Fingernails are long, dirty and not trimmed.
Head:
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Neck:
EYE ASSESSMENT

 Avocado doesn’t know how read newsprint 14 inches far.
EAR ASSESMENT

80 | P a g e
 Auditory canals contain dark-brown color of cerumen.
 Avocado was responsive to watch tick test.
 Nostrils are symmetrical.

 Avocado can clearly identify different scents.

pigmentation.
 Avocado has a 22 set of teeth; some milk teeth are still intact.
 Presence of dental carries was evident on the frontal teeth.
 Avocado can distinguish different flavor.
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CARDIAC ASSESSMENT

Arms:
 Avocado has light brown complexion.
Legs:
 Legs’ size is appropriate and symmetrical with Avocado’s weight.
 Toenails are dirty and not trimmed.
 Feet of Avocado were also dirty due to walking barefooted.
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observed.


Mental status:
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 Pleasant but sometimes unruly towards the assessment.

Sensory status:
back.
Motor status:

I. Olfactory >Sensory >Asked her to >The client >Avocado
84 | P a g e
mucous
membrane
to brain.
II. Optic >Sensory >She was asked >The client >Avocado
*Visual to read a print should read the doesn’t know
impulses for about 14 print properly how to read so
from eyes to inches away. with no difficulty. she was
brain. unresponsive to
this test.
III. Oculomotor >Motor > The client is > The client’s >Avocado’s
pupils and
elevates
eyelid.
IV. Trochlear >Motor >Instruct client >The client’s >Avocado’s eye

eye direction.
movement.
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V. Trigeminal >Sensory >the client was > The client >Avocado
and part of her face touched touched.
temperature is being correctly.
from face to touched.
the brain.
>Motor >Contraction of >Avocado’s

*Influences > The client was masseter and masseter and
clenching asked to bite, to temporal temporal muscle
and lateral palpate muscle. contracted.
jaw masseter and
movements. temporal lobes.
VI. Abducens >Motor >Instructed her > The client’s >Avocado’s eye
lateral eye laterally. move laterally. with no difficulty.
movements.
VII. Facial >Sensory > The client is > The client >Avocado was
fibers for identify vinegar correctly. vinegar.
taste of and salt
thirds of
tongue and
stimulated
secretions
86 | P a g e
from salivary
glands.
>Motor >The client >Avocado was

*Supplies > The client is should be able able to perform
the facial asked to smile, to perform the the instructions
muscles and frown, show instructions with with no signs of
affects facial teeth, raise no difficulty. difficulty.
expressions. eyebrows and
blow her
cheeks.
VIII. Acoustic >Sensory >Asked the >The client >Avocado was

balance. that, asked the words correctly and slight
close her eyes. standing with standing with
closed eyes. eyes closed.
IX. >Sensory >The client is > The client >Avocado

tongue &
sensory
fibers of the
pharynx that
87 | P a g e
result in the
gag reflex
when
stimulated.
X. Vagus >Sensory >The client is >The client’s >Avocado soft

heart, lungs, gag reflex. difficulty in she was able to
bronchi, swallowing and elicit gag reflex.
gastrointesti elicit gag reflex.
nal tract and
abdominal
viscera.
XI.Spinal >Motor >Palpate >The client’s >Avocado have

and head examiner’s hand opposite side toid muscle.
rotations. & ask the client the head was
to shrug turned.
shoulders.
XII. >Motor >Instructed her > The client >Avocado was
88 | P a g e
the directions directions with no difficulty
movement no difficulty
of food and
talking.


Avocado at this age is becoming more aware of herself as an individual. She

works hard at being responsible, being good and doing it right. She is now more
reasonable to share and cooperate. Some perceptual cognitive developmental traits
specific for this age group: Avocado understands the concepts of space and time, in
more logical, practical ways, beginning to grasp, eager to learn and accomplish more
skills; reading, writing, telling time. She also gets to form moral values, recognize
cultural and individual differences and is able to manage most of her personal need and
89 | P a g e
grooming with minimal assistance. At her age, Avocado might express her
independence by being disobedient. She is enthusiastic, noisy, imaginative, desires to
explore. Avocado likes to complete a task and she enjoys helping others.
Phallic Stage
The pleasure zone switches to the genitals. Freud believed that during this stage
girl develops unconscious sexual desires for their father. Because of this, she becomes
rivals with her mother and sees her as competition for the father’s affection. During this
time, girls also develop a fear that their mother will punish them for these feelings, such
as by castrating them. This group of feelings is known as Electrica Complex
According to Freud, out of fear of castration and due to the strong competition of
her mother, boys eventually decide to identify with her rather than fight her. By
identifying with her mother, the boy develops feminine characteristics and identifies
herself as a female, and represses his sexual feelings toward her father.
Now, According to Mommy Orange, Avocado is very close to her father. She
always wants to hug and catch the attention of her father. Earlier in her life she doesn’t
know how to follow her mother’s command; but now that she is getting older, Avocado
develops closeness to her mother.
Avocado, age 6, has a height of 107 cm and weighs 15 kilograms.

90 | P a g e
= 15 kilograms__ _
(1.14 meters) 2
= 15 kgs__ _
1.14 m2
= 13.16 kg/m2
BMI Interpretation
<18.5 Underweight
> 23.0 Overweight
23.0 – 24.9 At risk
25.0 – 29.9 Obese I
> 30.0 Obese II
Therefore, Avocado is said to be within underweight range based on Asia-Pacific

Obesity Guidelines.
According to Mommy Orange, Avocado’s primary problem is cough and colds but
doesn’t she doesn’t develop any complication because of this condition. Mommy
Orange treatment for this is by boiling Oregano leaves. Avocado also have felt tooth
ache earlier in her life.
Upon the assessment to Avocado, she experiences cough and colds. She does
not take any medications.
Avocado’s day starts at 7:00 AM. She plays with her siblings at their backyard at
around 8:00 AM. Also, she would help her mother in doing household chores. She
would take a bath at 8:30 AM and will go to school at day care center (prep). At 12:00
91 | P a g e
noon, she would go home and take her lunch with her family. When it is 1:00 PM
already, she would take her afternoon sleep. Around 4:00 PM, she would wake up and
play with her siblings again. She would take a rest at 6:00 PM she would play outside
together with her playmates. Then, she would take her dinner with her family. When the
clock reads at around 7:00 PM, she and her brothers and sister would watch TV until
9:00 and then after watching she would usually go to sleep.
B. FINAL ASSESSMENT
Daddy Apple
The student nurses haven’t met Daddy Apple throughout the home visits
because he is getting out for work as early as 5 am.
Mommy Orange
General Appearance
Mommy Orange is 44 years old. He has long, black hair with some grayish and
white discoloration. She is chubby and small. She is conscious and coherent while the
group interviews her. At our initial home visit, she was wearing blouse and short jeans
with slippers on. Her nails are trimmed and clean. She has steady gait and posture and
no signs of distress observed. She stands 162 cm. and weighs 62 kg.
Mommy Orange’s vital signs were taken and recorded as follows:
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Skin:
 Light brown in color.
 Warm, and dry to touch.
 No signs of dehydration noted.
 Skin folded over the forearm returned after 2 seconds.
 No redness or edema noted.
 Has no presence of scars noted.
Hair:
 Hair is in medium length.
 Hair is black in color with some grayish and white strands.
 Scalp is free from dandruff.
Nails:
 Pinkish nail beds.
 No inflammation noted.
 No clubbing or abnormal curvature of the nails.
 Nails are trimmed and neat.
Head:
 Round in shape and symmetrical on sides.
 No tenderness noted.
 No lumps noted upon palpation
 There are no fractures noted.
93 | P a g e
Neck:
 There are no lumps palpated.
 Trachea is on the midline position.
 Range of Movement is appropriate.
EYE ASSESSMENT
 Hair on eyebrow, eyelashes, and eyelids are evenly distributed.

 No discharge on the eyelids upon inspection.
 Sclera appears white.
 Bulbar and Palpebral conjunctivas are light brown to pinkish in color.
 No edema and lumps observed on nasolacrimal duct upon palpation.
 Pupils are equal in size.
 PERRLA (Pupils equally round and reactive to light and accommodation.)
 Mommy Orange was able to read newsprint 14 inches far.
 Has a coordinated eye movement.
EAR ASSESSMENT
 No lumps palpated on both ears.

 No lesions or signs of inflammation noted.
 The ear contains yellowish cerumen but not dry.
 Both ears are responsive to whisper test.
 Color of the ear is same with the facial skin.
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NOSE AND SINUS ASSESSMENT
 No presence of colds or nasal discharges.

 No tenderness noted upon palpation.
 Can distinguish different smell.
 No lumps palpated.
 No obstruction observed upon deep inhalation.
 The lips have small cracks but no lesion noted.

 The lips are light to pinkish in color.
pigmentation.
 No presence of aphthous stomatitis.
 No ulcers or nodules observed.
 Frontal teeth are evulsed. She hasn’t visited a dentist to check for possible
solution to the problem.
 Mommy Orange has 28 teeth with the absence of frontal teeth and some
premolars.
 No bleeding observed on the buccal mucosa and the gums.
 Gums are light brown in color but no lesions observed.
 There is no presence of lesions on the tongue.
 Mommy Orange can distinguish different taste.
 There is no inflammation of the tonsils observed.
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CARDIAC ASSESSMENT
 No irregular sounds heard upon auscultation.

 Apical pulse is in normal rate.
 There are no palpitations observed.
Arms:
 Equal in size and symmetrical in shape.
 No presence of edema, lesions and redness noted.
 Skin complexion is brown, warm to touch.
 Radial pulse is in normal value.
 There are no lumps noted upon palpation.
Legs:
 Legs large in size but symmetrical.
 Skin on legs and thigh is intact.
 Skin on legs and thigh is warm and dry to touch without edema noted.
 Tibial pulse can slightly be palpated.
 There are no presence of lesions, lumps and bruising noted.
 Legs have smooth coordinated movements.
 There is still the presence of rales on exhalation upon auscultation.

 There is no presence of lesions, redness or edema.
 Respirations are still labored because of smoking.
96 | P a g e
BREAST ASSESSMENT
Upon the permission of Mommy Orange, one girl from the group palpated Mommy’s
breast and the results are as follows:
 Breast moderate in size, round in shape, and symmetrical bilaterally.
 There are no lumps palpated on both breast.
 There is no tenderness felt upon movement.
 There are no peau d’ orange or abnormal skin appearance upon interview to
Mommy Orange.
 Upon interview to Mommy Orange, she stated that she hasn’t observed any dark
spots.

