ANGELES UNIVERSITY FOUNDATION

Angeles City
COLLEGE OF NURSING

COMMUNITY HEALTH NURSING:

FAMILY CASE ANALYSIS

“An Assessment of Royale Family in Barangay Virgen Delos Remedios”

Submitted by:
BSN II-3 – GROUP 13A
Corpuz, Mary Ann Joyce I.
Esquejo, Charlaine Marie G.
Quiambao, Katherine Camille D.
Ramos, Quinn Gabriel Allen S.

Submitted to:
Mr. Sammy David, RN
I. Introduction
“In family life, love is the oil that eases friction, the cement that binds
closer together, and the music that brings harmony.” – Eva Burrows

Family is a network of people that provides love, support, advice, comforting,

their time, and friendship. It consists of a father, mother, children, grandparents, in-laws,
relatives, and friends. Within a family, there are times when conflicts can’t be avoided.
The love of each family member is the oil that eases friction. When there’s love for one
another, it solves conflicts. With love, the family is able to forgive, understand, and
reconcile. The cement represents the bonding and trials of the family. Even though the
parents are busy from work, they still need to have time for their children. When going
through trials, make sure to overcome it together. The music is the agreement in feeling,
action, ideas, and interests. It means a family that will always be there to listen to all your
problems and give you great advices, a family who accepts you for who you are, accepts
your similarities and differences, and trust. Love, bond, and trust are the most important
thing in a family. Family is the one who will always be there when others walk away,
will guide you through the right paths, will sacrifice anything for the sake of your
happiness and future, will never judge you, will be the first one to care for you when
you’re sick, and most of all, family is the one who will love you unconditionally.
Nursing is a dynamic profession. Its scope covers a wide range of body of
knowledge which aims to promote optimum level of functioning and self – reliance to
each individual, family, hence, the community. Therefore, nurses especially the
community help nurses have a big role in building a healthy family.
Family is the basic unit of the community, and they are the basic unit of care. It is
first initiated within the family, the care, and provision of our needs. Therefore, the
student nurses recognize that the quality of living of the family has close relationship to
the health of each family member.
Community Health Nursing is a vocational profession which is to give service to
the community with dedication to meet the health needs identified by the members of the
community and the members of the heath providers. It involves a complex process; the
nurses must consider the resources of the family which would skillfully manipulate by
the nurse together with family to the advantage of each of the member of the family.
Family Case Analysis is a way for student nurses to reach out with the community
people to share knowledge and to alleviate their experienced problems. The student
nurses are given the opportunity to practice their nursing profession and share their
efforts to be an efficient nurse in the future. It is to upright the condition of the chosen
family resident in Barangay Virgen De Los Remedios is the main goal of the student
nurses. It is an opportunity for the student nurses to apply the learned concepts from the
academic to the reality of living depressed people.
They are residents of Barangay Virgen De Los Remedios, who are living in a
depressed area, comprises of not less than five family members, which needs
improvement with regards to their health and living condition. We chose this family
because they are the family willing to participate, chosen by the barangay health worker,
and fits in the criteria set by the group.

A. Objectives
a. Short Term: Student Centered
After 2 days of home visits to Barangay Virgen Delos Remedios, the student nurses will:
 Familiarize themselves with the community.
 Choose a family for their family case analysis.
 Introduce themselves to the family and explain their purposes.
 Gather information including demographic, socio-economic, cultural, and
environmental data.
 Perform health assessment to each family member.
 Identify the existing and potential problems that may affect the family’s health
status.

b. Short Term: Client Centered

After 2 days of home visit to Barangay Virgen Delos Remedios, the family will:
  Participate regarding the purpose of home visits.
 Provide complete and necessary information of each family member.
 Identify health problems present in their family.

c. Long Term: Student Centered

After 6 weeks of home visit to Barangay Virgen Delos Remedios, the student nurses will:
 Apply the therapeutic communication skills during the interview and gain the
cooperation of the family.
 Understand the health planning and practices of the family.
 Prioritize health problems jointly with the family.
 Plan nursing interventions to solve identified problems.
 Implement nursing interventions and health teachings.
 Help the family realize the importance of availing health services.

d. Long Term: Client Centered

After 6 weeks of home visit to Barangay Virgen Delos Remedios, the family will:
 Identify health problems present in their family.
 Realize the importance of having a good health practices.
 Comply with the health teachings rendered by the student nurses.
 Maintain an environment that is conducive to health and environment.

