2.

Mother Pink

I. General Appearance

Pink, a housewife, is 22 years of age, born on December 8, 1986. She

is a very supportive and understanding mother to her 2 children especially to
Baby Orange. She utilizes her time by giving adequate attention to her
family, doing some household chores and finds time to have leisure.

During the initial visit, the group saw Mother Pink sitting in front of
their house cuddling Baby Orange. She welcomed the group and kindly
entertained the student nurses. She was conscious, coherent, oriented to
time, person and place, wearing a dirty green T-shirt and brown shorts, Her
hair is shoulder-length straight hair tied in a black ponytail, and with fair
complexion, has a dry skin with long, dirty fingernails and toenails. She
stands 5 ft and 90 lbs in weight.

II. Vital Signs

Vital Signs Feb 1,2010 Feb 2,2010 Feb 9,2010

BP: 100/70mmHg 110/70 mmHg 110/80 mmHg

Temp: 36.8 ºC 36.6 ºC 37 ºC

PR: 80bpm 85 bpm 89 bpm

RR: 20 cpm 18 cpm 22 cpm

III. Height and Weight

Height: 5 ft

Weight: 90 lbs

BMI (Body Mass Index) = Weight in Kilograms

Height in m2

=____41 kgs_____

(1.5)m2

= 41 kgs_____

2.25 m2

= 18.22 kg/ m2

Nutritional Status: Underweight

IV. Examination of the Skin (Initial Assessment)

- Fair in complexion uniformed in skin color.

- With presence of scars on lower extremities.

- With rough spots and calluses on both palm hands and feet.

-Skin is warm to touch and appears to be oily.

-Good skin turgor.

V. Examination of Hair and Nails

-With shoulder length black, straight, dry hair, evenly distributed.

-Dandruff is present.

-No depression or lesions noted upon palpation.

-With brownish nail beds, smooth in texture, convex curvature of fingerplate.

-With long dirty fingernails and toenails.

-With capillary refill of 2 seconds.

VII. Examination of the Eyes

-Eyebrows and lashes are evenly distributed, symmetrically aligned and with
equal movement.

-Eyelids are intact, no discharge, no discoloration, lid close symmetrically,

involuntary blinks, 15-20 blinks/ min.

-Bulbar conjunctiva are transparent, capillaries sometimes evident, sclera

appears whitw.

-Palpebral conjunctiva appears shiny, smooth and pink.

-No edema or tenderness, nor tearing in the lacrimal gland, lacrimal sac and
nasolacrimal duct.

-Cornea appears transparent, smooth and shiny, details of iris are visible.

VIII. Examination of the Ears

- Both auricles same with the facial skin, symmetrically is aligned with the
outer canthus of the eye
-Auricles are mobile, firm, non-tender, pinna recoils after it is folded, distal
third contains hair follicles and with the presence of dry cerumen on
both ears.

IX. Examination of Nose and Sinuses

-External nose id symmetrical on both sides and straight.

-Air moves freely as the client breaths through the nares.

-Nasal cavity, mucosa is pinkish with clear watery discharge.

-There’s no tenderness in the maxillary and frontal sinuses.

X. Examination of the Mouth and Oropharynx

-Lips and buccal mucosa are symmetric, uniform pink, moist, smooth, and
able to purse lips, glistening and has elastic texture.

-Presence of 23 permanent teeth (missing 3 teeth on the lower right

part, 6 teeth on the lower left part), pink gums, moist, firm texture,
presence of plaques and dental caries on upper and lower teeth.

-Upon inspection, tongue and the floor of the mouth appears in central
position, pink, moist, slightly rough, with thin whitish coating, smooth, and
no lesions.

-Upon inspection, tongue moves freely, not tender, with smooth tongue base
with prominent veins.

-Soft palate appears light pink in color and smooth. Hard palate appears
lighter pink in color, more irregular in texture.

-Uvula is positioned in the midline of the soft palate.

-Oropharynx and tonsils appears pink in color, smooth and no discharge.

XI. Examination of the Neck

-Muscles equal in size, head-centered.

-Coordinated, smooth movement with no discomfort.

XII. Examination of the Lymph Nodes

-Upon palpation, neck lymph nodes are not palpable.

-Thyroid gland is not visible upon inspection and palpation.

XIII. Examination of Chest and Lungs

-Chest is symmetric.

-Spine vertically aligned.

-Spinal column is straight, left and right shoulders and hips are at same
height.

-Expiratoryexcursion is full and symmetric.

-No presence of adventitious sounds.

XIV. Examination of Abdomen

-Unblemished skin, uniform in color, appears flat, no evidence of

enlargement of liver or spleen, symmetric in contour.

-Audible bowel sounds: 21 bowel sounds per minute. No tenderness, no pain

during and after release of pressure.

XV. Examination of Upper and Lower Extremities

 -Long and dirty fingernails and toenails, able to flex extremities.

