Académique Documents
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Introduction
“Where does the family start? It starts with a young man falling in
love with a girl - no superior alternative has yet been found”.
--Winston Churchill
Indeed, it is a lovely start to find a man falling in-love with a young lady. It
is where the growth of a fruitful family is rooted. Nourishing that love between the
family members, it is heart-melting to reminisce that once, in the life of both this
parents, they were plainly in-love. Eventually, as the love grows, lives were
added. More love binds the relationship as a whole. More love stands as the
walls that protect. More love holds them up. More love binds them together.
Taking a simple look, you will see that the mother of the adopted family is
seriously committed to this love. No greater fulfillment is going to even the feeling
of being a part of this family even just for a while. As nurses, being under the
same roof with the clients, gave the student nurses in this study a glimpse of their
life as a family—their whole being.
Family as the client has been the main concern of this Family Case
Analysis (FCA). It is one basic principle of Community Health Nursing (CHN)
where it is stated that the family is the unit of care, for an individual would always
belong to a family. Thus, Family Health Nursing is the basic and core component
of CHN practice (Bailon-Reyes, 2006, p.8)
Family is the basic unit of the society. Moreover, the society is the public.
By that, it is clear that Public health is the main concern of CHN. Winslow defined
public health as the science and art of preventing disease, prolonging life, and
promoting physical and mental and efficiency through organized community
efforts towards a sanitary environment, the control of community infections, the
education of the individual in principles of personal hygiene, the organization of
medical and nursing service for the early diagnosis and treatment of disease and
the development of social machinery which will ensure to every individual in the
community a standard of living adequate for the maintenance of health” (p.30
Winslow, 1989).
The people that builds up the country and the world at large, and the same
persons who are potential of being ill or healthy makes up this “public”—the
community. Therefore, promoting a healthy community is the main goal of CHN.
Throughout the course of this FCA, the adopted family had been assisted in
identifying their existing problems as they were taught to cope with it and
eradicate unnecessary conditions and factors to improve their health and quality
of life as a whole. As to maintain the privacy of the adopted family, they were
assigned with pseudonames that would be used for the whole activity. Namely:
Mr. Lorenzo for the father, Mother Mae for the mother, Anthony for the youngest
(son), and Ann for the eldest (daughter).
The student nurses involved in this study aim to help the said family as far
as they can to add another piece of experience to their student lives. Also, to give
back the love lavished upon them though they were not lawfully part of this
family. Most especially, it helped them nourish the love and compassion found in
being Christ’s servant as nurses while their future careers is fast approach.
A. Objectives
a. Short Term
(Student-centered)
After one to two days of home visits, the student nurses will be
able to:
(Family-centered)
After one to two days of home visits, the family will be able to:
b. Long Term
(Student-centered)
After four to five days of home visits, the student nurses will be
able to:
(Family centered)
After four to five days of home visits, the family will be able to:
“Immersion” is the best way to describe the bustle of home visit. The group
felt very excited before they are immersed in the community and meet the
chosen family. On the 21st day of February, 2009 was the start of the group to be
in the community. They are assigned in zone 2 of Macapagal Village, Clark Field,
Pampanga. The student nurses have criteria in choosing a family in which the
family should be classified as poor where in the allowance of the each of the
family members are less than P2, 768.00, family member of five and above, a
living children less than 7 years old, and the most Important of all is that they are
willing to cooperate. The family is very supportive and very warm, very
cooperative and they are very friendly, they are also very accommodating to the
point that whenever they do something, they stop it or do it while entertaining us,
multi-tasking it is. They also always see to it that nobody stands and gives
everyone a very comfortable chair to seat to. They even thought us the barbecue
stick making, the mother’s sideline. They have a very cheerful aura.
T = 36.5°C/axilla
PR = 83bpm
RR =17 cpm
Height: 125cm
Weight:31 kg
BMI: 19.84
Nutritional status: normal
Anthony 5 y/o Male Youngest Still in During the initial visit Anthony
Kindergarten was seen clean white sando
and blue short. He has black
complexion with short nails.
Anthony is a 5 year old who
weight 15 kg and has height 111
cm. temperature: 36 *C: Pulse
Rate: 120 bpm: Respiratory
Rate: 23 cpm..
T = 36°C/axilla
PR =120bpm
RR =23cpm
Height: 111 cm
Weight: 15 kg
FNRI= normal weight should
be 14.4 to 23.5
Physical Assessment
Mental Status
• Client is alert and awake with eyes open and looking at the student nurse.
• She established eye contact when asked questions.
• She also smiles and frowns appropriately without difficulty.
• The client is cooperative, when asked, can answer properly.
• The client was able to express free-flowing thoughts and expresses realistic
perceptions.
• She is aware of self, other, time, home address and current location.
• She listens and can follow directions without difficulty.
• She was able to recall recent event without difficulty.
• She recalls her birthday and answer information correctly.
Motor Function -Walking gait – has slouched posture with opposing arm
swing upon walking; maintaining balance
Integumentary System:
• Skin is brown in complexion, no odor, and uniform in color. Her skin turgor is
normal because when her skin was pinched, it go back to previous state
immediately. The skin is not edematous and is in normal temperature. With
sensation to touch, pain & temperature.
Skull & Face (Head)
• She has a round skull, no contusions, bruises noted nodules and masses,
and no tenderness palpated. She has symmetrical facial movements as
evidenced by client’s ability to smile, frown, raise his forehead & eyebrows
& shows his teeth. Facial features and facial movements are symmetrical.
Hair
• Hair is long, dry, straight, thick, black and evenly distributed hair. There is
no dandruff, no area of loss of hair and no infection/infestation.
Nails
• Her nails are untrimmed and dirty as well. She has light brown, smooth,
epidermis is intact, has convex curve nails, no discoloration of the nail beds,
no clubbing of nails, normal capillary refill (<2-3 sec), and no edema.
Upper Extremities
• There are firm with coordinated movements;
• Her bones and joints have no deformities, tenderness nor swelling noted.
• She can sense touch, pain and temperature.
• The client is able to repeatedly and rhythmically touch the nose during the
“finger to nose test”.
Lower Extremities
• The muscles in the lower extremities are symmetrical.
• The client can resist against the pressure given by the student nurse and
elicited fine coordinated movements.
• The bones and joints in the lower extremities have no deformities and
pain, temperature and touch is felt.
• The client’s gait and balance is stable. She can walk in straight line and
can maintain balance.
B. CRANIAL NERVES
CN 1: OLFACTORY
Type: Sensory
Function: Smell
Tests perform: The student nurse asked the client to close her yes and identify
different aromas such as perfume and coffee.
Expected result: She is expected to identify the different aromas such as perfume
and coffee presented with hers closed.
Actual Result: Mother Mae was able to identify the aromas of perfumes and
coffee.
CN ||: OPTICS
Types; sensory
Function: vision and visual fields
Tests perform: the student nurse asked her to read on the newspapers
Expected result: the client will be able to read the newspapers
Actual result: Mother. Mae was able to read at a distance of 14”
CN |||: OCULOMOTOR
Types: motor
Function: Extra ocular movements of the eyes, movement of the sphincter of the
pupils.
Tests performed: the student nurse made use of a penlight at a distance of 1 foot
in front of the client’s eyes and asked the client to hold the head in a fixed
position facing the student and followed the movement of the penlight with eyes
only. The student nurses assess the 6 ocular movement and pupil reaction.
Expected result: client is expected to move her eyes though the cranial fields of
gaze that is from the center to the upper right, upper left lower right, lower left
and medially. Actual result: Mother Mae was
able to move her eyes though the cranial fields of gaze that is from the center to
the upper right, upper left lower right, lower left and medially.
CN|V: TOCHLEAR
Types: motor
Function: extra ocular eye movements specifically nerve eyeball downward and
laterally
Tests perform: the student nurse asked to asses the 6 ocular movements using
the penlight at distance or 1 foot and followed the penlight with the eyes only
Expected result: Mother Mae will be able to move her eyes downward obliquely
Actual result: Mother Mae was able to move her eyes downward obliquely
without moving hid head.
CN V: TRIGEMINAL
Type: motor
Function: jaw movement and mastication, Sensation of cornea, skin of face, and
nasal mucosa
Tests perform: The student asked the client to look upward, lightly touch lateral
sclera at eye to elicit blink reflex.
To test light sensation, the student ask the client to close eyes then wipe a wisp
of cotton over the client’s forehead
To test deep sensation, use alternating blunt and sharp ends of the cap of a pen
over the same area.