B. Entry, Climate of acceptance, first few words

July 2, 2010 – Friday
It was our first day to encounter with the family for our family case analysis. The
group rode the jeepney to the community with eager of knowing the family for their
FCA. The group, along with the community health worker, walked around the
community to find their family. Even though the student nurses were sweating, feeling
hot, and tired, they were still able to put a smile on their face. Although it took a while,
the group was able to find their family that fitted the criteria for the family case analysis.
 “Good morning po, Taga AUF po kami at naghahanap po kami ng family na
puwedeng ma-adapt para po sa FCA namin. Puwede po ba ang family niyo?” the group
said. “Ok lng. Halika pasok kayo,” Lola replied. Lola grabbed chairs from the inside and
told us to sit down. “Salamat po,” group said with a smile on their faces. The first
question was “Nay, ano po pangalan niyo?” It was awkward at first but as time passed by,
the student nurses and Lola Deer got used it. She was very cooperative and willing to
participate in all the things we did.

First home visit:

July 2, 2010 – Friday
It was the group’s first time to visit their family. They established rapport by
greeting the family, introducing each of the members of the family, and explaining their
purposes for their home visits. The group was working as a team. Two student nurses
from the group were asking questions to Lola Beauty regarding the needed information
data including demographic, socio-cultural, and cultural data of the family. While two
student nurses from the group started to assess the children, Brother Prince and Sister
Princess. After the questions were done being asked, it was Lola Beauty’s turn to be
assessed by the student nurses. The group made an appropriate appointment for the
assessment of the father and mother.

Second home visit:

July 9, 2010 - Friday
The group conducted their second home visit, at around 8:00 in the morning.
Upon arriving at their house the mother stated “pasok kayo.”, and the group goes inside
the house and started the things that should be done. The children are at the living room
as they play. Fortunately it was the time for us to interview and assess the vital signs and
physical assessment of each of the family members. Asked some questions to fill in some
data’s that is essential in making of the family case analysis, also take the measurements
of their house which the group fond out that they have inadequate living space, for the
floor plan, their living room, the size of the windows which they have inadequate
ventilation and size of the bedroom at the same time documented them. The group
noticed that Sister Princess have a swollen part near her left eye, we think that she is
beaten by a rat or a mosquito. Necessary information is gathered though an informal
interview or question and answer method. All the findings and information gathered were
document properly.

Third home visit:

July 16, 2010 - Friday
On the third home visit, the group was tasked to identify the problems that are
present in their chosen family. First of the problem was identified was the presence of
asthma, Sister Princess experienced attacks of asthma since she was 8 month old as
verbalized by Lola Beauty. The group noticed that the two children were thin and light as
they carry them. Hordeolum or stye was present on both children. The group assisted
Lola Beauty in bathing the children. After bathing them, the group decided to feed the
children of bread and cookies because they did not already have their breakfast that time.
One of the member let Sister Princess sleep after few minutes of taking a bath. Health
teachings where also given to the family about the problems identified by the group.
They discuss all of these problems, whether they are perceived by the family or not. The
group emphasizes that prevention is more important than cure. The family was given
necessary information to improve their health status and maintain their health.