 Number of bowel sounds is normal at the rate of 12 sounds per minute.
 There is no tenderness felt on all quadrants.
 There is no presence of abdominal hair.
Upon interview to Mommy Orange, she stated that:

 There is no pain upon urination and fecal excretion.
 There is the presence of episiorrhaphy or stitches from vaginal birth.
MUSCULOSKELEAL ASSESMENT
 Posture and Gait is steady, stable, coordinated and smooth.

 Upper and lower extremities have full ROM.
97 | P a g e
Mental status:
 Mommy Orange is conscious and coherent.
 Speech is clear and intonation is appropriate.
 Follows assessment instructions.
 Enjoys joking.

 There are no involuntary movements.
 Alternates finger to nose with eyes closed, occasionally tends to hit opposite side
of nose.
Sensory status:
back.
Motor status:
 Muscles are not a bit prominent because of fat deposition.
98 | P a g e
Grapes
Due to his work from 7:00 a.m. to 6:00 p.m., the group wasn’t able to assess
Grapes.
Strawberry
Strawberry has already built a family in Manila and she is not staying anymore in
the family’s house so the group was not able to assess her.
Mango
General Appearance
Client is alert and cooperative. Smiling but with mild anxiety. Dress is clean and neat.
Mango is properly groomed. Mango can walk steadily.
Mango’s vital signs were taken and recorded as follows:
Skin:
 Skin is dark brown in color.
99 | P a g e
Hair:
 Mango has short-length hair.
 Hair is black in color, straight, clean, medium textured.
 Presence of dandruff was reduced due to family and student nurses’
interventions.
Nails:
 Fingernails are short and properly trimmed.
 Fingernails are clean.
Head:
 Skull is intact and no presence of head fractures observed.
Neck:
 Neck is non-tender with full Range of Movement.
 Neck is symmetrical without masses, scars, and lesions.
 Thyroid gland or Adam’s apple is not quite prominent.
100 | P a g e
EYE ASSESSMENT

 There is no edema noted on nasolacrimal duct upon palpation.
 Sclera is white in color without dark spots.
EAR ASSESSMENT

 Auditory canals contain moderate amount of yellowish cerumen.
 Mango is responsive to watch tick test.

 Nasal discharge was relieved.
 Can distinguish different scents.
101 | P a g e

pigmentation.
inspection.
 Upper and lower teeth are secured.
CARDIAC ASSESSMENT

Arms:
 Equal in size and symmetrical bilaterally.
 Skin on arms is dark brown in color.
 Radial pulses normal in rate, and strong.
102 | P a g e
Legs:
 Legs’ size is appropriate for Mango’s weight.
 Toenails are clean and properly trimmed.
 Feet are clean.

of cough.
 Cough was relieved.

103 | P a g e
GENITO-URINARY AND REPRODUCTIVE ASSESSMENT
Upon interview to Mango, he verbalized that he doesn’t feel any pain upon

Mental status:
 Moody and short-tempered.
 Gives semiabstract answers but are appropriate.

104 | P a g e
Sensory status:
Motor status:
Watermelon
General Appearance
Client is alert and cooperative with the student nurses. She is smiling with
minimal anxiety towards the student nurses. Dress is clean and properly groomed.
Watermelon walks steadily. Her posture and gait is firm.
Watermelon’s vital signs were taken and recorded as follows:
Skin:
105 | P a g e
Hair:
 Hair is shoulder-length, black in color, straight, clean, medium textured.
 No dandruff noted upon inspection.
Nails:
 Fingernails are short, neat and properly trimmed.
Head:
Neck:
106 | P a g e
EYE ASSESSMENT

 Watermelon can read newsprint 14 inches far.
EAR ASSESMENT

 Auditory canal contains yellowish cerumen.
 Watermelon was responsive to watch tick test.
 Watermelon can hear and repeat whispered word.
107 | P a g e

 Nose symmetrical.
 No nasal discharges observed
 Watermelon can clearly identify different scents.
pigmentation.
 Watermelon has a complete 28 teeth for her age.
 No dental caries noted upon inspection.
 Watermelon can distinguish different flavor.
CARDIAC ASSESSMENT
108 | P a g e
Arms:
 Watermelon has light brown complexion.
Legs:
 Legs’ size is appropriate and symmetrical with Watermelon’s weight.
 Toenails are thick but not dirty.
observed.
109 | P a g e
Upon interview to Watermelon she verbalized that she doesn’t feel any pain upon

Mental status:
 Pleasant and friendly.
110 | P a g e

Sensory status:
back.
Motor status:
Banana
General Appearance
Client is alert and cooperative but has no idea what the student nurses are doing.
Smiling but with mild anxiety towards the student nurses. Dress is clean and he is
properly groomed. Banana walks steadily.
111 | P a g e
Banana’s vital signs were taken and recorded as follows:
Skin:
 Skin is dark to light brown in color.
 Minimal wounds were healing.
Hair:
 Banana has short-length hair.
 Hair is black in color, straight, clean.
 Dandruff was reduced upon interventions.
Nails:
 Fingernails are short and properly trimmed.
112 | P a g e
 Fingernails are clean and in medium thickness.
Head:
 Skull is intact.
 No presence of head fractures observed.
Neck:
 Neck is non-tender upon palpation with full Range of Movement.
 Neck is symmetrical without lumps, scars, and lesions.
EYE ASSESSMENT

 There is no edema or any obstruction noted on nasolacrimal duct upon palpation.
 Sclera is white in color and without dark spots.
EAR ASSESSMENT
113 | P a g e
 Auditory canals contain moderate amount of light brown color of cerumen.
 Banana is responsive to watch tick test.
 Nasal discharges were relieved.

 Banana can now distinguish different scents presented to him.

inspection.
pigmentation.
 Malocclusion of the upper frontal teeth was still evident.
 Banana has dental stains but without dental carries.
114 | P a g e
CARDIAC ASSESSMENT
 No feeling of chest pain.

Arms:
 Skin on arms is dark to light brown in color.
 Arms are equal in size and symmetrical bilaterally.
 Radial pulses are normal in rate, and strong.
Legs:
 Legs’ size is appropriate for Banana’s weight.
 Toenails are noted clean and properly trimmed.
 Feet of Banana are clean and free from bruises as well.
115 | P a g e

 Cough and Colds were relieved.
of cough.


116 | P a g e
Mental status:
 Facial expressions are subjective to Banana’s feelings towards the entry of the
student nurses.
 Banana is not quite oriented to person, place, time, and events.
 Banana cannot verbalized own feelings due to his young age and state of mind.

Sensory status:
Motor status:
Avocado
General Appearance
117 | P a g e
Client is alert but still slightly uncooperative towards the student nurses but is
understandable because of his young age. Avocado sometimes feels scared towards
the student nurses’ action. Different expressions of smiling and frowning were observed.
Dress is now cleaned and properly groomed. Posture and gait is steady.
Avocado’s vital signs were taken and recorded as follows:
Skin:
 Skin is light brown in complexion.
Hair:
 Hair is shoulder-length, black in color, straight but not properly groomed.
 Dandruff was reduced upon interventions.
Nails:
118 | P a g e
 Fingernails are short, clean and properly trimmed.
Head:
Neck:
EYE ASSESSMENT

119 | P a g e
 Avocado doesn’t know how read newsprint 14 inches far.
EAR ASSESMENT

 Auditory canals contain minimal amount of yellowish cerumen.
 Avocado was responsive to watch tick test.
 Nostrils are symmetrical.

 Nasal discharges were relieved upon student nurses and family’s interventions.
 Avocado can clearly identify different scents.

120 | P a g e
pigmentation.
 Avocado has a 22 set of teeth; some milk teeth are still intact.
 Avocado can distinguish different flavor.
CARDIAC ASSESSMENT

Arms:
 Avocado has light brown complexion.
Legs:
 Legs’ size is appropriate and symmetrical with Avocado’s weight.
121 | P a g e
 Toenails are short and properly trimmed.
 Feet of Avocado were clean.
observed.


122 | P a g e
Mental status:
 Pleasant but sometimes unruly towards the assessment.

Sensory status:
back.
Motor status:
123 | P a g e
III. Socio-economic, Cultural and Environmental Assessment
A. Type of Family
The type of Family that the group has adopted is a nuclear family. It consist
only of a father, a mother and children. The Fruit family consist of Daddy Apple,
Mommy Orange, they have six children but Strawberry doesn’t live with them
because she has now a separate family in Manila. Grapes, Mango, Watermelon,
Banana, Avocado are the only children left living in the family’s house.
B. Dominant family member/s in terms of decision-making especially to health care
In terms of decision-making, both of the couple decide for the management of

their financial needs. But in terms of health care needs, the primary decision-maker
is Mommy Orange, because she knows more of the health care available in the
community than Daddy Apple. Mommy Orange is more concerned with the health
condition of each member because she knows more of her family’s need in terms of
health; she is also with her children most of the time unlike Daddy Apple who works
as a jeepney driver for the whole day.
C. Source of Income and Expenditures
INCOME
Daddy Apple’s jeepney 10,000 Php/month

driving
124 | P a g e
Grapes’ job 4,000 Php/month
Total 14000 Php/month
The Fruit Family’s only source of income is Daddy Apple and Grapes. Mommy
Orange is a plain housewife. Strawberry, the eldest daughter, doesn’t live with them and
the family do not receive any remittence from her. While the other children are still
studying.
In terms of NEDA’s requirement of Php 2,768.60 per month per individual, the
family’s income is insufficient for them; they only have Php 2,000 per individual.
Monthly Income- 14, 000 Php

Number of Individuals- ÷ 7______
2, 000 Php/month/individual
EXPENDITURE
Jeepney Boundary
and Gas 4,000 Php/month
Expenses
Utilities 3,500 Php/month
Food, Groceries 2, 500 Php/month
Children’s School 1,500 Php/month
Expenses
Vices 1,500 Php/month
TOTAL 13, 500 Php/month
125 | P a g e
The major expense of the family is the jeepney business because the vehicle is
only rented, they have an additional burden for that added with the gas expenses. Next
is their source of water and electricity, their house needs, their children’s school
expenses and the couples vices like alcohol, cigarette and bingo game.
Total Income 14, 000 Php/month