Allow the client to chew, open, and clench her jaw, while palpating the jaw
muscles.
Actual result: The client was able to blink after the sclera is touched
The client was able to identify the light and deep sensations through the objects
presented.
The client was able to open and clench her jaw without extra effort.
CN V|: ABDUCEN
Type: motor
Function: lateral movement of the eyes
Tests perform: the student nurse stand directly in front of the lint and hold
penlight at a distance of 1 foot and asked client to hold head follow the
movement of the penlight with her yes only.
Expected result: She will be able to follow the lateral movement of the penlight.
Actual result: She was able to follow the lateral movement of the penlight.
CN V||: FACIAL
Type: motor
Function: facial expression, taste (anterior or 2/3 of tongue)
Tests perform: she was asked to raise her eyebrows, smile, show teeth and puff
out cheeks.
Expected result: she is expected to raise her eyebrows, smile, show teeth and
puff out cheeks.
Actual result: she was able to raise her eyebrows, smile, show teeth and puff out
cheeks
The client was able to identify the different tastes placed on the anterior two-
thirds of the tongue.
CN V|||: VESTIBULOCOCHLEAR
Type: sensory
Function: sense of hearing and balanced
Tests perform: whispered few words at the client back and allow repeating client
back.
Expected result: Mother Mae will be able to hear the words that the student nurse
whispered to the client.
Actual result: Mother Mae was able to hear the words that the student nurse
whispered to the client.
CNIX: GLOSSOPHARYGEAL
Type: motor and sensory
Function: pharyngeal movement and swallowing ability
Tests perform: whispered few words at the client back and allow repeating client
back.
Expected result: When asked to say “ah”, she will be able to say it and she will
be able to elicit the gag reflex. And she will be able to move the tongue from side
to side and up and down.
Actual result: Mother Mae was able to move the tongue foam side to side and up
and down and was able to say “ah” when asked. She also elicited gag reflex.
CN X: VAGUS
Type: motor and sensory
Function: swallowing and speaking
Tests perform: assess with cranial nerve IX, assess client speech for hoarseness
and ask the client to swallow and speech
Expected result: she will be able to state her name without hoarseness voice and
was able to swallowing.
Actual result: she was able to state her name without hoarseness voice and was
able to perform swallowing.
CN XI: ACCESORY
Type: motor
Function: head movement and movement of shoulders muscle
Tests perform: the student nurse asked the client to shrug her shoulder against
resistance of the student nurse’s hand and turn head side against resistance.
Repeat both sides.
Expected result: she must be able to shrug her shoulder against resistance of the
student nurse’s hand and turn head side against resistance.
Actual result: She was able to shrug her shoulder against resistance of the
student nurse’s hand and turn head side against resistance.
CN XII: HYPOGLOSSAL
Type: motor
Function: movement of the tongue and stretch of the tongue
Tests perform: She was asked to protrude her tongue at midline, and then move
it side to side.
Expected Result: She should be able to protrude her tongue at midline, and then
move it side to side
Actual result: She was able to protrude her tongue at midline, and then move it
side to side.
B. Obstetrical History:
All of the deliveries of Mrs. Mae were done in the hospital via Normal
Spontaneous Delivery with the aid of the midwife. After being confirmed that
Mrs. Mae is positive for pregnancy test she has her frequent prenatal checkups
that started for her two months of pregnancy.. She had her frequent check-ups;
her check up for the 2nd to 6th month is every month, for 7th and 8th month, twice a
month, and for the 9th month every week. Mrs. Mae had her Tetanus Toxoid
vaccine in her early pregnancy and after giving birth.
During her pregnancies she experienced morning sickness that usually last
for a weeks According to her, she craved for mangoes,oranges, and Tamarind.
According to her, she believes in some superstitions regarding pregnancy like not
eating twin bananas because it may bring about twin babies and not wearing
necklace because it might choke the baby. She also avoid taking a bath after
delivering a baby, she only takes a bath after three days.
C.Nutritional Status
Nutritional Status
BMI= Weight in Kilograms
(Height in meters)2
= 49 kg = 49kg
(1.52 m2) 2.31
= 21.21 (normal)
Age: 30 y/o
Height: 152cm
Weight: 49 Kg
Mother Mae mentioned that she did not experience any major illnesses or
hospitalizations before. She only had occasional fever, cough and colds. . But
when further asked, she made mention of her mother who died of brain cancer.
Physical Assessment
Mental Status
• Client is alert and awake with eyes open and looking at the student nurse.
• She is aware of self, other, time, home address and current location.
• She established eye contact when asked questions.
• The client is cooperative, when asked, can answer properly.
• The client was able to express free-flowing thoughts and expresses realistic
perceptions.
• She also smiles and frowns appropriately without difficulty.
• She listens and can follow directions without difficulty.
• She recalls her birthday and answer information correctly.
• She was able to recall recent event without difficulty
Motor Function
• Walking gait –coordinated movement, sitting
Integumentary System:
• Skin is brown in complexion, no odor, and uniform in color. Her skin turgor is
normal because when her skin was pinched, it goes back to previous state
immediately. The skin is not edematous and is in normal temperature. With
sensation to touch, pain & temperature.
Hair
• Hair is long, dry, straight, thick, black and evenly distributed hair. No area of
loss of hair and no infection/infestation.
Nails
• Her nails are untrimmed and dirty as well. She has light brown, smooth,
epidermis is intact, has convex curve nails, no discoloration of the nail beds,
no clubbing of nails, normal capillary refill (<2-3 sec), and no edema.
Abdomen
• Uniform in color, not distended, rounded symmetric contour and movements
upon by respiration and with audible bowel sounds every 5 to 20 seconds, No
lesions noted, no tenderness, and relaxed abdomen with smooth and
consistent tension.
Motor Function
Walking gait
• Opposing arm swing upon walking; maintaining balance
Upper Extremities
• There are firm with coordinated movements;
• Her bones and joints have no deformities, tenderness nor swelling noted.
• She can sense touch, pain and temperature.
• The client is able to repeatedly and rhythmically touch the nose during the
“finger to nose test”.
Lower Extremities
• The muscles in the lower extremities are symmetrical.
• The client can resist against the pressure given by the student nurse and
elicited fine coordinated movements.
• The bones and joints in the lower extremities have no deformities and pain,
temperature and touch is felt.
• The client’s gait and balance is stable. She can walk in straight line and can
maintain balance.
CRANIAL NERVES
CN 1: OLFACTORY
Type: Sensory
Function: Smell
Tests perform: The student nurse asked the client to close her yes and identify
different aromas such as perfume and coffee.
Expected result: She is expected to identify the different aromas such as perfume
and coffee presented with hers closed.
Actual Result: Mother Mae was able to identify the aromas of perfumes and
coffee.
CN ||: OPTICS
Types; sensory
Function: vision and visual fields
Tests perform: the student nurse asked her to read on the newspapers
Expected result: the client will be able to read the newspapers
Actual result: Mother. Mae was able to read at a distance of 14”
CN |||: OCULOMOTOR
Types: motor
Function: Extra ocular movements of the eyes, movement of the sphincter of the
pupils.
Tests performed: the student nurse made use of a penlight at a distance of 1 foot
in front of the client’s eyes and asked the client to hold the head in a fixed
position facing the student and followed the movement of the penlight with eyes
only. The student nurses assess the 6 ocular movement and pupil reaction.
Expected result: client is expected to move her eyes though the cranial fields of
gaze that is from the center to the upper right, upper left lower right, lower left
and medially.
Actual result: Mother Mae was able to move her eyes though the cranial fields of
gaze that is from the center to the upper right, upper left lower right, lower left
and medially.
CN|V: TOCHLEAR
Types: motor
Function: extra ocular eye movements specifically nerve eyeball downward and
laterally
Tests perform: the student nurse asked to asses the 6 ocular movements using
the penlight at distance or 1 foot and followed the penlight with the eyes only
Expected result: Mother Mae will be able to move her eyes downward obliquely
Actual result: Mother Mae was able to move her eyes downward obliquely
without moving hid head.
CN V: TRIGEMINAL
Type: motor
Function: jaw movement and mastication, Sensation of cornea, skin of face, and
nasal mucosa
Tests perform: The student asked the client to look upward, lightly touch lateral
sclera at eye to elicit blink reflex.
To test light sensation, the student ask the client to close eyes then wipe a wisp
of cotton over the client’s forehead
To test deep sensation, use alternating blunt and sharp ends of the cap of a pen
over the same area.