Final home visit:

July 23, 2010 - Friday
II. Family Constellation
Lola 49 years Grandmother Female 2nd Year High Upon the initial
Beauty oldAge Position in Educational
school assessment, Lola Beauty
Name Gender Present Health Status
the family Status was cooperative,
coherent, and aware to
the place, time and
person. She was wearing
a white shirt and blue
shorts, carrying Brother
Prince, and had her hair
tied up. She has presence
of dandruff and has dirty
nails.
VS taken as follows:
Temp= 37.3°C
BP= 155/100 mmHg
PR= 90 bpm
RR= 20 bpm
Papa 28 years Father Male 1st Year High Upon initial assessment,
King old school Papa King was conscious
and oriented as to date,
time and place. He was
wearing long maong
shorts, has no top, and
with slippers. His mood
was appropriate to the
situation, he was
cooperative, and has
coordinated movements,
straight posture and good
muscle tone.
VS taken as follows:
BP= 130/100 mmHg
T= 37.2ºC/axilla
P= 98 bpm
R= 20 bpm
Mother 25 years Mother Female High School Upon initial assessment,
Queen old graduate Mama Queen was
conscious and oriented as
to date, time, and place.
She was wearing a t-shirt,
pants, and shoes ready to
go to work. Her mood
was appropriate to the
situation, she was
cooperative, and
 coordinated movements.
VS taken as follows:
BP= 110/90 mmHg
T= 35.8 ºC/axilla
P= 70 bpm
R= 16 bpm
Brother 4 years Eldest Child Male Never been to Upon initial assessment,
Prince old school Brother Prince was
wearing a blue shirt and a
blue shorts and a pair of
slippers. He was unable
to express himself
through speech. He has
presence of dandruff and
has long, dirty nails. He
is slightly thin.
VS taken as follows:
Temp= 35.8°C
PR= 103 bpm
RR=29 bpm
Sister 1 year Youngest Female Never been to Upon initial assessment,
Princess and 7 daughter school Sister Princess was
months wearing a yellow
sleeveless shirt and white
shorts and a pair of
slippers. She was unable
to express herself through
speech. She is slightly
thin and has presence of
dandruff, wound on the
right forehead, has rashes
on the left side of the
neck, and has long, dirty
nails.
VS taken as follows:
Temp= 36°C
PR= 51 bpm
RR= 44 bpm

III. Health Assessment

1. Lola Beauty (Grandmother)

Initial Assessment (July 2, 2010---Friday)

General Appearance

Upon the initial assessment, Lola Beauty was cooperative, coherent, and aware to
the place, time and person. She was wearing a white shirt and blue shorts, carrying
Brother Prince, and had her hair tied up. She has presence of dandruff and has dirty nails.
Vital Signs

BP= 155/100 mmHg

Temp= 37.3°C
PR= 90 bpm
RR= 20 bpm

Physical Assessment

Skin
Lola Beauty has fair complexion. She has a good skin turgor as evidenced by
when the skin was pinched at the arm; the skin goes back to its previous state. No edema
and no lesions noted upon inspection.

Hair and Scalp

Lola Beauty has a short black hair and it is evenly distributed upon inspection.
Has presence of dandruff and the scalp is rough upon palpation.

Nails
Nails are pinkish, convex curve with 160° angle, long and dirty. Has a normal
capillary refill time which is 2 seconds.
Skull
Skull is round and symmetrical in size and has no nodules or masses noted upon
palpation.