Total Expenses 13, 500 Php/ month
Savings 500 Php/month
In case of emergency, the family has only 500 Php/ monthly savings. Their other
source of money if there is an emergency need is their neighbors.
D. Working Hours
Daddy Apple usually wakes up and prepares for work at 5 in the morning. He
is going home for lunch at 12 nn.- 1 p.m. According to Mommy Orange, her husband
usually go home after work at 9 in the evening. Grapes, the oldest son starts work at
7 in the morning and go home at 5 in the afternoon.
E. Ethnic Background and Religious Affiliation
None of the couple is native at Angeles City. Daddy Apple originates from
San Luis, Pampanga while Mommy Orange originates from Eastern Samar. As for
their religion,the whole family are currently Roman Catholics. According to Mommy
Orange, they sometimes attend Sunday masses, all of their children are baptized in
the church. The family doesn’t practice their faith that much, they don’t often go to
masses.
F. Significant other’s role/s in the family life.
126 | P a g e
The individuals who serve as their significant others are their neighbors, their
neighbors aren’t related to them by blood. Their S.O. mostly serve as an emotional
support for them. In times of sadness, Mommy Orange play bingo with them. The
Fruit family don’t rely on them much on financial support because just like them, their
S.O. also finds difficulty in earning money. The family’s relatives are far away from
them so they are not receiving any form of support coming from their relatives.
G. Health habits and beliefs
The group learned the health habits and beliefs of the family from Mommy
Orange. According to her, they believe on herbolarios, but they still go to the health
center if the problem worsen. They also self-medicate like using herbal medicines
like oregano, sambong, pandan and the like. They believe sambong, pandan, ugat
ng ilib treats kidney problems while oregano treat cough and colds. According to
Mommy Orange, some of the superstitious belief they believe are: when a person is
pregnant, she must refrain from taking bath in the night and she must sleep on
straight position to prevent the risk for craziness. They also believe that if a black cat
pass on their way, their day will be unlucky.
H. Family’s involvement in community activities
The Fruit Family involves themselves mostly on heath-related activities. The

immunization of all the children, which was conducted in the health center, are
complete. Mommy Orange also attends the mother’s class conducted by the student
nurses regularly.
I. Family’s utilization of community resources
The Fruit Family’s only community resource utilized is the school. And the
children benefit from that. But sometimes, they don’t go to school because their lazy
according to their mother.
127 | P a g e
J. Housing Condition
The house of the family is a concrete-wood type. The walls are concrete,
while their roof is made up of wood materials. The house of the family is a rented
apartment.
*for better view of the TFA, a bigger copy is provided in the appendices (page 199).
a.
Adequacy of living Space Normal Requirement
Adults 3 m2
Children 1.5 m2
Infants 0 m2
TOTAL FLOOR AREA= 4.21m. X 2.29 m. = 9.64 m2
ADEQUACY OF LIVING SPACE= 9.64 m2 / 7(# of family members)

= 1.38 m2 (inadequate)
128 | P a g e
ADEQUACY OF VENTILATION INTERPRETATION
< 18 % Poor Ventilation

18-19 % Fair
> 19 % Adequate Ventilation
TOTAL WINDOW OPENING= 1.12 m X .58m = .65 m2
ADEQUACY OF VENTILATION= TOTAL WINDOW OPENING X100

TOTAL FLOOR AREA
.65 m2 X 100
=
9.64 m2
= 7 % poor ventilation
Sleeping Arrangement- The Fruit family has only one bed, their bed is a wooden-type.
Only Grapes sleeps in the Bed; while the rest of the family sleeps on the floor.
Adequacy of Furniture- The Fruit family has a bed, a cabinette, a drawer box for their
clothes, a long chair, a kitchen table, they also have T.V. but it is dysfunctional. The
furniture of the family almost occupy the whole floor area, the furnitures are adequate
for their daily survival but the free space is inadequate for them.
Presence of insects and rodents- According to Mommy Orange, there is the presence
of mosquitoes and cockroaches. The possible breeding site for these vectors is the
bathroom and drainage. Their problem of rodents was releived after housing a cat.
Accident Hazards- The student nurses observe some of the accident hazards of the
Fruit family like: the family’s LPG tank is near their bed. This problem can aggreviate
because Mommy Orange and Daddy Apple smokes. The roof is damaged which can be
a fall hazard. Their free space is also inadequate which can be a risk for injuries
especially for children.
b. Food sources, storage and cooking facilities
129 | P a g e
Their store their food by means of a covered casserole. According to Mommy
Orange, they are the one who prepare for their food. As for their cooking facility, they
have a gas stove. The group observed that the family’s cooking facilities are dirty which
can be a source for infection; the group also observed that the family do not practice
proper handwashing before and after meals.
c. Water supply
The family’s source of water supply is the Angeles Water District. As for their
drinking supply, sometimes they buy distilled water. The water of the family is potable
for drinking but needs further boiling to assure safetiness of the drinking water.
d. Toilet facility
The toilet of the Fruit family is a septic tank but without a water carriage. They
owned their toilet facility and the group oberserved that the family’s toilet is in good
condition.
e. Drainage system
The drainage system of the family is uncovered and stagnant. The group
observed that the drainage is dirty and can be a breeding site for mosquitoes and other
vectors of diseases.
f. Social and health facilities available
Barangay Virgen de los Remedios has a basketball court, a health center and a
barangay hall. The family utilize mostly the health center for consultation.
g. Communication and transportation facilities
130 | P a g e
The family communicate with each other especially the working individuals via
their cellular phones. While the family transports from one place to another by the
jeepney that Daddy Apple use in his work.
IV. PROBLEM IDENTIFICATION
A. List of Problem Identified
No. Problems Identified Score Rank
Poor Home Condition: Presence of vector of diseases

1 4.34 1
e.g. rodents, mosquitoes, flies, roaches
2 Presence of Health Deficit: Cough and Colds 4.17 2
Family size beyond what family resources can

3 3.34 3.5
adequately provide
Unhealthful lifestyle and Personal Habits: Poor Personal

4 3.34 3.5
Hygiene
Unhealthful lifestyle and Personal Habits: Walking

5 2.84 5
Barefooted
6 Poor Home Condition: Inadequate Lighting 2.50 6
7 Poor Home Condition: Inadequate Living Space 2.17 7
8 Presence of Health Deficit: Malnutrition 2 8
131 | P a g e
Unhealthful lifestyle and Personal Habits: Cigarette
9 1.5 9
Smoking
B. Priority Setting
Problem # 1
Presence of Breeding Sites of Vectors of Diseases
CRITERIA COMPUTATION SCORE JUSTIFICATION
1. NATURE OF THE 2/3= X 1 0.67 Presence of breeding sites of

PROBLEM vectors of diseases is a
health threat because it can
3 = Health deficit pose a greater risk of
2 = Health threat acquiring infection. The risk
1 = Foreseeable for infection can be
crisis aggravated by unsanitary
lifestyle. Rodents can cause
leptospirosis; cockroaches
can lead to sepsis while
mosquitoes can be a great
risk for acquiring dengue.
132 | P a g e
2. MODIFIABILITY The problem is easily
OF THE 2/2= X 2 2 modifiable:
PROBLEM
Current knowledge,
2 = Easily technology and
modifiable intervention:
1 = Partially
modifiable > The family are
0 = Not Modifiable knowledgeable about the
problem and as part of their
intervention they often use
Current knowledge, insecticides. The family also
technology and  has a cat for the belief that
interventions
cat’s favorite meal is a rat.
Family Resources 
Family resources:
SN Resources 
> The family has insecticide
Community  in the home as part of their
Resources intervention in eradicating the
problem.
Student nurse resources:
> The primary resource that

the student nurses can give
to the family is health
teachings. The student
nurses can teach the family
about proper cleaning of the
house to prevent breeding
sites of these vectors of
diseases.
Community Resources:
> The community can have

seminars on how to clean the
house especially the corners
and the drainage. They can
have a campaign fighting for
the existence of dengue,
leptospirosis and infection
brought about by these
133 | P a g e
vectors of diseases.
The problem has moderate

3. PREVENTIVE 2/3 X 1= 0.67 preventive potential due to
POTENTIAL the following criteria:
3=High Severity of the problem:

2=Moderate
1=Low > The problem is not severe
because none of the
members of the family has
Severity ▲ acquired any diseases
caused by these vectors of
Duration ▼ diseases.
Current ▲
Management Duration of the Problem:
High -risk Group ▲ > The duration of the
problem is long because it
has been existing since the
couple transferred to the
present apartment 26 years
ago.
.
Current Management:
> The family has a

management in dealing with
134 | P a g e
this problem. They often use
insecticide as the primary
intervention. They also
housing a cat.
Exposure of high-risk
group:
> All of the family members

are exposed to this problem
since they all live in a same
house except for Strawberry
who now has a separate
family in Manila.
4. SALIENCE 2/2 x 1= 1 The family is aware of the

existence of the problem and
2 = A serious problem they think that this needs an
needing immediate immediate attention to
attention prevent the infestation of
1 = A problem not these vectors to their food,
needing immediate clothes and other belongings.
attention
0 = Not perceived as a
problem
TOTAL 4.34
SCORE
Problem # 2
Presence of Cough and Colds
135 | P a g e
1. NATURE OF THE 3/3= X 1 1 Cough and Colds is a health

PROBLEM deficit because there is
already the existence of the
3 = Health deficit problem and failure in
2 = Health threat maintenance of health even
1 = Foreseeable before the entry of the nurses
crisis with the family.

PROBLEM
Current knowledge,
1 = Partially
modifiable > The family’s current
0 = Not Modifiable intervention in eradicating the
problem is by drinking boiled
Oregano leaves. Though
Current knowledge, Oregano is not one of the ten
technology and  recommended herbal
interventions
medicine of the DOH; it is still
Family Resources  proven to be safe and
effective against cough.
SN Resources 
Family resources:
Community 
Resources > The family’s resource is the
herbal medicine Oregano,
boiling facilities like
casserole, LPG stove among
others.

about interventions to
prevent the presence and the
136 | P a g e
re-occurrence of the problem
like proper hygiene and
protection.
> The community can have a

backyard herbal planting to
prevent large cost of factory-
manufactured medicines.
They can plant lagundi and
oregano.