Allow the client to chew, open, and clench her jaw, while palpating the jaw
muscles.
Actual result: The client was able to blink after the sclera is touched
The client was able to identify the light and deep sensations through the objects
presented.
The client was able to open and clench her jaw without extra effort.
CN V|: ABDUCEN
Type: motor
Function: lateral movement of the eyes
Tests perform: the student nurse stand directly in front of the lint and hold
penlight at a distance of 1 foot and asked client to hold head follow the
movement of the penlight with her yes only.
Expected result: She will be able to follow the lateral movement of the penlight.
Actual result: She was able to follow the lateral movement of the penlight.
CN V||: FACIAL
Type: motor
Function: facial expression, taste (anterior or 2/3 of tongue)
Tests perform: she was asked to raise her eyebrows, smile, show teeth and puff
out cheeks.
Expected result: she is expected to raise her eyebrows, smile, show teeth and
puff out cheeks.
Actual result: she was able to raise her eyebrows, smile, show teeth and puff out
cheeks
The client was able to identify the different tastes placed on the anterior two-
thirds of the tongue.
CN V|||: VESTIBULOCOCHLEAR
Type: sensory
Function: sense of hearing and balanced
Tests perform: whispered few words at the client back and allow repeating client
back.
Expected result: Mother Mae will be able to hear the words that the student nurse
whispered to the client.
Actual result: Mother Mae was able to hear the words that the student nurse
whispered to the client.
CNIX: GLOSSOPHARYGEAL
Type: motor and sensory
Function: pharyngeal movement and swallowing ability
Tests perform: whispered few words at the client back and allow repeating client
back.
Expected result: When asked to say “ah”, she will be able to say it and she will
be able to elicit the gag reflex. And she will be able to move the tongue from side
to side and up and down.
Actual result: Mother Mae was able to move the tongue foam side to side and up
and down and was able to say “ah” when asked. She also elicited gag reflex.
CN X: VAGUS
Type: motor and sensory
Function: swallowing and speaking
Tests perform: assess with cranial nerve IX, assess client speech for hoarseness
and ask the client to swallow and speech
Expected result: she will be able to state her name without hoarseness voice and
was able to swallowing.
Actual result: she was able to state her name without hoarseness voice and was
able to perform swallowing.
CN XI: ACCESORY
Type: motor
Function: head movement and movement of shoulders muscle
Tests perform: the student nurse asked the client to shrug her shoulder against
resistance of the student nurse’s hand and turn head side against resistance.
Repeat both sides.
Expected result: she must be able to shrug her shoulder against resistance of the
student nurse’s hand and turn head side against resistance.
Actual result: She was able to shrug her shoulder against resistance of the
student nurse’s hand and turn head side against resistance.
CN XII: HYPOGLOSSAL
Type: motor
Function: movement of the tongue and stretch of the tongue
Tests perform: She was asked to protrude her tongue at midline, and then move
it side to side.
Expected Result: She should be able to protrude her tongue at midline, and then
move it side to side
Actual result: She was able to protrude her tongue at midline, and then move it
side to side.
Nutritional Status
Physical Assessment
Mental Status
• Client is alert and awake with eyes open and looking at the student nurse.
• She is aware of self, other, time, home address and current location.
• She established eye contact when asked questions.
• The client is cooperative, when asked, can answer properly.
• The client was able to express free-flowing thoughts and expresses realistic
perceptions.
• She also smiles and frowns appropriately without difficulty.
• She listens and can follow directions without difficulty.
• She recalls her birthday and answer information correctly.
• She was able to recall recent event without difficulty
Motor Function
• Walking gait –coordinated movement, sitting
Integumentary System:
• Skin is brown in complexion, no odor, and uniform in color. Her skin turgor is
normal because when her skin was pinched, it go back to previous state
immediately. The skin is not edematous and is in normal temperature. With
sensation to touch, pain & temperature.
Skull & Face (Head)
• She has a round skull, no contusions, bruises noted nodules and masses,
and no tenderness palpated. She has symmetrical facial movements as
evidenced by client’s ability to smile, frown, raise his forehead & eyebrows &
shows his teeth. Facial features and facial movements are symmetrical.
Hair
• Hair is long, dry, straight, thick, black and evenly distributed hair. No area of
loss of hair and no infection/infestation.
Nails
• Her nails are untrimmed and dirty as well. She has light brown, smooth,
epidermis is intact, has convex curve nails, no discoloration of the nail beds,
no clubbing of nails, normal capillary refill (<2-3 sec), and no edema.
Abdomen
• Uniform in color, not distended, rounded symmetric contour and movements
upon by respiration and with audible bowel sounds every 5 to 20 seconds, No
lesions noted, no tenderness, relaxed abdomen with smooth and consistent
tension.
Motor Function
Walking gait
• Opposing arm swing upon walking; maintaining balance
Upper Extremities
• There are firm with coordinated movements;
• Her bones and joints have no deformities, tenderness nor swelling noted.
• She can sense touch, pain and temperature.
• The client is able to repeatedly and rhythmically touch the nose during the
“finger to nose test”.
Lower Extremities
• The muscles in the lower extremities are symmetrical.
• The client can resist against the pressure given by the student nurse and
elicited fine coordinated movements.
• The bones and joints in the lower extremities have no deformities and
pain, temperature and touch is felt.
• The client’s gait and balance is stable. She can walk in straight line and
can maintain balance.
CRANIAL NERVES
CN 1: OLFACTORY
Type: Sensory
Function: Smell
Tests perform: The student nurse asked the client to close her yes and identify
different aromas such as perfume and coffee.
Expected result: She is expected to identify the different aromas such as perfume
and coffee presented with hers closed.
Actual Result: Mother Mae was able to identify the aromas of perfumes and
coffee.
CN ||: OPTICS
Types; sensory
Function: vision and visual fields
Tests perform: the student nurse asked her to read on the newspapers
Expected result: the client will be able to read the newspapers
Actual result: Mother. Mae was able to read at a distance of 14”
CN |||: OCULOMOTOR
Types: motor
Function: Extra ocular movements of the eyes, movement of the sphincter of the
pupils.
Tests performed: the student nurse made use of a penlight at a distance of 1 foot
in front of the client’s eyes and asked the client to hold the head in a fixed
position facing the student and followed the movement of the penlight with eyes
only. The student nurses assess the 6 ocular movement and pupil reaction.
Expected result: client is expected to move her eyes though the cranial fields of
gaze that is from the center to the upper right, upper left lower right, lower left
and medially. Actual result: Mother Mae was
able to move her eyes though the cranial fields of gaze that is from the center to
the upper right, upper left lower right, lower left and medially.
CN|V: TOCHLEAR
Types: motor
Function: extra ocular eye movements specifically nerve eyeball downward and
laterally
Tests perform: the student nurse asked to asses the 6 ocular movements using
the penlight at distance or 1 foot and followed the penlight with the eyes only
Expected result: Mother Mae will be able to move her eyes downward obliquely
Actual result: Mother Mae was able to move her eyes downward obliquely
without moving hid head.
CN V: TRIGEMINAL
Type: motor
Function: jaw movement and mastication, Sensation of cornea, skin of face, and
nasal mucosa
Tests perform: The student asked the client to look upward, lightly touch lateral
sclera at eye to elicit blink reflex.
To test light sensation, the student ask the client to close eyes then wipe a wisp
of cotton over the client’s forehead
To test deep sensation, use alternating blunt and sharp ends of the cap of a pen
over the same area.
Allow the client to chew, open, and clench her jaw, while palpating the jaw
muscles.
Actual result: The client was able to blink after the sclera is touched
The client was able to identify the light and deep sensations through the objects
presented.
The client was able to open and clench her jaw without extra effort.
CN V|: ABDUCEN
Type: motor
Function: lateral movement of the eyes
Tests perform: the student nurse stand directly in front of the lint and hold
penlight at a distance of 1 foot and asked client to hold head follow the
movement of the penlight with her yes only.
Expected result: She will be able to follow the lateral movement of the penlight.
Actual result: She was able to follow the lateral movement of the penlight.
CN V||: FACIAL
Type: motor
Function: facial expression, taste (anterior or 2/3 of tongue)
Tests perform: she was asked to raise her eyebrows, smile, show teeth and puff
out cheeks.
Expected result: she is expected to raise her eyebrows, smile, show teeth and
puff out cheeks.
Actual result: she was able to raise her eyebrows, smile, show teeth and puff out
cheeks
The client was able to identify the different tastes placed on the anterior two-
thirds of the tongue.