-Lower extremities have the presence of scars.

-Can discriminate sharp objects from dull objects.

 Final Assessment : February 9, 2010

Hair: straight, black and dry shoulder length hair, evenly distributed.

Scalp: presence of dandruff

Skull: normal skull configuration, no lesions, not tenderness upon palpation.

Eyes: hair evenly distributed on eyebrows, eyebrows symmetrically aligned,

equal movement, eyelashes equally distributed, lids close symmetrically,
anicteric sclera, pink palpebral conjunctiva, pupils are black in color.

Ears: symmetrical in size and position, auricle aligned with outer canthus of
eyes, auricles are firm and not tender

Nose: external area is symmetric and straight, no discharge, not tender, no

lesions, air moves freely as the client breathes through the nares.

Lips: No pallor, symmetrical in contour.

Teeth and Gums: still has incomplete set of yellowish teeth with
pink retracted gums.

Tongue: on a central position, with whitish coating, no lesions, moves freely,

no tenderness.

Palates and Uvula: with light pink, smooth, soft palate, lighter pink hard
palate, uvula positioned in midline of soft palate.
Tonsils: pink and smooth, not inflamed.

Chest: no tenderness, no mass noted, full and symmetric chest expansion,

no adventitious sounds, normal respiratory rate.

Abdomen: no evidence of enlargement of liver or spleen, with symmetric

contour, with 20 audible bowel sounds.

Extremities: no tenderness or swelling; presence of scars on lower

extremities.

Skin: Dark complexion, with dry skin, absence of pallor and edema.

Nails: Short and Clean fingernails

Neurological Assessment

Cranial Nerves Type Normal Findings Actual Findings

1. Olfactory Sensor • Client must be  The client was
y able to recognize able to identify the
(Cranial Nerve 1) and identify aroma being
common odors presented by saying
with eyes closed, if it smells
such as alcohol “mabango” if it
and men’s smells good and
perfume. “mabaho” if it smells
bad. And she was
able to identify the
aroma being
presented if it is
alcohol and men’s
perfume.
2. Optic Sensor • The client must  The client was
y be able to read able to identify the
(Cranial Nerve 2) newsprint at least color shown to her
14 inches away, by saying if it is
let the client “black” and reads
identify the color. the word “cancer”.
3. Oculomotor Motor • Client must  The client was
have the ability to able to move and
 move eyes to be follow the penlight’s
(Cranial Nerve 3) able to follow up and down
objects in up and direction, by moving
down direction. the eyes and not the
Pupil size, equality head. (+ PERRLA)
and reaction to
light must be
tested, using
penlight.
(+PERRLA)
4. Trochlear Motor • The client  The client can
follows the look obliquely
(Cranial Nerve 4) movement of the without any
penlight in oblique movement of the
directions with head.
coordination.
5. Trigeminal • The client must  The client
be able to blink manifested blinking
(Cranial Nerve 5) upon touching the reflex when cotton is
cornea with the introduced in the
-Opthalmic Sensor use of cotton. side of both corneas.
Branch y

-Maxillary Branch Sensor

y
-Mandibular
Branch Motor &
Sensor
y
6. Abducens Motor • The client must  She was able to
be able to follow move her eyes
(Cranial Nerve 6) the lateral following the index
direction of gaze, finger of the
by following the examiner in a lateral
index finger of the direction.
examiner.
7. Facial Motor & • The client must  She was able to
Sensor be able to smile, manifest different
(Cranial Nerve 7) y frown, and raise facial gestures as
eyebrows, puff mentioned and
cheeks and close instructed by the
eyes for the motor examiner for her
function. motor function.

• The client must  She was able to

 be able to identify identify various
various tastes tastes place on the
place on tip and tip and sides of the
sides of the anterior tongue such
anterior 2/3 of the as candy for
tongue: candy for “matamis” for sweet
sweet and salt for and salt for
sour for the “maasim” for sour
sensory function. for her sensory
function.
8. Acoustic Sensor • The client must  She was able to
y be able to walk walk without falling,
(Cranial Nerve 8) with steady gait able to balance
and without falling herself by walking in
and be able to the measuring tape.
hear what the She was able to hear
examiner is the word “Kyla”.
whispering.
9. Motor & • The client must  The client has
Glossopharyngeal Sensor be able to swallow no difficulty in
y without pain and swallowing the food
(Cranial Nerve 9) able to elicit gag given to her.
reflex for the
motor function.  The client has
identified the taste
• The client must of a candy as
identify the taste “matamis” for sweet
of a candy for and salt as
sweet and salt for “maasim” for sour
sour place on the that has been
posterior 1/3 of placed on the
the tongue for the posterior 1/3 of the
sensory function. tongue for her
sensory function.
10. Vagus Motor & • The client must  She was able to
Sensor be able to swallow swallow without
(Cranial Nerve 10) y and elicit gag difficulty and she
reflex by pressing elicited gag reflex
a tongue blade in when spoon was
this case a spoon inserted and able to
on the posterior speak without
tongue and able to difficulty.
speak without
hoarseness of the
 voice and if there
is sensation of the
pharynx and
larynx.
11. Accessory Motor • The client must  The client was
be able to elevate able to move head
(Cranial Nerve 11) shoulders and from side to side
turn head at one with resistance.
side with
resistance.
12. Hypoglossal Motor • The client must  She was able to
be able to move press on side of
(Cranial Nerve 12) tongue form side each cheek and was
to side and be able to protrude her
able to protrude tongue without
the tongue. difficulty.