2=Moderate
1=Low > The problem is severe
because it is aggravated by
poor ventilation and
Severity ▼ inadequate living space.
There is the presence of
Duration ▲ cross-infection between the
Current ▲ family members.
Management
Duration of the Problem:
High -risk Group ▲
> The problem of cough and
cold is intermittent and is not
present every day because of
the family’s intervention.
.
Current Management:
> The family’s current

management is by boiling
Oregano. According to
different research sites,
Oregano is indeed use in
treating cough.
137 | P a g e
group:
> Only three among the

seven members living in the
house had acquired such
condition so the potential of
the problem to be prevented
is increase.
4. SALIENCE 1/2 x 1= 0.5 The family is aware of the

existence of the problem but
2 = A serious problem doesn’t need any immediate
needing immediate attention to this problem.
attention They are aware of the
1 = A problem not problem as evidence by the
needing immediate presence of interventions like
attention boiling Oregano leaves.
problem
TOTAL 4.17
SCORE
138 | P a g e
Problem # 3.5:
Family Size beyond what family resources can adequately provide
1. NATURE OF THE 2/3= X 1 0.67 The problem is a health

PROBLEM threat, inadequacy of the
family resources to suffice
3 = Health deficit their daily needs may result
2 = Health threat to serious health problems if
1 = Foreseeable not corrected e.g.
crisis malnutrition which is now
actually evident in the family
since Mango, Banana and
Avocado are considered to
be undernourished. The
family will find it also difficult
to manage health problem
like buying medications.
2. MODIFIABILITY The problem is partially

OF THE 1/2= X 2 1 modifiable for the following
PROBLEM criteria:
2 = Easily modifiable Current knowledge,

1 = Partially modifiable technology and
0 = Not Modifiable intervention:
> The family are aware of the

problem and they are doing
everything they can
especially Daddy Apple and
Grapes to increase their
income. Daddy Apple is
extending his working hours.
Family resources:
> The family’s manpower is

inadequate since only two of
the family is working and the
non-working members of the
family are still young and still
139 | P a g e
studying. While Mommy
Orange can’t find a job since
she is busy providing care to
her studying children
> The Student Nurses can

pinpoint some tips on how
they are going to minimize
their water and electric
consumption and enumerate
some foods that are
nutritious yet cheap which
may help in lowering their
expenses. Examples of this
are:
 Use fluorescent lamp
instead of light bulbs.
 Close the faucet when
not in use
 Remove or even just
decreasing the family’s
vices like alcohol,
cigarette and bingo
game.
 Foods such as
vegetables, tofu and the
like.
> The community has no

resources to totally eradicate
the problem but they can
have seminars to teach the
family about proper
budgeting, they can also
build cooperative to increase
the profit of each family.

140 | P a g e
3=High
2=Moderate
1=Low
Severity of the problem:
> The family's monthly

income is small and would
not suffice their needs
compare with the NEDA
prescribed share amount of
money that each of the family
members must have:
NEDA- P2, 768.60

Fruit family has 7 current
members-P14,000
(P14,000/7 = P2,000)
> The problem of the family

existed after the birth of the
fourth to sixth child. The
problem aggravates because
of increase in members of
the family.
.
Current Management:
> The family has current

management; Daddy Apple is
lengthening his working
hours to increase his income.
group:

of the Fruit Family are
exposed to the problem of
inadequate resources.
.
141 | P a g e
4. SALIENCE 2/2 x 1= 1 The family sees this as a
problem, which is for them,
2 = A serious problem needs an immediate action
needing immediate as evidenced by when the
attention Student Nurses did their
1 = A problem not needing interview Mommy Orange
immediate attention
was able to verbalize their
problem
problem financially.
TOTAL 3.34
SCORE
142 | P a g e
PROBLEM # 3.5
Unhealthful lifestyle and personal practices: Poor personal hygiene
1. NATURE OF THE 2/3 x 1 0.67 The problem is categorized

PROBLEM as health threat. Poor
personal hygiene may
3 = Health deficit precipitate or predispose the
2 = Health threat family members to acquire
1 = Foreseeable certain diseases if not solved
crisis immediately.

OF THE 2/2x2 2 modifiable:
PROBLEM
Current knowledge,
1 = Partially
modifiable > Current knowledge and
0 = Not Modifiable technology in eradicating the
problem is present and
applicable. Family knows that
Current knowledge, having poor personal hygiene
technology and  can lead to different kinds of
interventions
diseases especially to
Family Resources  children.
SN Resources  Family resources:
Community  > The family has their own

Resources toothbrush, toothpaste, soap
and soap that they can use to
maintain themselves clean.
> The student nurses are

able to provide measures in
solving the problem and
demonstrate interventions to
promote good personal
143 | P a g e
hygiene. Student nurse work
hand in hand to help the
family comply with proper
hygiene and must teach the
family members on how to
take care of the body to
promote wellness among its
members.
> The community health

center together the barangay
officials implement program,
seminars with regards to the
proper hygiene to avoid cross
contamination of diseases
and microorganisms, there
are also stores available
within the community where
they can buy all necessary
things they needed to provide
the body to be cleansed.
The problem has low

3. PREVENTIVE 2/3x1 0.67 preventive potential due to

2=Moderate
since all members of the
family are seen with
Severity ▼ untrimmed and dirty fingers
which may be a source of
Duration ▼ different diseases.
Current ▲
Management Duration of the Problem:
High -risk Group ▲ > The problem exists for a
long period of time as
evidenced by demonstration
of poor personal hygiene
among members of the
144 | P a g e
family.
Current Management:
> There is a current

management being
performed by the family to
eradicate the presence of the
problem such as taking a
bath and brushing their teeth
but not on a regularly basis.
Other members of the family
seldom clean and trim their
nails.
group:
> Since there is no

occurrence of disease
caused by poor personal
hygiene among family
members there is an
increased chance in
preventing acquisition of
diseases.
4. SALIENCE 0/2 x 1= 0 The family perceived the

problem as a felt need not
2 = A serious problem requiring immediate change.
needing immediate The family thinks it is normal
attention since they are used to it.
1 = A problem not
needing immediate
attention
problem
TOTAL 3.34
SCORE
145 | P a g e
PROBLEM # 5
Unhealthful lifestyle and personal practices: Walking barefooted
1. NATURE OF THE 2/3= X 1 0.67 The problem is categorized

PROBLEM as health threat. The problem
imposes risk on children if
3 = Health deficit not resolved immediately.
2 = Health threat Walking barefooted increase
1 = Foreseeable the risk of children to develop
crisis parasitism which can
eventually lead to
malnutrition another is that
they might step on some
pointed objects which can
place them at risk for injury.

OF THE 2/2= X 2 1 modifiable for the following
PROBLEM criteria:

Current knowledge, > Current knowledge and

technology and  technology in eradicating the
interventions
problem is present and
Family Resources  applicable. The family is
aware of the presence of the
SN Resources  problem. Mother instructs
children about wearing
Community  slippers to avoid accidents
Resources and prevent acquisition of dirt
but doesn’t know that not
wearing slippers puts her
children at risk for parasitism
.
146 | P a g e
Family resources:
> The family has their own

slippers but not usually
wearing them when going
outside or even when they
are inside the house. Mother
instructs children about
wearing slippers to avoid
accidents and prevent
acquisition of dirt.
> The student nurses are

able to reinforced to the
children the advantage of
wearing slippers and
encourage them o comply
with health teachings given.
Student nurses also
discussed the consequences
of not wearing slippers and
encouraged the mother to
always keep an eye on her
children.
> The community health

center provides information
about disease prevention
such as parasitism this also
gives information about
proper hygiene as part of
promotion of health.

3. PREVENTIVE 2/3x1 0.67 preventive potential due to

2=Moderate
1=Low > The problem is not severe
147 | P a g e
Severity ▲ since all members of the
family did not yet
Duration ▼ experienced presence of
Current ▲ severe parasitism.
Management
> The problem exists for a
long period of time since the
toddler years of the children
because the members of the
family were used not to wear
slippers when going outside
or even inside the house.
Current Management:
> There is a current

management being
performed by the family to
eradicate the presence of the
problem. Mother instructs her
children to wear slippers but
since they were not used to it
they don’t continue to
practice it.
group:
> All of the children are

exposed to the problem and
the possible complication that
it can bring like parasitism.
4. SALIENCE 1/2 x 1= 0.5 Family perceives the problem

but not needing immediate
2 = A serious problem attention since they haven’t
needing immediate attention experience any problem such
1 = A problem not needing as parasitism or any injury
immediate attention from walking barefooted.
problem
148 | P a g e
TOTAL
SCORE 2.84
Problem # 6:
Poor home condition: Inadequate Lighting
149 | P a g e
1. NATURE OF THE 2/3 x 1 0.67 Inadequate lighting is

PROBLEM considered as a health threat
because the family could not
3 = Health deficit perform their activities and
2 = Health threat tasks well due to inadequate
1 = Foreseeable lighting during morning and
crisis especially at nighttime.
2. MODIFIABILITY OF 1/2x2 1 The problem is partially

THE PROBLEM modifiable.

Family × > The family is aware that

Resources such problem exists but they
cannot do such measures to
Community solve the problem due to lack
Resources √ of financial resources.
Family resources:
Student √
Resources > Since the family is
Knowledge, financially incapable of buying
Technology the prescribed bulb to use,
and they just make use of what
√
Interventions they have.
to manage
the problem Student Nurses Resources:
> Through the knowledge and

skills, the student nurses
provided health teachings
such as during daytime to
clear curtains so that light may
pass. Also they helped family
to clear the floor from
accidental hazards; they are
prone to accidents because
they cannot see things clearly.
Community resources:
> Certain stores in the vicinity

sell higher wattage-bulbs that
are enough to provide
adequate lighting especially at
night. But due150 to | financial
Page
constraints, they cannot avail
of this.
Problem # 7:
Poor home condition: Inadequate living space
1. NATURE OF THE 2/3= X 1 0.67 Inadequate living space is a

PROBLEM health threat since it can be a
risk for injury especially for
3 = Health deficit Avocado and Banana who
2 = Health threat love to play and run within
1 = Foreseeable the house. The inadequacy
crisis of living space is also a threat
for communicability of
diseases such as coughs and
colds.
151 | P a g e
2. MODIFIABILITY The problem is not modifiable
OF THE 0/2= X 2 0 for the following criteria:
PROBLEM
Current knowledge,
2 = Easily modifiable technology and
1 = Partially modifiable intervention:
0 = Not Modifiable
> The family are aware of the
Current knowledge, problem but don’t have any
technology and  interventions done to
interventions
manage the problem such as
Family Resources  proper positioning and proper
number of furniture that must
SN Resources  be only allotted to their
house. They have no current
Community  technology since they only
Resources rented their apartment so
they can’t increase their living
space.
Family resources:
> The family has inadequate

financial resources to find for
an apartment bigger and
more adequate for the
number of family members.
> The Student Nurses skills

and knowledge can help the
Fruit family by planning on
how to arrange their furniture
so that they may increase
somehow their living space,
at least to minimize the
problem if not to fix it totally
> The community has

inadequate resources to
152 | P a g e
manage the problem since
most of the houses in
Barangay Virgen de los
Remedios are inadequate for
the number of family
numbers. If most of the
families in the community
have this problem, then the
community has inadequate
financial supply because of
greater cost needed.