CN V|||: VESTIBULOCOCHLEAR
Type: sensory
Function: sense of hearing and balanced
Tests perform: whispered few words at the client back and allow repeating client
back.
Expected result: Mother Mae will be able to hear the words that the student nurse
whispered to the client.
Actual result: Mother Mae was able to hear the words that the student nurse
whispered to the client.
CNIX: GLOSSOPHARYGEAL
Type: motor and sensory
Function: pharyngeal movement and swallowing ability
Tests perform: whispered few words at the client back and allow repeating client
back.
Expected result: When asked to say “ah”, she will be able to say it and she will
be able to elicit the gag reflex. And she will be able to move the tongue from side
to side and up and down.
Actual result: Mother Mae was able to move the tongue foam side to side and up
and down and was able to say “ah” when asked. She also elicited gag reflex.
CN X: VAGUS
Type: motor and sensory
Function: swallowing and speaking
Tests perform: assess with cranial nerve IX, assess client speech for hoarseness
and ask the client to swallow and speech
Expected result: she will be able to state her name without hoarseness voice and
was able to swallowing.
Actual result: she was able to state her name without hoarseness voice and was
able to perform swallowing.
CN XI: ACCESORY
Type: motor
Function: head movement and movement of shoulders muscle
Tests perform: the student nurse asked the client to shrug her shoulder against
resistance of the student nurse’s hand and turn head side against resistance.
Repeat both sides.
Expected result: she must be able to shrug her shoulder against resistance of the
student nurse’s hand and turn head side against resistance.
Actual result: She was able to shrug her shoulder against resistance of the
student nurse’s hand and turn head side against resistance.
CN XII: HYPOGLOSSAL
Type: motor
Function: movement of the tongue and stretch of the tongue
Tests perform: She was asked to protrude her tongue at midline, and then move
it side to side.
Expected Result: She should be able to protrude her tongue at midline, and then
move it side to side
Actual result: She was able to protrude her tongue at midline, and then move it
side to side.
B. Immunization Status
1st dose 2nd dose 3rd dose
Error! Bookmark
BCG _______ _______
not defined.
DPT
OPV
HEPA B
D. Nutritional Status
Ht: 111cm
Wt: 15 kg (normal) Age: 60months
FNRI= Normal weight 14.4-23.5 Therefore, Anthony is Normal
LIVING CONDITION
The house structure is made of hollow blocks, concrete cement and
cut wood. There is a gap between the walls and roofing, allowing entrance of
cold and hot air and insects. During the day, they are lighted by artificial
lighting because sunlight cannot light the house due to some environmental
factors such, as their house is covered by big trees; Also the location of their
windows do not provide entry for the light to come in. The house is not stable
and has many threats. The wires are exposed since they do not have a
ceiling and during rainy season water flows to their house making them at risk
for some diseases like Leptospirosis. It has a bedroom, kitchen, toilet, and a
living room. There are 6 windows throughout the house which measures
93.98cmX60.96cm (living room), 75.2cmX86.36cm (bedroom),
60.96cmX71.12cm (kitchen). Their windows do not have screens w/c allows
the entry of mosquitoes and flies. Also they have an incandescent light bulb
which is located in the bathroom (60watts) 1 fluorescent(40watts) in the living
room, 1 fluorescent in the bedroom(18watts), 1 fluorescent outside near the
door(18watts). The household was also positive from mice & cockroaches
due to the garbage exposed in front of their house. According to the mother
their house has approximately 11m2
TOILET FACILITY
They have a small bathroom near the kitchen. They use plastic container
as a dipper in flushing the toilet. The toilet is fairly clean because there is some
urine smell but there is no fecal stains observed in the toilet bowl. The roof also
has small holes on it.
WATER SUPPLY
They obtain their water supply from jetmatic, which is owned by their neighbor.
According to them, they pay 2 pesos per pale. They drink the water from the
jetmatic and store it in a pitcher. The family regularly boils the water before
drinking it. This provides them to have a potable drinking water.
DRAINAGE SYSTEM
They have an open type of drainage system. It is man-made type of
drainage system in which they dug pits where water can flow and will not be
directed towards their house in case of heavy rains or typhoons; since their
house is located at a slope of the village. This is a man-made drainage facility
where they dug pits to make flood-water and the like to be in free flowing when it
is raining while the water usually dries up and absorbed by the soil when the rain
stops.
GARBAGE DISPOSAL
They do no have proper ways of throwing their garbage. Their garbage is
placed outside of the house and is burned. All the waste materials including
bamboo waste, plastic, leftover foods etc. are burned all together. Sometimes
they just place it in an area and leave it there where it is exposed to chickens,
ducks, and, flies, cockroaches and other insects w/c is a threat to the health of
the family. The collection of garbage in their community is irregular.
Resources of the
Community
The community resources
are also available to assist the
family in terms of consulting
about the disease condition.
The problem is moderately
C. Preventive 2/ 3 x 1 0.67 preventable.
Potential (PP)
Severity or gravity of the
Severity =PP problem.
or The problem has high
Gravity gravity because it can affect
the health status of the other
Duration =PP members. Also it can alter
the functioning of Ann in the
Current =PP family making the role
Manage assumptions within the
ment family altered too.
Exposur =PP Duration of the Problem
e to any The problem has
high risk existed approximately two
group days before the student
nurses arrived.
Current Management
Since the supposed
provider of care Mother Mae
knows some herbal
medicines that can be a
remedy to the cough, it is
currently managed.
Exposure to any high risk
group
Since the brother of
Ann is younger and spends
most of the time with Ann, he
is at risk to be infected in
case the cough is caused by
infection.
Resources of the
Community
The community resources
are also available where they
could provide teachings and
early diagnosis of possibly
occurring disease.
Problem #3: Inappropriate role Assumption (Mrs. Mae has the power to
decide) as a Health Threat
CRITERIA COMPUTATION SCORE JUSTIFICATION
Resources of the
Community
The community resources
are also available to assist the
family in terms of regular
garbage collection or garbage
cans provided all through out the
community vicinity.
Current Knowledge
The family does not
recognize the problem
existing because they are
not aware of the possible
routes of spreading the
infection.
Resources of the Family
The family can have
Current X herbal medicines to treat the
Knowledge sick member and they can
Resources have precautions in
of the interacting with the sick
Family individual like frequent hand-
Resources washing.
of the Resources of the Nurses
Nurses Knowledge and time of
Resources the student nurses are
of the available to establish
Community awareness and recognition
of the problem. They are
also knowledgeable for the
teachings to help the family
expand their knowledge of
the possible modes of
transmission of the infection.
Resources of the
Community
The community resources
are also available where they
could provide teachings.
Furthermore, it can provide
medications for the ill person to
treat underlying disease.
Current Knowledge
The family does not
Current x recognize the presence of
Knowledge the exposed electrical wires
Resources x and the danger it may bring.
of the Resources of the Family
Family The family has adequate
Resources resources to make a
of the particular intervention to the
Nurses problem especially that
Resources father Lorenzo is an all-
of the around laborer. However,
Community they do not know the
existence of the problem and
so they do not make use of
their resources.
Resources of the Nurses
Knowledge and time of
the student nurses are
available to establish
awareness and recognition
of the problem. Also, they
have proper know-how to
perform independent nursing
intervention like help the
family fix the exposed wires
with electric tapes.
Resources of the
Community
The community resources
are also available to assist the
family in terms of available tools
and manpower.
Current Knowledge
The family does not
Current X recognize the problem
Knowledge existing AEB mother Mae
Resources X verbalizing that they utilize
of the this process to eliminate
Family their wastes. Yet, she did not
Resources made mention some
of the questions of its ill effects.
Nurses Resources of the Family
Resources The family either can dig
of the a hole where they can burry
Community these wastes. Or they can
collect them in a plastic bag
and wait for the collectors to
get it. Yet they do not utilize
any of these.
Resources of the Nurses
Knowledge and time of
the student nurses are
available to establish
awareness and recognition
of the problem. They are
also knowledgeable for the
teachings to help the family
expand their knowledge of
the ill effects of air pollution
through burning of plastic.
Resources of the
Community
The community resources
are also available where they
could provide teachings.
Furthermore, the garbage
collection occurs at times.
Current Knowledge
The family does not
Current X recognize the problem
Knowledge existing because they are
Resources not aware of the accident
of the hazards.