Nutritional Status by Age, Weight and Height

 Age: 23 years old

 Weight:90 lbs/41 kgs
 Height: 5 ft/ 1.5 m

BMI (Body Mass Index) = Weight in Kilograms

Height in m2

=____41 kgs_____

(1.5)m2

= 41 kgs_____

2.25 m2

= 18.22 kg/ m2

BMI Categories:
 • Underweight = <18.5
• Normal weight = 18.5-24.9
• Overweight = 25-29.9
• Obesity = BMI of 30 or greater

Nutritional Status: 18.22 kg/ m2

: Underweight

 History of Past and Present Illness

According to Mother Pink, she didn’t experience severe illnesses which

may lead to hospitalization or confinement. She only experiences those usual
illnesses such as fever and cough which is due to some changes in the
weather in their community, such as experiencing extreme coldness. And for
her own management she only rests for the whole day and just sleeps and
increased her oral fluid intake. Sometimes, she’s doing self medication like
taking Salbutamol for cough and Paracetamol for fever. She experienced
chicken pox at the age of 14 and German measles at her childhood days. No
further complications were further experience during having these past
illness.

She experiences stomachache because there are times that she even
forgets to eat her food this is because of her countless chores. She
experiences pain specifically at the epigastric area. According to her, if she
will eat, the pain will subside. At times, she also feel stomachache each time
she takes carbonated drinks, Her own management for her condition is by
taking Aluminum Hydroxide Magnesium Hydroxide with Simethicone (Kremil
S).

Obstetrical History
 Mother Pink has a regular menstrual cycle. G2T2P0AL2 is her obstetric
record. She was only 13 years old when she had her menarche. Menstrual
flow occurs within 3-5 days in a month. She has 2 children, all are living. She
never planned to use any contraceptives or any family planning method. She
gave birth 2 times. All are living.

Her first pregnancy (Purple) was normal via NSD. She experienced
morning sickness, and always feels like she wanted to eat sinigang . She
gains weight while she’s pregnant; her original weight just resumed after
pregnancy. She took medicine at times when she feels she’s not well
specifically Paracetamol for headache. She did not have complicated disease
or illness. She believes that the right time for check up during pregnancy is
in the 7th-9th month of pregnancy. Purple was delivered at the hospital via
NSD on October 27, 2006 and her first baby was breast fed.

During her second pregnancy, (Orange) was also delivered NSD at

hospital on June 16,2009. She also experienced morning sickness, and
always feels like she wanted to eat sour foods like sampaloc, kamias, food
dips in vinegar and the like. She did not take any medicines since she did not
experience any serious illness. Rest was her management for mild headache
and fatigue. At times during her 2nd-3rd month of pregnancy, she feels
sudden mood swings and irritation. She had check-up during her 5th-9th
month of pregnancy.

Activities of Daily Living

6:00 am Wakes up
6:00-8:00 am Cook their breakfast.
Clean the house.

7:00-8:00 am Breakfast
8:00-9:00 am Take care of her 2 chilldren
9:00-10:00 am Rest.
10:00-11:00 am Cooks for lunch.
11:00-11:30 am Rest
11:30-12:30 pm Lunch.
12:30-1:00 pm Rest.
1:00-4:00 pm Do household chores
Chatting with neighbors
Watch T.V
Take care of her 2 children
4:00-5:00 pm Cook.
5:00-6:00 pm Takes a bath and prepares their dinner.
6:00-7:00 pm Dinner.
7:00-9:00 pm Watch T.V
9:00-10:00 Prepare to sleep
10:00 p.m- 6:00 Sleeps with her husband Father Blue and two
am children.

Early 4 in the morning, she wakes up and cooks for her family’s
breakfast. She prepares food for her husband who is working as a
construction worker. She performs some of the household chores like
cleaning their house, sweeping the floor, and the like. She takes care of her
two children then rest. After which, she has to get up to cook their lunch. She
eats lunch together with her two children. She then rest for a while again, go
outside, and chat with her neighbors or watch T.V. as she take good care of
her children too. Cooks or reheat their dinner and then eats the dinner
together with all of the family members. She then rests and prepares herself
to sleep around 10:00 in the evening.