3. PREVENTIVE 1/3 X 1= 1 preventive potential due to

2=Moderate
1=Low > The problem is considered
to be severe AEB after
Severity ▼ computing the share of each
Duration ▼ family member on their living
space it shows that upon
Current ▼ dividing the whole floor area
Management of the Fruit Family’s house,
each of the family member
yields only 1.38 m2 showing
that the total floor area of the
house is inadequate as to
compare with the prescribed
by the National Building code
of the Philippines R.A 6541
that each of the family must
have at least a share of 3 m2,
therefore if it will be further
divided considering the
space occupied by their
furniture it will yield a more
lower results. Furthermore,
153 | P a g e
there is also the
communicability of cough
and colds among family
member.
> The problem of inadequate

living space has been
existing for a long time
approximately 26 years after
the couple married and
transferred to their present
house.
.
Current Management:
> The family does not have

any current management on
their problem regarding
Inadequate living space as
evidenced by Mommy
Orange statement when the
student nurses asked her
about their management to
the problem:
“wala, wala na sanay na
kami”.
group:

of the Fruit Family are
exposed to the problem as
they all live on that house
except for one member which
is Strawberry who separately
lives with her own family in
Manila.
154 | P a g e
4. SALIENCE 1/2 x 1= 0.5 Inadequacy of Living Space
is viewed by the family as a
2 = A serious problem serious problem. Though this
needing immediate problem needs an immediate
attention action, because the family
1 = A problem not lacks resources; they treat
needing immediate this problem not needing
attention immediate action.
problem
TOTAL 2.17
SCORE
Problem # 8:
155 | P a g e
Malnutrition
1. NATURE OF THE 3/3= X 1 1 Malnutrition is a health deficit

PROBLEM because there is already the
existence of the problem and
3 = Health deficit failure in maintenance of
2 = Health threat health even before the entry
1 = Foreseeable of the nurses with the family.
crisis
2. MODIFIABILITY The problem is partially

PROBLEM
Current knowledge,
1 = Partially
modifiable > The family doesn’t seem to
0 = Not Modifiable have knowledge in managing
the problem because it is
existing for a long time and
Current knowledge, there seems no improvement
technology and  of their condition, they don’t
interventions
also know the proper food
Family Resources  they can serve to the family.
SN Resources  Family resources:
Community  > The family has the proper

Resources resources because they can
buy nutritious yet cheap food
like vegetables like
malunggay, monggo. Or as
substitute for meat the family
can buy tokwa.

156 | P a g e
about proper food to eat
without compromising their
inadequate financial
resource.
> The community has

adequate financial resources
and Barangay Virgen de los
Remedios has a small
population for them to have
feeding programs and
deworming especially for the
children. The health center
can allocate micronutrient
supplementation to the
children to supply their
inadequacies.
The problem has low

3. PREVENTIVE 0/3 X 1= 0 preventive potential due to

2=Moderate
because three of the family
members are below normal
Severity ▼ values which can affect their
mental status in school while
Duration ▼ Mommy Orange is
Current ▼ overweight which can be a
Management risk for hypertension and
other cardiovascular
High -risk Group ▼ diseases.
> The problem of malnutrition

for the children has long
been existed since their
earlier years. While Mommy
Orange’s problem started
157 | P a g e
since she gave birth to her
second child 20 years ago.
.
Current Management:
> The family has no current

management to solve this
problem. The student nurses
haven’t seen any vegetable
or any nutritious food in the
family’s home. The children
are also walking barefooted
which can be a cause of
infestations of worms that
can aggravate the problem.
group:
> This factor lowers the

preventive potential of the
problem for the family since
four of them are already
malnourished. The number of
family members acquiring the
condition is greater than
those who did not acquire the
said condition
4. SALIENCE 0/2 x 1= 0 The family is unaware of the

problem and even though the
2 = A serious problem student nurses told them
needing immediate their problem they don’t
attention seem alerted with the
1 = A problem not complication and the
needing immediate condition itself.
attention
problem
TOTAL 2
SCORE
158 | P a g e
Problem # 9:
Unhealthy lifestyle: Cigarette Smoking
1. NATURE OF THE 2/3 x 1 0.67 The problem is considered as

PROBLEM a health threat since smoking
can greatly affect the health
3 = Health deficit of other members of the
2 = Health threat family. Cigarette smoking
1 = Foreseeable contributes to a remarkable
crisis number of diseases,
including coronary heart
disease, stroke, chronic
obstructive pulmonary
disease, peripheral vascular
disease, peptic ulcer disease,
and many types of cancer.
2. MODIFIABILITY 0/2 x 2 0 The problem is not

OF THE modifiable.
PROBLEM
Current knowledge,
2 = Easily modifiable technology and
1 = Partially modifiable intervention:
0 = Not Modifiable
> The family is aware of the
Current knowledge, problem but they opt not to
technology and  change or do something
interventions
about it. They are also not
Family Resources  knowledgeable about the
conditions that can be
SN Resources  acquired because of it.
Community 
Resources Family resources:
> Daddy Apple and Mommy

Orange are the smokers in
the family. They do not have
any resources in solving the
problem because they lack
the initiative to change this
159 | P a g e
habit. Furthermore, they are
not aware of the possible
health consequences of
smoking.
Student nurses resources:
> Student nurses’ knowledge

about smoking can be
considered as student
resources since they can
share to the family what
smoking is and its
complications. Health
teachings can be provided by
the student nurses.
Community resources:
>The community does not

have any resources which
can help the family solve the
problem. There are no
programs or seminars
regarding the effect of
smoking in one’s health.
3. PREVENTIVE 1/3 x 1 0.33 The problem has low

POTENTIAL preventive potential.

2=Moderate
because both the father and
Severity ↓ the mother are affected.
Mommy Orange verbalized
Duration ↓ that Daddy Apple has cough
which further aggravate the
Current ↓
possibility of acquiring
Management communicable diseases
160 | P a g e
Presence of ↑ within the family because the
High risk other children also developed
groups cough.
Duration of the problem:
> The problem has long

existed inside the family,
since Daddy Apple started
to smoke when he was 15,
and Mommy Orange
started to smoke when he
was 17.
Current Management:
> There was no current

management noted. Both
don’t have any interventions
or apt measures to remove
their smoking habit.
Presence of High Risk

groups:
> The whole family is at risk

for developing illnesses,
particularly respiratory illness
since they are living in the
same house and they can
inhale the smoke.
4. SALIENCE 1/2 x 1 0.5 The family recognizes it as a

problem but not needing
2 = A serious problem immediate attention.
needing immediate
attention
1 = A problem not
needing immediate
attention
problem
161 | P a g e
TOTAL 1.5
SCORE
162 | P a g e
V. Family Nursing Care Plan
Problem # 1
Presence of Breeding Sites of Vectors of Diseases
163 | P a g e
Cues Analysis of Objectives Interventions Rationale Method Resources Expected
the problem of Required Outcome
Family
Contact
S> “madami Inability to Short term: > Assess the >To provide Family Short-term:
mga ipis dito, provide a After 2 hours presence of appropriate H Resources: The family
pati lamok, home of nursing vectors interventions O shall have
buti nga yung environment intervention, M >Manpower verbalized
mga daga conducive to the family will > Encourage >To prevent E resources the
nabawasan” health be able to to check the the generation such as time importance
maintenance verbalize the every corner time of the V and effort of a clean
O> Presence due to: importance of of the house vectors I environment
of a clean S >Financial and the risk-
mosquitoes a. Failure to environment I resources factors of the
in the see benefits and the risk- > Encourage >To prevent T presence of
bathroom. factors of the to use the vectors S Student vectors.
b. Inadequate presence of properly the from Nurses
> Presence knowledge of vectors. insecticide multiplying Resources:
of importance of
cockroaches sanitation. > Provide >To prevent >Knowledge
especially Long term: health poisoning and and health Long Term:
below the c. Lack of skill After 2-3 teachings to further teachings in The family
cabinet. in carrying out home visits, the family problems to proper shall have
measures to the family will about the arise. sanitation and
participated
improve home be able to proper use of precautionaryin the
environment. participate in insecticide. measure in cleaning of
the cleaning using their
of their > Encourage > To increase pesticide environment
environment to eat their immune to prevent
to prevent nutritious food system and to >Community multiplication
multiplication especially protect their resources: of the
of the food rich in selves from Seminars and vectors.
vectors. Vitamin C having disease programs .
about proper
sanitation.
> Evaluate the >To measure if
family’s the family
reaction about understands
164 | P a g e
the health the health
teachings. teachings
presented.
Problem # 2:
Presence of Cough and Colds
165 | P a g e
Family
Contact
S> “ayan, Inability to Short term: > Assess > To provide Family Short-term:
yung provide After 2-3 presence of appropriate H Resources: The family
madalas adequate hours of coughs and interventions O shall have
nilang sakit, nursing care to nursing colds M >Manpower understood
ubo tsaka the sick, intervention, E resources the disease
sipon” as member of the the family will > Explain > For the such as time itself and the
verbalized by family due to: be able to what is cough family to V and effort mode of
Mommy understand and colds understand I transmission.
Orange a. Inadequate the disease further the S >Herbal
knowledge itself and the meaning of I medicines
O>two of the about the mode of the disease T
family severity, transmission. and the mode S Student
members complications, of Nurses
(Banana and prognosis of transmission Resources:
Avocado) the condition. Long term: Long Term:
have nasal After 2 home > Encouraged > It helps >Knowledge The family
discharges, b. Inadequate visits, the increase fluid loosening and health shall have
cough and knowledge of family will be intake secretions teachings in demonstrated
colds the nature and able to proper measurement
extent of demonstrate > Encourage > to increase prevention of s to prevent
>Banana’s nursing care measurements to eat body’s the the disease
vital signs: needed to prevent the nutritious resistance and occurrence from
T: 35.9 °C disease from foods immune and re- worsening.
c. Inadequate worsening especially system occurrence
RR: 20 cpm
family foods rich in . of cough and
PR: 85 bpm resources for Vitamin C colds.
care,
specifically: > Encourage > To prevent >Community
>Avocado’s to cover
lack of physical transmission resources:
vital signs: mouth and
resources and of Backyard
T: 36.5°C nose when microorganisms
financial Herbal
PR: 72 bpm constraints. sneezing planting of
Lagundi to
RR: 28 cpm > Encourage > Because it is manage the
not to share an easy way high cost of
clothing for the factory-
microorganism manufactured 166 | P a g e
s to transfer. medicines.
> Evaluate the >To measure