Family Resources of the Family
Resources The family can fix the
of the exposed wires especially
Nurses that the father is an all-
Resources around laborer and is
of the knowledgeable of fixing it..
Community Resources of the Nurses
Knowledge and time of
the student nurses are
available to establish
awareness and recognition
of the problem. They are
also knowledgeable for the
teachings to help the family
expand their knowledge of
regarding the danger of the
exposed wires and the injury
it may cause.
Resources of the
Community
The community resources
are also available where they
could provide teachings.
Furthermore, it can provide
manpower to help in fixing the
accident hazards.
Problem 1
First Level of Assessment: Presence of Coughs (Ann) as a Health Deficit
Second Level of Assessment: Inability of the family to provide nursing care to its sick member due to:
a. Lack of knowledge and skill in carrying out the necessary treatment/procedure/care
b. Ignorance of facts about the disease and health condition
Method of Family
Cues Analysis of the Objectives Nursing Rationale Contact Resources Expected
Problem Interventions Required Outcome
S > “Mga 2 days ne Inability of the Short Term: >Identify reasons -to provide baseline Home visits >Family’s
manguku. Balamu family to provide After 1-2 days of behind acquiring data to which cooperation Short Term:
pin mimika ya eh!” nursing care to its home visits, the the disease treatment will be The family shall
as verbalized by sick member due family will be able > Discuss the mode directed >Student Nurse’s have been able to
mother Mae. to: to recognize the of transmission with - to prevent transfer of time, effort, skills recognize the
a. Lack of necessity of the family. disease and knowledge necessity of
O > The client knowledge and skill intervention in the > Encourage intervention in the
manifested: in carrying out the relieving the increase fluid >Community relieving the
> non productive necessary coughs intake. - to relieve itchy throat resources: Health coughs and colds
coughing treatment/procedur Long Term: or liquefy possible center’s free Long Term:
e/careb. Ignorance After 4-5 days of secretions medication The family shall
of facts about the home visits, the > provide warm - To mobilize have used safe and
disease and health family will use safe versus cold liquids secretions. effective ways in
condition and effective ways as appropriate. treating or
in treating or > Provide gentle alleviating the
alleviating the back rubbing disease condition
disease condition > Always check - to provide comfort like increasing fluid
like increasing fluid child’s back for intake or taking
intake or taking sweat. Wipe the -to limit or rule out herbal medications.
herbal medications. back for sweat. aggravating factors.
> Encourage to - To increase body’s
take in Vitamin C resistance to
regularly. microorganism
> Advise mother to - To identify proper
seek medical treatment and
advice. interventions.
Problem 2
First level Assessment: Unhealthful Lifestyle and Personal Habits or Practices: CIGARETTE SMOKING as a Health
Threat
Second level Assessment: Inability to recognize existence of the problem due to:
a. Ignorance of facts or inadequate knowledge of ill effects of smoking
b. Attitude in life which hinders recognition of the problem
Method Of
Nursing Resources Expected
Cues Analysis Of The Objectives Rationale Family
Interventions Required Outcomes
Problem Contact
-To gain the
S = “Bayung Inability to Short term: > Establish rapport cooperation of Home visits > Time and Short term:
tawu ya pa recognize After 2 home the client interest of the The family shall
sisindi ne. existence of the visits, the family > Provide health -To help the family have verbalized
Kayari na ning problem due to: will verbalize teachings about family be understanding of
metung, understanding of smoking and its aware of the > Participation the ill effects of
makasindi ne a. Ignorance of the ill effects of effects negative and smoking both on
ing katuki.” As facts or smoking both on effects of cooperation of the smoker &
verbalized by inadequate the smoker and smoking. the family those who inhale
Mother Mae knowledge of ill those who inhale > Encourage the -To lessen the the second hand
effects of smoking the second hand family member who habit of > Knowledge, smoke.
O= smoke. smokes to lessen smoking and skills and
> lips of Mr. b. Attitude in life the number of eventually attitude of the Long Term:
Lorenzo are which hinders Long Term: sticks he lights in a stopping its student nurses The family, esp.
dark in color recognition of the After 6 days of day. use. Mr. Lorenzo shall
[seen on problem home visits, Mr. > Encourage the -To avoid have done efforts
pictures] Lorenzo will smoker to smoke affectation of to reduce by about
make efforts to outside the house. children to 1-2 sticks the
>consumption reduce by about inhale the number of
of 1 pack per 1-2 sticks the second hand cigarette he
day as stated number of cigar > Keep children smoke. smokes a day.
by Mother Mae sticks he smokes away from -To avoid
in a day. smokers. inhaling the
smoke that
could cause
respiratory
problems.
Problem 3
First level Assessment: Inappropriate role Assumption (Mrs. Mae has the power to decide) as a Health Threat
Second level Assessment: Inability to recognize existence of the problem due to:
a. Ignorance of facts or inadequate knowledge
b. Attitude/philosophy in life which hinders recognition of the problem
Method
Nursing Resources Expected
Cues Analysis Of The Objectives Rationale Of Family
Interventions Required Outcomes
Problem Contact
S =Ø Inability to recognize Short term: > Establish rapport -To gain the Home > Time and Short term:
existence of the problem After 2 home > Provide health cooperation of the visits interest of the The family shall
O= due to: visits, Mrs. teachings about the client family have verbalized
Mrs. Mae Mae will be negative effects of -To help the family understand the
stressed out that a. Ignorance of facts or able to leaving the decision be aware of the > Participation importance of
she makes the inadequate knowledge understand the on one parent alone negativity of their and cooperation consulting her
decisions at b. Attitude/philosophy in importance of >Stressed out practice. of the family husband in
home because life which hinders consulting her benefits of having -For them to weigh decision-making
her husband is recognition of the husband in combined opinions the advantages > Knowledge, Long Term:
always not problem decision- before deciding. and disadvantages skills and Mr. Lorenzo shall
around. making. > Encourage the of sharing in attitude of the then be able to give
Furthermore, she family member to decision-making student nurses his part in the
described her Long Term: always assume their tasks. decision-making
husband as non- After 6 days of roles with -To remind them process whenever
dominating and home visits, responsibility and be that equality in he is around or in
calm&quiet. Mr. Lorenzo not dominating or authority is needed making major
will be able to inferior but only fair. to gain mutual decisions for the
give his part in > Discourage the respect. family.
the decision- weak authoritarian -To develop a
making attitude of Mr. strengthened and
process Lorenzo and confident authority
whenever he is encourage him to in him esp. that he
around or in take part in making is the head of the
making major choices for their family.
decisions for family. . To make them
the family. > Include the children feel belongingness
in tackling the and let them voice
decisions and out themselves.
options.
Problem 4
First level Assessment: Presence of Rodents and Cockroach as a Health Threat
Second level Assessment: Inability to provide a home environment that is conducive to health maintenance due to:
a. inadequate knowledge of preventive measures
b. inadequate financial family resources
Inability to make decisions with respect to taking appropriate action due to:
a. failure to comprehend the nature, magnitude/scope of the problem.
b. Low salience of the problem
Analysis Of The Nursing Method Of Resources Expected
Cues Objectives Rationale
Problem Interventions Family Contact Required Outcomes
S =”Dacal > Explain the -To inform the Home visits > Time and Short term:
ipas keni bale. Inability to Short term: present family about the interest of the
Bahay-ipis ne provide a home After the environmental present condition Observations family The family shall
pin awus ing environment that initial home condition of the have verbalized
anak ku keng is conducive to visit, the surrounding of Interview > Participation understanding
bale mi eh.” health family will be the house and cooperation of the harmful
maintenance due able to > Advise the family -To have a clean of the family effects of
O = The to: verbalize to regularly clean the and healthy insects and
following were a. inadequate understanding surroundings of their environment that > Knowledge, rodents inside
observed: knowledge of of the harmful house is conducive to skills and their house.
preventive effects o health attitude of the
> Presence measures insects and > Instruct the mother -To prevent them student nurses Long-term:
cockroach b. inadequate rodents inside to cover their kitchen from being
financial family their house. utensils or store in contaminated by > Cleaning The family shall
>manual resources the cabinet the cockroaches materials like perform and
eradication of Long-term: > Instruct the mother broom and soap demonstrate
cockroaches Inability to make After 5 days of regularly to cover -To prevent it or insecticides compliance of
decisions with home visits, their water from becoming a health teachings
> temporary respect to taking the family will breeding for and effective
disposal of appropriate be able to insects and eradication of
garbage action due to: a. perform and > Instructed the rodents the rodents.
inappropriately failure to demonstrate mother to properly > Rooting out the
. comprehend the compliance of throw their garbage cause of the
nature, health and cover it problem serves
magnitude/scope teachings and as one of the
of the problem. effective best solutions in
b. Low salience eradication of problem coping
of the problem the rodents.