Problem # 3.5
Family size beyond what family resources can adequately provide
167 | P a g e
Family
Contact
S> Ө Inability toShort term: > Explore the > To evaluate Family Short-term:
make After 2 hours family’s how the H Resources: The family
O> The decisions withof nursing perception of family’s O shall have
family's respect tointervention, the severity of emotion is M >Manpower verbalized
monthly taking the family will the problem affected by the E resources their
income is appropriate be able to problem. such as time emotional
small and health action verbalize V and effort competence
would not due to: their > Pinpoint > To lessen I in their
suffice their emotional some tips on the family’s S Student exposure of
needs a. Feeling of competence how they are expenditures I Nurses the problem.
compare with helplessness in their going to and to allocate T Resources:
the NEDA brought about exposure of minimize their the financial S
prescribed by perceived the problem. water and resources to >Knowledge
share amount magnitude of electric only important and health
of money that the problem. consumption things. teachings in
each of the Long term: and proper Long Term:
family b. Lack of After 2 home enumerate management The family
members insight as to visits, the some foods of allotted shall have
must have: alternative family will be that are financial verbalized
courses of able to nutritious yet resources. and
NEDA- P2, action open to verbalize and cheap which Skills, time demonstrated
768.60 them demonstrate may help in and effort. proper use
Fruit Family- proper use lowering their and
P14,000 and expenses. >Community budgeting of
budgeting of Examples of resources: available
(P14,000/7 = available this are: Seminars financial
P2,000) financial 1. Use about proper resources.
resources fluorescent management
lamp instead of resources.
>the family’s of light bulbs.
expenses is 2. Close the
estimated 13, faucet when
500. not in use
Therefore the 3. Remove or
family only even just
has 500 Php decreasing
savings per the family’s 168 | P a g e
month. vices like
alcohol,
cigarette and
Problem # 3.5
Unhealthy Lifestyle and Personal Habits: Poor Personal Hygiene
169 | P a g e
Family
Contact
S> “ pag >Inability to Short-term: > Assessed >To gather Family Short-term:
minsan kasi recognize each member baseline data H resources:
nakakalimuta presence of After 2-3 of the family needed for O After 2-3
n kasi nila na problem due to hours of regarding planning M >Manpower hours of
putulan yung lack of home visit, personal implementation E resources: home visit,
mga kuko adequate the family will hygiene the family
nila kahit knowledge be able to V trust and shall have
mahaba na” verbalize >Educate the >For the family I openness to able to
As verbalized >Inability to understanding family about to gain S nursing verbalized
by the make on proper the knowledge I interventions understanding
Mommy decisions with hygienic importance of about practice T on proper
Orange respect to measure to personal of good S Cooperation hygienic
taking maintain hygiene and hygiene and health measure to
O>Untidy appropriate healthy ways to gain their teachings maintain
look of the health actions lifestyle. promote good participation given healthy
member of due to failure personal lifestyle.
the family to comprehend hygiene >Non-
the nature, Long-term: Human Long-term:
>Having long magnitude and >Explain the >Increase resources:
and dirty scope of After 3 days consequences family’s After 3 days
fingernails on possible of home that they can awareness soap of home
both hands consequences visits, the get with poor shampoo visits, the
and feet of the problem family will be personal nail cutter family shall
able to hygiene toothbrush have
manifest toothpaste manifested
progress >Initiate the >Motivate the towel progress
regarding the maintenance mother to take comb regarding the
right practice of proper the right practice
of having hygiene responsibility of Student of having
proper among the grooming her nurses proper
hygiene family children resources:: hygiene
members
Therapeutic
>Instruct the >Prevent communicati
family to clean microorganism on
their nails s to stay in
when nails are nails which Time and 170 | P a g e
long may cause effort and
diseases knowledge
about
Problem # 5
Unhealthful lifestyle and Personal Habits: Walking Barefooted
171 | P a g e
Family
Contact
S> >Inability of the Short-term: > Assessed > To gather Family Short-term:
“Sinasabihin family to family baseline data H resources:
ko nga sila recognize After 2-3 knowledge needed for O trust and After 2-3
na magsuot presence of hours of about the planning M openness to hours of
ng tsinelas problem due to home visit, severity of the implementation E nursing home visit,
pero nasanay the family will problem interventions the family
na kasi sila a. lack of be able to V shall have
kaya minsan adequate verbalize >Discuss the >Proper I Cooperation verbalized
wala sila knowledge. understanding importance of wearing of S on health understanding
tsinelas pag on wearing slippers will I teachings on
nasa labas b. failure to how to abide slippers lessen the T given how to abide
ng bahay” As see the with simple occurrence of S with simple
verbalized by complication of instructions. soil transmitted >Non- instructions.
the Mommy the problem. helminthiasis Human
Orange resources:
Long-term: slippers Long-term:
O>The group > Explain the > So that they
noticed that After 4-5 consequences will be Student After 4-5 days
the children days of home that they can encourage to nurses of home
do not wear visits, the get with of wear slippers resources: visits, the
slippers when family will walking all the time family shall
walking strictly abide barefooted. Therapeutic have strictly
outside the with the communication abided with
house simple > Encourage >If the mother the simple
instructions mother to will take a look Time and instructions
that the group always have always if the effort and that the group
have provide an eye to the children are knowledge have provide
and will be children so wearing about and will be
fee from the that they will slippers. They possible fee from the
risk of abide with will practice it consequenc risk of
parasitism. wearing as a habit. es of the parasitism
slippers problem
>Suggest to > The health Willingness

go to health center may to attain the
center provide objectives of
information both family 172 | P a g e
about the and student
disease
prevention Community
Problem # 6
Poor Home Condition: Inadequate Lighting
173 | P a g e
Family
Contact
S> > Inability to Short term: >Assess >To have a >Knowledge, Short term:
“Medyo provide a After 3 hours lighting baseline data H time and After 3 hours
madilim ang home of home visit, Condition O perseverant of home visit,
bahay environment the family will M of student the
namin,” as w/c is be able to >Discuss to > To make the E nurses. family shall
verbalized by conducive to recognize family the family aware have
the mother. health importance of importance of that good V > Family’s recognized
maintenance having having lighting can I understanding the
O> Only 2 and personal adequate adequate make their S , cooperation importance of
light bulbs development lighting. lighting activities of I and having
were used by due to: daily living T participation adequate
the family; Long term: easier S and their lighting
each for the a. Inadequate After 3-4 financial
living room family days of home resources Long term:
and another resources visits, the > Help and > To promote After 3-4 days
in the specifically family will be assist family to passage of of home
bedroom financial able to open window. light visits,
each having constraints comply w/ the the family
only 10 watts. health shall have
b. Lack of reaching > Encourage >To allow for complied with
> Windows adequate given as family to avail proper lighting the health
are blocked knowledge in evidenced by bulb teachings
by curtains the importance opening of given as
and there is a of having the windows >Clean the > To allow evidenced by
house in front adequate light bulbs adequate opening of
of their house lighting supply light their windows
w/c blocks inside
the sunlight. c. Lack of
knowledge
> No regarding the
fluorescent or effect and
174 | P a g e
any bulb light importance of
inside the lighting
comfort
room.
Problem # 7
Inadequate Living Space
175 | P a g e
Family
Contact
S> Inability to Short term: > Explore the > to analyze Family Short-term:
“pasensya na provide a After 2 hours family’s how far the H Resources: The family
maliit ang home of nursing perception of family is O shall have
bahay environment intervention, the magnitude affected with M >Manpower verbalized the
namen” conducive to the family will of the the problem. E resources importance of
health be able to problem. such as time adequate
O> upon maintenance verbalize the V and effort living space
dividing the and personal importance of > Provide > to increase I and the
whole floor development adequate general the family’s S Student hazards that
area of the due to: living space knowledge on awareness of I Nurses a poor space
Fruit Family’s and the how the problem T Resources: can give.
house, each a. Inadequate hazards that communicable and to provide S
of the family family a poor space diseases them the >Knowledge
member resources, can give. could be importance of and health
yields only specifically: easily having an teachings in
1.38 m2 1. financial transmitted in adequate living proper
showing that constraints Long term: a limited space. nutrition. Long Term:
the total floor 2.lack of space After 2 home space. Skills, time The family
area of the to construct visits, the and effort. shall have
house is facility family will be > Assist the > To demonstrated
inadequate able to family in maximize the >Community proper
as to b. Failure to demonstrate arranging and space of resources: arrangement
compare with see benefits of proper organizing house. Seminars of furniture to
the investment in arrangement their things about how to lessen their
prescribed by home of furniture to such as maximize problem of
the National environment lessen their furniture and the allotted inadequate
Building code improvement. problem of appliances. living space. living space.
of the inadequate
Philippines c. Lack of skill living space. > Advise the
R.A 6541 that in carrying out family to >To lessen the
each of the measures to remove things waste and
family must improve home that are obstruction
have at least environment. unnecessary causing
a share of 3 and not inadequate
m2, needed. space.
>presence of 176 | P a g e
too many > Evaluate the
furniture family’s >To measure if
compare to reaction about the family
Problem # 8:
Presence of Health Deficit: Malnutrition
177 | P a g e
Family
Contact
S> Ө Inability to Short term: > Explore the > to obtain a Family Short-term:
make After 2 hours salience of the baseline data H Resources: The family
O>BMI of the decisions with of nursing family and so the student O shall have
following respect to intervention, how much nurses can M >Manpower recognized
family taking the family will they are prepare E resources the
members: appropriate be able to alerted with appropriate such as time importance of
health action recognize the the problem. health V and effort nutrition,
>Mommy due to: importance of teachings I proper eating
Orange: nutrition, based on the S >Financial habits.
23.66 kg/m2 a. Failure to proper eating family’s I resources
(overweight) comprehend habits. perception of T
the nature and the problem. S Student
>Mango: magnitude of Nurses
18.47 kg/m2 the problem. > Discuss with > to increase Resources: Long Term:
(underweight) Long term: the family the the family’s The family
b. Low After 2 home possible awareness and >Knowledge shall have
>Banana: salience of the visits, the complication importance in and health demonstrated
12.5 kg/m2 problem family will be of malnutrition proper nutrition teachings in effectively
(underweight) able to proper and in
c. Fear of demonstrate > Ask the > To allocate nutrition. consistency
>Avocado: consequences effectively family about nutritious foods Skills, time how to
13.16 kg/m2 of action, and in their budget without and effort. prepare
(underweight) specifically: consistency for food suppressing cheap but
economic how to the family’s >Community nutritious
consequences prepare budget for resources: food, proper
cheap but food. Deworming, interventions
nutritious feeding to prevent
food, proper > Inform the >To inform the programs aggravation
interventions family about family that they and of the
to prevent nutritious but can have seminars in problem.
aggravation cheap food proper nutrition preparing .
of the like from food nutritious
problem. malunggay, without and cheap
monggo and suppressing meals.
tokwa. their income.
> Teach the > To prevent 178 | P a g e

family about aggravation of
proper the problem
precautions such as
Problem # 9
Unhealthful lifestyle and Personal Habits: Cigarette Smoking
179 | P a g e
Cues Analysis of Objectives Intervention Rationale Metho Resources Expected
the problem s d of Required Outcome
Family
Contac
t
VI. Family Coping Index
S> “15 > Inability to Short Term: > Check the > To H Family Short term:
palang make lifestyle and determine if O Resources:
naninigarilo decisions After 3 personal they have M After 3
na asawa with respect hours, of habits of healthful E >Manpowe hours, of
ko pati ako to taking home visit, each lifestyle and r resources home visit,
nagsimula appropriate Mommy member of personal V such as Mommy
ako health action Orange will the family practices I time and Orange shall
manigarilyo due to verbalize S effort have
nung 17 addiction the effects I verbalized
ako;”as caused by of smoking > Discuss > To make T >Financial the effects
verbalized chronic and second with the each S resources of smoking
by Mommy smoking hand family the members of and second
Orange habits smoking. side effects the family be Student hand
of cigarette aware of the Nurses smoking.
O> smoking bad effects of Resources:
>mother Long Term: smoking, Long Term:
was seen especially in >Knowledg
smoking After 3-4 their health e and After 3-4
upon entry days of status. health days of
of the home visits, teachings home visits,
student Mommy > Encourage >To prevent about the Mommy
nurses in Orange will mother to further dangers of Orange shall
their house be able to reduce her complications smoking have shared
share her cravings to of smoking her
> a pack of understandi cigarettes >Communit understandin
cigarette ng about the and advise y g about the
was seen in effects of her to resources: effects of
the living smoking to challenge Seminars smoking to
room Daddy her husband about the Daddy
Apple and to reduce effects of Apple and
>Mother will reduce cigarette smoking in shall have
has dark her craving intake. the human reduced her
brown gums to body. craving to
and cigarettes. >To reduce cigarettes.
yellowish > Instruct the the risk of
teeth. family to eat having heart
nutritious diseases and
>Smell of a foods and to high blood
smoke was have regular pressure
noted inside exercises brought about
the house everyday by smoking
>pack >Instruct the > To avoid

years= mother to withdrawal
(Number of gradually symptoms.
stick per withdraw
day/ 20) from
multiplied smoking 180 | P a g e
by the > To divert
number of > Encourage their attention
years diversion away from
Initial Visit Final Visit
CRITERIA 1 3 5 1 3 5 JUSTIFICATION
1. PHYSICAL At the Initial Home Visit, the

INDEPENDENCE Physical independence of the
family was scored as 3 for the
following reasons: All family
members including the
children can get in and out of
their bed, they can walk
without any support person or
equipment. However
Avocado, does not know how
to bath on her own. And Mrs.
Orange is very busy doing
household chores to
compensate for her daughter.
At the final home visit, the

Physical Independence of the
following reasons: all family
members especially the
children can walk and act on
their own without any
support. After the student
nurses’ interventions,
Avocado can illustrate proper
bathing techniques one step
at a time like proper use of
the soap, shampoo and
toothbrush.
181 | P a g e
2. THERAPEUTIC At the initial home visit, the

COMPETENCE Therapeutic Competence of
the family was scored as 3 for
the following reasons: The
family use interventions in
treating certain conditions.
They are using herbal
medicines like Sambong,
Pandan ang Ugat ng Ilib for
kidney problems; Oregano for
cough and colds. The uses of
some of these medicines are
appropriate. However, they
do not do some precautions
to prevent the re-occurrence
of such condition. The group
saw Mango, Watermelon,
Mango, Banana and Avocado
walking barefooted, eating
using their dirty hands which
can promote infections.
After the final home visit, the

Therapeutic Competence of
the Family was still scored as
3 for the following reasons:
The family is now doing some
precautionary measures to
prevent diseases like their
now walking with slippers on.
However, the student nurses
have known that they drink
factory manufactured
medicines without any
prescription from the doctor.
The proper use of medicine
to a specific disease needs
further instruction from the
HCP.
182 | P a g e
3. KNOWLEDGE OF At the initial home visit, the

HEALTH CONDITION Knowledge of the Health
Condition of the family was
scored as 3 for the following
reasons: they know some
salient facts about some of
their disease experienced
well enough to take
interventions necessary.
However, Mrs. Orange does
not know that 2 of her
children (Avocado and
Banana) are underweight and
doesn’t seem to be alerted
with the possible complication
of malnutrition.

Knowledge of Health
Condition was still scored as
3 for the following reasons:
after knowing that some of
the children are
malnourished, Mommy
Orange doesn’t still seem to
see this as a major problem.
The family doesn’t much give
importance to proper
nutrition. The Children are still
insisting to eat junk foods and
drink carbonated beverages
which are unhealthy
especially for Avocado,
Mango and Banana who are
undernourished.
183 | P a g e
4. APPLICATION OF At the initial home visit, the

PRINCIPLES OF Application of Principles of
PERSONAL AND Personal and General
GENERAL HYGIENE Hygiene were scored as 1 for
the following reasons: All
children have very dirty
clothes, unkempt appearance
and dirty nails. Their pet
which is a cat is sleeping in
their bed, this could result to
lice transmission and allergic
reaction to cat’s fur. Their
toilet is also the site where
they wash their dishes which
could result to cross
contamination of bacteria.

Application of Personal and
General Hygiene were scored
as 3 for the following reasons:
there is the improvement in
the appearance of the Family,
they dress are clean and
neatly. Their nails are clean
and trimmed. Their walking
with slippers on. But these
improvements need
consistency. The only
problem which seems to be
difficult to solve for them is
their washing of dishes in the
comfort room.
184 | P a g e
5. HEALTH CARE At the initial home visit, the

ATTITUDES Health Care Attitudes of the
following reasons: they
accept health care in some
degree but with reservations.
Example to that is their use of
quack doctors in treating
fever; they will only go to the
doctor if the symptoms did
not subside. In short, they
assume doctors and health
center only as a second
choice in treating their
condition. And one more
thing, they seem not to care
much on their dental care.

Health Care Attitudes of the
family was still scored as 3 for
the following reasons: their
problem of dental carries is
slowly degrading because of
the student nurses
interventions. The children
have learned how to use their
toothbrush and what is the
proper brushing of teeth.
However, no change in score
given, because their first
priority to go when disease
occurs are still quack doctors
because of low cost.
185 | P a g e
6. EMOTIONAL At the initial home visit, the

COMPETENCE Emotional Competence of the
following reasons: Daddy
Apple is relieving the stresses
of their life by drinking
alcohol. While Mommy
Orange plays Bingo to forget
her problem. Mommy Orange
is lacking some sort of
responsibility because she
leaves her children
unattended. Mango lacks
emotional calmness because
he frequently scolds his
younger siblings and his
temper is a bit short. Avocado
which is already 6 years old
still drinks from a bottle.

Emotional Competence of the
following reasons: the group
has seen Mango to be more
calm and hospitable in his
attitude towards the student
nurses and especially to his
siblings. The group had
practice Avocado not to drink
from her bottle. It is was only
scored as 3 because Mommy
Orange finds quitting
cigarette smoking a hard task
and needs further
interventions from student
nurses and longer home visits
to alleviate that problem.
186 | P a g e
7. FAMILY LIVING At the initial visit, the Family

PATTERNS Living Patterns of the family
was scored as 1 for the
following reasons: the
children do not want to go to
school that day and yet the
mother didn’t motivate them
the importance of schooling.
Banana, Avocado and Mango
do not want to take a bath
because of the cold water but
the mother does not do
interventions to solve this
problem. One more thing, the
activities of each family
member is different from the
other so they don’t have
much time to get along with
each other.

Family Living Patterns of the
following reasons: the family
has shown the group how
they go along with each
other. There is no sense of
tension felt between the
family members. Mommy
Orange do interventions to
the children to take a bath like
boiling the water. The degree
of respect of some of the
children for Mommy Orange
is high except for Mango who
doesn’t seem to follow his
mother’s advices.
187 | P a g e
8. PHYSICAL At the initial home visit, the

ENVIRONMENT Physical Environment of the
following reasons: there is the
presence of health hazards
like their LPG tank is near
their bed. They have poor
ventilation because they do
not have windows. They have
poor lighting. There is no play
space for the children except
the streets. There is the
presence of vectors of
diseases like mosquito and
cockroaches.