Problem 5
First Level: Inadequate/Insufficient Family Resources as Health Threat
Second Level: Inability to provide food storage facilities conducive to health maintenance due to:
a. inadequate family resources specifically limited physical resources
b. failure to see benefits of investments in home environment improvement
Inability to make decisions with respect to taking appropriate health action due to:
a. lack of knowledge as to alternative courses of action open to them
b. low salience of the problem
Method of
Cues Analysis of the Objectives Nursing Rationale Family Resources Expected
Problem Interventions Contact Required Outcome
S= “Manakitan Inability to Short Term: > Compute for - to provide Home visits Determination Short Term:
yamung sustain and After 1-2 days the family’s comparison and and hard work The family
7,500php ing meet their basic of home visits, expenses and identify of the family. shall have
bulan in asawa needs due to the family will be salary. deficiency when planned means
able to plan
ku. eh” as lack of family means to
it comes to Time and effort to improve their
verbalized by resources, improve their financial status for both the condition such
the mother. especially condition such as >Give the family family and the as intake of
income. intake of - to give the student. nutritious yet
information
O = The family nutritious yet family an idea cheaper food.
regarding the
income per cheaper food. on how to earn Health
different ways
month is only P on earning extra extra income Teachings Long Term:
7,500 divided Long Term: provided by the The family
into 4 of them. After 5-6 days income. student nurse is shall have been
of home visits, > Encourage the
They are the family will be family to plant
necessary. able to
considered able to recognize vegetables. - to earn extra recognize
poor since only effective ways to > Provide tips on money; to effective ways
P 1,875 is increase and proper provide for food to increase and
allotted per maximize their budgeting. - to maximize maximize their
family member. income or > Encourage the use of income or
minimize their them to buy money minimize their
expenses like cheaper but expenses like
prioritizing nutritious foods - to meet the prioritizing
promotion of such as cheaper
health to avoid
nutritional promotion of
meats or needs without health to avoid
expenses due to vegetables.
illness. compromising expenses due
health needs to illness.
Problem 6.5
First Level: Lack of food storage facilities as a Health Threat
Second Level: Inability to provide food storage facilities conducive to health maintenance due to:
a. inadequate family resources specifically limited physical resources (e.g. Lack of space to construct
facility)
b. failure to see benefits of investments in home environment improvement
Inability to make decisions with respect to taking appropriate health action due to:
a. lack of knowledge as to alternative courses of action open to them
b. low salience of the problem
Cues Analysis of the Objectives Nursing Intervention Rationale Method of Resource Expected
Problem Family s Outcome
Contact Required
S> Ø >Inability to provide Short Term: >Assess the presence -To differentiate present Home >Student Short Term:
O> left food storage facilities After 1-2 days of methods utilized by the situation to the ideal for Visit nurse’s, The family shall
overs conducive to health home visit, the family to store food determination on the time, have demonstrated
were maintenance due to: family will be able focus of intervention effort and proper storage of
stored on a. inadequate family to demonstrate >Discuss with the family >To help the family skills food and
casserole resources specifically proper storage of the existence of the recognize the current >Family’s understand the
>lack of limited physical food and problem problems as well as its time, rationale and
refrigerat resources (e.g. Lack of understand the effect to their health cooperati possible
or that space to construct rationale and >Stress importance of >To encourage on and consequences of
prevents facility) possible giving appropriate participation from the decision improper food
food b. failure to see consequences of attention to proper family in changing making storage
spoilage benefits of investments improper food storage of food and its inappropriate habits competen
in home environment storage benefits ce Long Term:
improvement >Advice the family to >To promote equal >Commu The family shall
>Inability to make Long Term: After 5 maintain open authority in decision nity’s have promoted and
decisions with respect days of home visit, communication and making each material apply proper food
to taking appropriate the family will be discuss about obtaining responsibilities for the resources storage in their
health action due to: able to promote equipments that will be rest food everyday living as
a. lack of knowledge and apply proper conducive to their health storage evidence by
as to alternative food storage in maintenance equipmen presence of
courses of action open their everyday >Advice the family to ts (e.g. covered food
to them living as evidence consider alternative food >To meet the family’s refrigerato
b. low salience of the by presence of storage to prevent food financial capabilities r, food
problem covered food spoilage and cover,
stored or avoiding contamination (e.g. Tupperwa
left overs. Tupperware) re)
Problem 6.5
First level Assessment: Poor Environment Sanitation: Improper Drainage System as a health threat
Second level Assessment: Inability to make decisions with respect to taking appropriate health action due to:
a. Failure to comprehend the nature, magnitude/scope of the problem.
Inability to provide a home environment which is conducive to health maintenance due to:
a. Limited physical resources like lack of space to construct facility
b. Lack of knowledge on preventive measures.
c. Inadequate family resources specifically financial constraints and manpower.
Cues Analysis of the Objectives Nursing Rationale Method of Resources Evaluation
problem Intervention contact required
S = “Pag Inability to make Short term: After >Discuss the - To know the -Home visits Human Short term: The
mumuran, decisions with respect 1-2 days of home importance of complication & -Interview resources: family shall have
lulub keni bale to taking appropriate visits the family good provide baseline Family’s verbalized
health action due to: -Observation
ing danum. will verbalize environmental information & cooperation and understanding of
Atin kasi a. Failure to understanding of sanitation. acknowledge the time student’s the importance of
siwang eh!” comprehend the the importance of presence of the knowledge time sanitation & its
O = drainage nature, it and its possible >Encourage problem. and effort. effects to health
magnitude/scope of
system is only effects to health cleaning of the such as the water
the problem.
a constructed such as the water area where most - To control the can enter the
pit that allows Inability to provide a
can enter the flies or mosquito spread of disease house and
flow of water home environment house and breed. or cause of soaked-wet all
be deviated which is conducive to soaked-wet all dengue. their house
from the health maintenance their house >Inspire the appliances.
house due to: appliances. family to clean - To promote .
towards a. Limited physical their good
another resources like lack of Long term: After surroundings so environmental Long term: The
direction; still space to construct 4 days of home that when water sanitation. family shall have
this is facility visits, the family floods out, the been able to
ineffective b. Lack of knowledge will be able to water that will properly
during rainy on preventive demonstrate enter their house demonstrate
days. measures. proper efforts to will be less dirty. proper efforts to
=there is a c. Inadequate family construct a construct a
hole beneath resources specifically proper drainage >Provide health - To inform the proper drainage
the door that financial constraints system. teachings family of the system.
allows and manpower. regarding the benefits of having
passage of benefits of having a good drainage
water into the a good drainage system.
house. system.
Problem 8
First Level of Assessment: Improper Garbage Disposal as a Health threat
Second Level of Assessment: Inability to provide a home environment which is conducive to health maintenance and
personal development due to:
a. Failure to see benefits of investment in home environment improvement
b. Lack of knowledge of importance of hygiene and sanitation
c. Ignorance of preventive measures
Cues Analysis of the Objectives Nursing Rationale Method of Resources Evaluation
problem Intervention contact required
S> O Inability to Short term: >Assess the -to obtain a -Home visits -student nurses’ Short term:
provide a home After 2-3 days of general housing baseline data -Interview time, effort, and The family shall
O> garbage environment home visit, the condition -to determine skill have developed
-Observation
placed on a which is family will develop >Identify the degree of -family’s time awareness on
awareness on the the importance
plastic bag conducive importance of
unsanitary nursing and cooperation, of good
was seen health good garbage disposal intervention compliance, environmental
hanging near maintenance environmental >Assess the needed participation and sanitation as
the cooking and personal sanitation as reasons of the -to provide understanding evidenced by
facility. development evidenced by failure to dispose background >community disposing the
due to: disposing the garbage properly information for waste containers garbage properly
a. Failure to garbage properly >Discuss with the nurses to and garbage and
see benefits of and implementing the family the know which collection implementing
investment in cleanliness possible health habit to correct cleanliness
Long term:
home After 5 days of
consequences of -to encourage Long term:
environment home visit, the improper initiative to The family shall
improvement family will be able garbage disposal maintain a have maintained
b. Lack of to maintain a -Help the family clean a clean
knowledge of clean environment find the environment by environment that
importance of that is conducive appropriate place a proper is conducive to
hygiene and to health where to dispose disposal of health
sanitation maintenance as or temporarily waste maintenance as
c. Ignorance of evidenced by place the house -to initiate the evidenced by
disposing the disposing the
preventive garbage in a more
wastes family’s garbage in a
nature appropriate compliance to more appropriate
container like can. teachings container like
about can.
sanitation that
were given.