Physical Environment of the
following reasons: the
presence of poor lighting and
poor ventilation is not solved
because of the congestion of
the family’s home. However,
the problem of dirty home is
alleviating through the
student nurses intervention
and health teachings. The
presence of vectors of
diseases is managed by
insecticides. The student
nurses imparted health
teachings to the family for
proper use of insecticides.
188 | P a g e
9. USE OF At the initial home visit, the

COMMUNITY Use of Community Facilities
FACILITIES of the family was scored as 3
for the following reasons: they
have utilized the health center
well especially for Mrs.
Orange whom she uses for
her past prenatal checkups;
she also attends mother class
conducted by nurses.
However, the other family
members don’t seem to be
cognizant with different
community facilities; what
they are only utilizing is their
school. They don’t know
about the other facilities of
the community like the
barangay hall for counseling
when the family has
problems.
The Use of Community

Facilities was scored as 5 for
the following reasons: the
family is very cooperative to
the community’s facilities
evident to that is their
presence in the mother’s
class conducted by the
student nurses. Through the
interventions of the student
nurses, they also become
cognizant of the facilities that
the barangay hall can offer.
VII. LEARNING DERIVED:
189 | P a g e
I personally learned the importance of the family in the society, as the basic unit
of the society, it is important to maintain the health of the family. Comparing the family
with the human body, as when one part of the body is infected, later on the whole body
will be affected systemically, just like with the family and society, when a family is
considered ill, later on the society will be systemically affected.
I also learned the importance of good communicating skill. With the absence of a
good communicating skill the student nurse will not be able to establish rapport with his/
her client, thus affecting the assessment process, making the problem identification and
prioritization be difficult, thus, altering the maximum care you may give to the family.
Assessment is the very crucial part of doing the family case analysis, with all the
data that you will gather throughout the assessment process, there you will derived the
problems you will intervene to correct this problems.
The most important thing that a student nurse must have is the initiative, time,
effort, and patience, without those things you will not be able to gather all the
information you need, the client’s cooperation and compliance is also a vital ingredients
for the success of making a family case analysis.
- SUNSHINE ARIZALA
LEARNING DERIVED:
190 | P a g e
Before the actual encounter between the student nurses and the family, I always
find doing Family Case Analysis as non sense and boring. But doing the FCA for the
second time makes me realize more that the main purpose of this project is touching
lives. I never expect that I will enjoy doing Family Case Analysis, but I did. I’ve learned
different values.
In finding for the data to be gathered in our family case analysis, I learned
teamwork. You can’t do all things on your own. You have to cooperate to your group
mates to occupy what you lack of. In dealing with our family you must show empathy.
You must be in their foot to realize what they feel. Developing a good working
relationship is important to elicit quality exchange of information.
At the start I assumed that this was just a task. But at the end of the day you will
realize that you have not lost anything instead you have gain a lot. You have gain
lessons and realization that will remain in your heart for a long time.
Socially, we were able to develop better therapeutic communication skills,
physically, we finally had time to exercise by going up to the family’s house,
psychologically, we used our minds to come up with possible writings and emotionally,
we learned how to be thankful of what we have and share our blessings with other
people who are in need.
- JOHN AUFER D. DAVID
LEARNING DERIVED:
191 | P a g e
We all know that the Family is the Basic need of Society, meaning if there is no
Family, there is no society. We never expected to learn this much from a family whom
were just strangers at one point as well as from one another.
This FCA proved to show that this isn’t just a report that is required to pass. But a
report where you get so caught up and so involved, you tend to find yourself
understanding the real reason. This project has given us the meaning why
communication and interacting is so important. Communicating takes place so much in
everyday life but this time it felt different. Those words became actions and actions
made a difference.
The Family Case Analysis has taught us so many things. It taught us how to
really get involved in work, and take it seriously and of course emotionally. You cannot
just work without any feelings, what would that make you, numb? We all wanted to be a
reason for hope for a better life of this family and that being too serious isn’t enough,
loving and enjoying what you are doing will make the work more meaningful. We all
struggled to make this report possible but if you look deeper, this just proves to show
that cooperation, dedication and unity were combined.
- KRISTEL PAULA DELA PEÑA
LEARNING DERIVED:
192 | P a g e
The community is just not a place where they live in, but a place where many
people are affected as one and being there with the family made us feel that we too
gained something
We learned that there are a lot of people who are less fortunate and health
education can teach them important information to help prevent certain infections,
diseases or unwanted outcomes. We can make a difference in people’s actions and it is
possible to change the way they perceive life.
With this report, it enhanced our social skills, and getting all the information we’ve
acquired showed that we can get along with people. How many people can go up and
ask all these questions, not to mention when some of them are very personal. We were
able to gain the family’s trust, and that gave us a plus factor feeling knowing that we’re
doing a good job with them, and that they enjoy our company.
- MA. TIFFANY FLORES
LEARNING DERIVED:
193 | P a g e
Community exposure has given me a lot of realizations in life. This exposure
needs a lot of energy, both mentally and physically. This exposure was really tiring in
which we have realized that community health nursing is one of the most tiring aspect of
nursing. This exposure has strengthened the bond within our group and especially with
the family. Rapport was built within us, likewise within the family which is important in
community health nursing to elicit exchange of quality information.
After the exposure, we realized that we are fortunate; we can eat three full meals
a day plus the in-between snacks while they can’t even have a full meal. We can buy
whatever we want even if we don’t really need it while they can’t even buy all their
necessities. We have this much while they have that little but still they learn to live
contented, we realized that we almost always take things for granted which should not
be.
- ERIKA JOY ISIDRO
VIII. SOCIOGRAM
194 | P a g e
This chapter illustrates graphic representations of the several home visits made,
including the interactions of the student nurses with the families, the assessment,
planning, interventions and evaluation done.
LEGENDS
NURSES MEASUREMENT
SS
FAMILY VITAL SIGNS

TAKING
INTERVENTIONS HEALTH
TEACHINGS
HEALTH
ASSESSMENT
FIRST HOME VISIT
195 | P a g e
The group visited the family and introduces their selves to the
family. The student nurses were able to established rapport with
the family and started their tasks. The group first assessed the
health status of each family member. Then the group assessed
for their initial vital signs. While assessing for their Vital signs
someone in the group assessed for the Fruit Family’s house, and
its conduciveness for health.
SECOND HOME VISIT
196 | P a g e
On the second home visit the group brought a breakfast for
the Fruit family as one of their interventions. In addition, the
group also took the measurement of the house like total
floor area, window opening and door opening. The group
also advise the children especially Avocado the importance
of proper hygienic care.
THIRD HOME VISIT
197 | P a g e
On the third home visit the group performed their final
assessment to the family. The group also performed
interventions like cleaning the house, sweeping the floor,
bathing the children, washing the dishes. And as a token
of appreciation, the group gave them some things that they
can use for their house.
IX. SPOT MAP and TOTAL FLOOR AREA
198 | P a g e
199 | P a g e
WIDTH= 90 INCHES
WI
DT
C.R.
L
H=
E 41
N
INC
G
HE
T
H S
=
1
6
6 LENGTH= 46.2 INCHES
I
N WIDTH= 26 IN
C WIDTH= 23
H INCHES L=
70 DOOR
E
S L= IN
44 WINDOW C
INC H
HES E
S
TOTAL FLOOR AREA
200 | P a g e
X. DOCUMENTATION
THE FRUIT FAMILY
(Mommy Orange, Mango, Watermelon, Banana and Avocado)
THE FRUIT FAMILY’S HOUSE:
201 | P a g e
202 | P a g e
NURSE-FAMILY INTERACTION:
203 | P a g e
ASSESSMENT:
204 | P a g e
NURSING INTERVENTIONS:
205 | P a g e
206 | P a g e
XI. BIBLIOGRAPHY
Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing & Childrearing
Family 5th ed. Manila: C&E Publishing Inc, 2007
Webber & Kelly Health Assessment in Nursing 3rd ed. Manila: C&E Publishing Inc, 2007
Untalan, A. Concepts and Guidelines in COPAR. 1st ed. Manila: Educational Publishing
House, 2005.
Maglaya, A. Nursing Practice in the Community. Marikina City: Argonauta Corp., 2004.
Cuevas, F. et. al. Public Health Nursing in the Philippines. 10th ed. Manila: C&E
Publishing Inc,
Handouts in Nursing Care Management 101- Family Nursing Care Plan, Problem
Prioritization
Handouts in Health Assessment
207 | P a g e

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I.

Community is considered as the recipient of service wherein it comprises a group

Furthermore, community health nursing is a field of nursing that renders

• A family that will easily be identified to be depressed or deprived

 Gained the trust of the family regarding health.

 Established rapport with the students.

 Verbalized understanding of the rationale behind each intervention that

This Family Case Analysis aims to answer the following questions:

2. How may the family be described as to:

5. How may the problems identified in the family be classifies as to:

6. How may the problems identified be prioritized and ranked as to:

B. Entry, Climate of Acceptance, First Few Words, Number of Home Visits

First Home Visit (December 03, 2009)

Second Home Visit (December 04, 2009)

Third Home Visit (December 10, 2009)

Mommy 44 years Mother F Elementary

Upon the final

GRAPES 26 years First Child M Elementary

She was not

14 years Third Child M Going to

Upon the final

Upon the final

BANANA 8 years old Fifth Child M Going to

Upon the initial

Upon the final

Mommy Orange’s vital signs were taken and recorded as follows:

SKIN, HAIR AND NAIL ASSESSMENT

HEAD AND NECK ASSESSMENT

 Hair on eyebrow, eyelashes, and eyelids are evenly distributed.

 No lumps palpated on both ears.

NOSE AND SINUS ASSESSMENT

MOUTH AND PHARYNX ASSESSMENT

 The lips have small cracks but no lesion noted.

 No irregular sounds heard upon auscultation.

PERIPHERAL AND VASCULAR ASSESSMENT

THORAX AND LUNG ASSESSMENT

 There is presence of rales on exhalation upon auscultation.

 Umbilicus is in midline position.

Upon interview to Mommy Orange, she stated that:

 Posture and Gait is steady, stable, coordinated and smooth.

Cerebellar and motor function:

CRANIAL NERVES ASSESSMENT

Cranial Nerve Assessment Normal Actual Finding

II. Optic Provide adequate The client Mommy Orange

III. Oculomotor Reaction to light: Illuminated and Mommy Orange

IV. Trochlear Hold a penlight 1 ft. Client’s eyes Mommy

V. Trigeminal While client looks Client should Mommy Orange

Ask the client to The client She was able to

X. Vagus Ask the patient to The client Mommy Orange

XI. Accessory Ask client to shrug Client should be Mommy Orange

BMI = Weight in kilograms__ _

Height in square meters

Asia-Pacific Obesity Guidelines

18.6 – 22.9 Healthy Weight

> 23.0 Overweight

23.0 – 24.9 At risk

25.0 – 29.9 Obese I

> 30.0 Obese II

MEN < 90 cm (35 inches)

Waist Circumference: 75 cm. (NORMAL)

WHR= waist circumference

= 0.94 (CENTRAL OBESITY)