Problem 9: First Level of Assessment: Risk for Infection as a Health Threat
Second Level of Assessment: Inability to recognize the presence of the problem due to:
a. Ignorance of facts/lack of knowledge
Inability to provide adequate nursing care to the at risk member of the family due to:
a. Ignorance of facts about health condition
b. Lack of knowledge in carrying out necessary precaution
Cues Analysis of the Objectives Nursing Rationale Method of Resources Evaluation
problem Intervention contact required
S> “Mga 2 days Inability to Short term: >Identify reasons -to provide baseline -Home visits -student nurses’ Short term:
ne manguku” recognize the After 2-3 days behind acquiring the data to which -Interview time, effort, and After 2-3 days
presence of the of home visit, disease treatment will be skill of home visit,
directed -Observatio
O> Ann has problem due to: the family will -family’s time and the family shall
> Discuss the mode - to prevent transfer n
coughs and a. Ignorance of develop cooperation, have developed
colds facts/lack of awareness of transmission with of disease compliance, awareness
knowledge about the family. participation and about
Inability to contributing > provide warm - To mobilize understanding contributing
versus cold liquids secretions.
provide factors that >community factors that
as appropriate.
adequate might increase waste containers might increase
> Provide gentle - to provide comfort
nursing care to risk for spread back rubbing for the and garbage risk for spread
the at risk of infection like ill individual collection of infection like
member of the contact to > Always check -to limit or rule out contact to
family due to: droplet child’s back for aggravating factors. droplet
a. Ignorance of secretions. sweat. Wipe the - To increase body’s secretions.
facts about back for sweat. resistance to
health condition Long term: > Encourage to take microorganism Long term:
b. Lack of After 5 days of in Vitamin C After 5 days of
knowledge in home visit, the regularly. - contact with it is a home visit, the
carrying out family will be >Advise other route for family shall
necessary able to hinder members to avoid transmission of have been able
precautions the spread of contact with pathogen to hinder the
infection AEB secretions of ill spread of
treating the individual. -to avoid inhalation infection AEB
primary ill >Advise ill individual of secretion by other treating the
individual. to cover mouth and members primary ill
nose when coughing - To identify proper individual.
or sneezing treatment and
> Advise mother to interventions.
seek medical advice.
Problem 11 First Level: Presence of Accident Hazards (Exposed electrical wires) as a Health Threat
Second Level: Inability to provide a home environment, which is conducive to health
maintenance and personal development due to:
a. Ignorance of preventive measures
b. Failure to see benefits of investment in home environment improvement.
c. Lack of skills in carrying out measures to improve home environment
Cues Analysis of the Objectives Nursing Rationale Method of Resources Expected
Problem Intervention Family Contact Required Outcome
S> Ø >Inability to provide a Short Term: >Assess the -To assess Home Visit >Student nurse’s Short Term:
O> exposed home environment, After 1 day of general housing degree of knowledge, time, The family shall
electrical wires which is conducive to home visit, the condition nursing effort and skills in have been able
were seen health maintenance family will be able intervention to maintaining the to recognize and
hanging close to and personal to recognize and >Help the family be given; obtain family’s identify dangers
the doorway in development due to: identify dangers in identify and baseline data environment safe in the presence
and out of the a. ignorance of the presence of recognize -To involve the and accident free of accident
accident hazards hazards and
house. preventive accident hazards family in the >Family’s time,
and know the know the
>Mr. Lorenzo is measures existing in their achievement of compliance and
importance and importance and
not always b. Failure to long term benefits
house their accident cooperation as long term
around to help fix see benefits of having an >Discuss to the free environment well as skills in benefits of having
the exposed of accident free family the -To increase the maintaining an an accident free
wires investment environment as importance of family’s accident hazard environment as
in home evidence by the having an knowledge and free environment evidence by
environment efforts made to accidents free encourage them >Community’s efforts made to
improvemen keep the family environment and to maintain an material keep the family
t. aware of the its long term accident free resources like aware of the
c. Lack of danger of the benefits. environment storages facility, danger of the
skills in exposed wires. >Discuss to the -To provide divider, etc. exposed wires.
carrying out Long Term: After family the possible background
measures to 5 days of home consequences of knowledge of Long Term:
improve visit, the family the presence of what to expect in The family shall
home will manifest accident hazards a failure of have manifested
environment application of the >Help the family maintaining an application of the
teachings given eliminate accident accident free teachings given
AEB elimination AEB elimination
hazards existing environment
of accident of accident
and provide ways >To make the
hazards like hazards like
properly kept
on how to tape family think and properly kept
cables and wires. them and prevent make ways on cables and wires.
them being improving their
exposed. housing
condition.
Problem 11
First level Assessment: Poor environmental Sanitation: Air Pollution as a Health Threat
Second level Assessment: Inability to recognize existence of the problem due to:
a. Ignorance of facts or inadequate knowledge of ill effects of gas emissions in
burning plastics and other materials
b. Attitude in life which hinders recognition of the problem
Inability to provide a home environment, which is conducive to health maintenance due to:
a. failure to see benefits of investment in home environment improvement
b. ignorance of preventive and alternative measures.
Method
Nursing Resources Expected
Cues Analysis Of The Objectives Rationale Of Family
Interventions Required Outcomes
Problem Contact
S = “Sisilaban Inability to recognize Short term: > Establish rapport -To gain the Home > Time and Short term:
mi ngan ing existence of the After 2 home visits, cooperation of the visits interest of The family shall
basura mi problem due to: the family will > Provide health client the family have verbalized
ken. Pati a. Ignorance of facts or verbalize teachings about the ill -To help the family be understanding of the
plastic.” as inadequate knowledge understanding of effects of burning the aware of the negative > ill effects of burning
verbalized by of ill effects of gas the ill effects of garbage outside like of their practice of Participation the garbage
Mother Mae emissions in burning burning the dangerous gas burning the garbage and including plastic
plastics and other garbage including emissions and possible air cooperation materials outside
O= materials plastic materials pollution. of the family
>presence of b. Attitude in life which outside. > Encourage the -To lessen the danger Long Term:
ashes and hinders recognition of family member to shift of inhaling the smoke > The family shall
burnt the problem Long Term: to another way of emitted by the burning Knowledge, have done efforts to
materials After 6 days of getting rid of their process. skills and think of another way
piled up on Inability to provide a home visits, the waste like burying attitude of of disposing or
their front home environment, family will make biodegradable -To avoid affectation of the student getting rid of their
yard. which is conducive to efforts think of materials. children to inhale the nurses garbage instead of
health maintenance another way of gas emitted by the burning.
due to: disposing or > Discourage the plastic.
a. failure to see getting rid of their practice of burning the And to provide
benefits of investment garbage instead of plastic in case they do decision or choice for
in home environment burning. not want to shift to the family.
improvement digging & burying. -To avoid accidents
b. ignorance of > Keep children away like burns especially
preventive and from the flame. for the playful children.
alternative measures. .
Therapeutic 1 3 5 1 3 5 Initial:
Competence ♥
This category
On the initial visit, during the interview, Mother Mae stated that she uses (OTC) over-the-
includes all counter drugs without consulting a doctor or even just in the health center. She also
procedures or mentioned that she prefers to go to herbolarios rather than doctors. But though she
treatment consults doctors when her children are the ones that are ill.
prescribed for
the care of Final:
♥
illness, such as
After giving advices to Mother Mae about the necessity of seeking professional (medical)
giving
medications and assistance when encountering sickness within the family, she demonstrated willingness to
using visit the clinic and consult to the authorized provider of care. She also mentioned that she
appliances, is willing to participate in the up-coming activities and seminars that will be held at the
dressings, health center where in her presence was recognized by the student nurses after the course
exercises and of the FCA.
relaxation, and
special diets.
CATEGORY INTIAL FINAL JUSTIFICATION
SCORE SCORE
Knowledge of 1 3 5 1 3 5 Initial:
Health ♥ Before the student nurses made the necessary interventions or give teachings, Mrs. Mae
Condition showed confusion in the condition of Ann’s cough. Also, when asked about her history, she
This category is refused to include the cancer of her mother where in it should be included.
concerned with
the particular
health condition
that is the
occasion for
♥ Final:
care (e.g.
knowledge of
After thoroughly explaining the disease condition and possible reasons of its occurrence,
the disease,
Mrs. Mae showed enthusiasm in knowing the disease. She also manifested a clear
understanding
acceptance of the new knowledge learned.
of
communicability
of diseases and
modes of
transmission)
CATEGORY INTIAL FINAL JUSTIFICATION
SCORE SCORE
Application of 1 3 5 1 3 5 Initial:
Principles of
♥
Personal and During the initial visit, the student nurses observed the some practices that do not
general Hygiene
contribute to proper hygiene and sanitation of the house. Anne was not well groomed. And
This is concerned
with the family they place their garbage hanging next to their cooking facility. They also burn their garbage
action in relation
to maintaining instead of burying or waiting for the collectors.
family nutrition,
securing
adequate rest and
relaxation for the
family members
and carrying out ♥ Final:
accepted
preventive
measures such as During the final visit, and the visits after the student nurses initiated activities to improve the
immunization, family’s hygiene, the house started to be observed clean and in order. Mother Mae also
medical appraisal
and safe showed change in wanting her child Ann be presentable. She also explained to Anthony
homemaking
habits in relation that he needs to wear his shoes in going to school.
to storing and
preparing food.
CATEGORY INTIAL FINAL JUSTIFICATION
SCORE SCORE
Emotional 1 3 5 1 3 5 Initial:
Competence
This category has ♥
to do with the During the initial home visit, the family members do fairly well but sometimes the children
maturity and
integrity with were left unattended. Mother Mae and her husband are seldom seen together. And a
which the
members of the neighbor commented that she would always shout at her husband.
family are able to
meet the usual
stresses and
problems of life,
and to plan for
happy and fruitful Final:
living. This
involves the ♥
degree to which After interventions, Mrs. Mae verbalized that though she shouts at Mr. Lorenzo, it would not
individuals accept
necessary mean or start a fight. This shows that though they are misinterpreted at times, they are
disciplines strongly bonded with love and emotional security with one another. And she does not regret
imposed by one’s
family culture; the of marrying at a young age.
development and
maintenance of
individual
responsibility and
decision; and
willingness to
meet reasonable
obligations.
CATEGORY INTIAL FINAL JUSTIFICATION
SCORE SCORE
Physical 1 3 5 1 3 5 Initial:
Environment ♥
This category is
During the initial visit, the house of the family was in poor condition. It has accident
concerned with hazards, poor cooking facilities and improperly disposed garbage. Added to this are the
the home and
community or garbage burned outside and the electrical wires exposed. There are also breeding sites for
work
insects and the improper drainage system.
environment as
it affects family
health. This ♥
Final:
includes
condition for
housing, After the Nursing Intervention, the house’s condition improved. The student nurses advised
presence of
accidence the family to throw their garbage outside instead of keeping in hanging near their cooking
hazards, facility. They were also advised to get rid of their burning practices and start eliminating
screening,
plumbing, hazards in their home.
facilities for
cooking and for
privacy, level of
community,
availability and
conditions of
schools and
transportation.
CATEGORY INTIAL FINAL JUSTIFICATION
SCORE SCORE
Use of 1 3 5 1 3 5 Initial:
Community ♥
During the initial visit, the family sends their son and daughter Ann and Anthony to the
facilities
This category
community’s elementary school. Thus, it indicates that they know some of the community
has to do with facilities and services. However, they do not make use of the medical services provided in
which family
members know the health center because of lack of confidence and their self-medicating habits. Further
about with which
more, they seek herbolarios first.
they use
available
community
resources for
health,
education, and ♥ Final:
welfare. The
coping ability
does not After the information were given that provided awareness to the family by the student
indicate the nurses, the family started to seek medical privileges provided in the community health
level of the need
for services, but center. They used the facilities they need appropriately and promptly (e.g. free
rather the
degree to which medications); knows when to call for help and whom to call. The student nurses also
they can cope noticed her participation in mothers’ classes.
when they must
seek such aid.
VIII. Learning Derived
The family case analysis made me realized a lot of things and gave me
experiences that I can cherish in my life. I enhanced my social ability in doing our
family case analysis because we need to interact with them in gathering
information.
I realized that doing this project we have helped the family enhance their
knowledge about health. The family helped me realized to be thankful with the
blessing I receive everyday, to be satisfied with the things that I have in my life.
God bless.
Clefanny Ann M. Bayani
BSN III-5
“The first duty of a human being is to assume right functional relationship to
society–more briefly, to find your real job and do it.”
–Charlotte Perkins Gilman
Working is biblical. Jesus even emphasized that whosesoever not being
fruitful must be cut off from His people. The fig tree that it did not bear fruit
causing it to die and to wither exemplified this gigantic responsibility for us to be
productive and be of help to others.
As a Christian, I want to live out this benevolent task. As a nurse I want to
extend my helping hand to my patients. Moreover, as a student I want to take
part in making our group works satisfactory.
Gladly, this activity molded me the way I wanted. I developed the “working
attitude” that made me a step further towards nursing competence and sense of
responsibility. Also, I developed persistence just to finish the part assigned to me
and to pursue perfection to honor our Lord and to benefit my group mates.
Most importantly, I found the essence of this career and the big part it
contributes to society. I learned the lessons I need to gain to be more Christ-like–
a compassionate heart. I discovered the purpose behind this God-led journey–to
channel His foremost care to the least of His people. And I realized the fullness of
life by being able to observe life in different views.
Generally, you can’t just be someone roaming around while watching
others make a difference in this world. You have to be in practice and stand up
for God and humanity. Think of this: the work will never be finished unless you’ve
started. Glory to God, that’s the same thought I had ‘till I made it to the end.
Blando, Sherida Mae R., SN
BSN III-5 Group 18
Community Health Nursing is both applications of Nursing and public
Health which gives human service to every member in the community. It had
made great contributions in the health of people providing health services and
health teachings. It extends individuals and families in their homes, place of work
and schools.
Community health Nurses are very significant in providing health services
in different places of the community and they give health teachings on how to
prevent certain diseases and cure them from their illness.
Family Case Analysis is a task of the community health nurses in
assessing the family to identify their abnormalities. It helps the family conscious
of health dilemmas to resolve their problem using the community resources.
I’ve learned many things during our duty in the community. In every place
we go, many things we discover. One of these is learning. We learned based
from our experiences. There is a big difference between knowledge and skills.
Upon exposure you really need energy to do things. You also apply the
knowledge that you have learned unlike knowledge you just understand or
memorize certain rational without any application.
The hardest part in the community requirement is this FCA but I learned a
lot. I learned how to establish rapport effectively and to be patient upon
assessing them especially tequila. I learned how to interview therapeutically and
assess their physical assessment and know their abnormalities; providing health
teachings concerning their health and environment. I learned that teamwork
really matters. In this FCA it enhanced my grammar in English. I realized upon
this FCA that I am fortunate in my life. Upon seeing or experiencing the family
that we assess regarding their status in life. I appreciate now the blessing that
God have given to me, with this FCA serve as reflector of life in me and as an
application to all the knowledge I learned during my second year as a nursing
student.
- -Rajah Lorenzo Sotelo, S.N
Legend:
Living room
Masters bedroom
kitchen
Bathroom
Documentation
This
One of the problems recognized was the danger of burning the garbage
practiced by the family.
The student nurses helped in
maintaining the house clean like
sweeping the floor.
This is
the
toilet
facility. Though it does not have a water
carriage, it looks clean and tidy.
This is the
inside of their house. The house looks small
but it has the appliances they need.
They seem to
be ready in
The sideline
of Mrs. Mae
and her
neighbors is sharpening BBQ sticks. It is hard
way to earn money. Just 8 pesos per 1000
pieces.
*REFERENCE: Rodolfo F. Florentino, M.D. et. Al. FNRI-PPS Anthropometric Tables and
Charts for Filipino Children (Based on the suggested marginal cut-off points), Manila,
Philippines, 1992.
The anthropometric method of measuring the nutrition status of an individual may reveal
the condition of his body that results from the utilization of essential nutrients made available
from his daily diet. (Serraon – Claudio, Basic Nutrition for Filipinos, 2002
TSR:
Adult: 13 y/o above = 3m²
Child: 1 y/o (0-12 y/o) = 1.5m²
= Summation of TSR/per member
TSR> TSA = inadequate
TSR<TSA = adequate