Face
 Facial movement has coordination and has balanced facial features. There is absence
of edema.
Eyes and Vision
Eyebrows evenly distributed, eyelids close symmetrically approximately 16 blinks
per minute, white sclera, pink palpebral conjunctiva and transparent bulbar conjunctiva,
pupils are well rounded and reactive to light and accommodation, absence of abnormal
secretions. During the Corneal Sensitivity Test, client blinks when cornea is touched
indicating that he has intact cranial nerve no. 5 (trigeminal). She can see and read
newsprint clearly.
Ears and Hearing
No abnormal discharges noted, ears are on the level of outer canthus of the eye, has
dark pinna and recoil after it is folded, with minimal cerumen. During the Whisper test,
the client is able to hear normal voice tone at a distance of 1-2 inches.
Nose
Air moves freely as Lola Beauty breaths through her nares, nasal septum intact and
in midline, no swellings and lesions, absence of abnormal discharges.
Lips
Dark pink in color, moist and smooth, able to purse lips, symmetry of contour.
Tongue
Central position, pink, moist, slightly rough, no lesions, with raised papillae, moves
freely, not tender, no palpable nodules.
Neck muscles
Lola Beauty’s sternocleidomastoid and trapezius muscles are equal in size, head
centered, coordinated smooth movements with no discomforts, equal muscle strength, is
able to turn the head to one side against the resistance of our hands, able to shrug
shoulders against the resistance of our hands, no palpable lymph nodes, trachea is on the
midline of the neck upon inspection, thyroid gland not visible on inspection, full
pulsation and symmetric pulse volume of the carotid artery, jugular vein not distended,
no enlargement of lymph nodes.
Lungs and Thorax
 Spine vertically aligned, spinal column is straight, full and symmetric chest
expansion, with normal breath sounds, no tenderness or masses noted upon palpation.
Heart

Normal heart sound (lub-dub upon auscultation), has a normal heart rate of
98 beats per minute and has regular rhythm and has a BP of 155/100 mmHg, no murmurs
heard upon auscultation.

NEUROLOGICAL ASSESSMENT
• Mental Status - conscious, awake; knows his name; where he is currently and
who he is at the moment; answers questions asked to him accordingly; uses
Kapampangan whenever he answers the questions asked.
• Sensory Function - able to distinguish a light touch using tip of cotton; able to
distinguish hot from cold water; pointed the place where the pricking pain was
pointed; can readily determine the position of fingers and toes.
• Motor Function- has upright position and gait steady with opposing arm
swinging; walks unaided maintaining balance; can alternately supinate and
pronate at rapid pace; moves smoothly and coordinately.

Cranial Nerves

CRANIAL NERVE ASSESSMENT EXPECTED ACTUAL

TECHNIQUE OUTCOME FINDINGS
I: Olfactory Ask the client to The client will be Lola Beauty was able
Type: Sensory identify aromas able to identify to identify the
Function: Smell like cologne, different aromas aromas of cologne,
alcohol and like cologne, alcohol and vinegar.
vinegar, with each alcohol and
nostril separately vinegar, unless
with eyes close. such condition
like cold is
present.
II: Optic Ask the client to The client will be Lola Beauty was able
Type: Sensory read words on a able to read the to read the articles in
Function: Vision piece of paper with words at 12-14 the newspaper at 12-
each eye first then inches. 14 inches.
both eyes at 12-14
inches.
III: Oculomotor Ask client to look The client’s eyes Lola Beauty had a
Type: Motor straight ahead then will have a normal normal reaction to
Function: Upward and approach the pupil reaction for PERRLA.
downward movement of pupils with a penlight and PERRLA.
observe for pupil
constriction.
IV: Trochlear Ask client to hold The client will be Lola Beauty has
Type: Motor the head still and able to follow the good coordination of
Function: Extra-ocular follow the movement of the eye movements and
movement of eyes in oblique thermometer as it thermometer. able to follow the
movement moves in the six movement of the
cardinal eye thermometer.
movements.
V: Trigeminal Ask the client to The client will be Lola Beauty was able
Type: Motor and Sensory make chewing able to make to make chewing
Function: Sensation of cornea, movements, open chewing movements, open the
skin of face and jaw movement the mouth against movements, open mouth against
resistance, move the mouth against resistance, move jaw
jaw from side to resistance, move from side to side and
side and open jaw from side to open mouth widely.
mouth widely. side and open
mouth widely. Blinking Reflex was
Cotton is wisp at noted to Lola Beauty
the side of the Blinking Reflex
client’s eyes. was noted.
VI: Abducens Have the client to The client will be Lola Beauty has
Type: Motor hold his head able to follow the good coordination of
Function: Extra-ocular
movement of eyes in a lateral
movement
VII: Facial
Type: Motor and Sensory
Function: Movement of facial eyebrow, puff the
muscles and sense of taste on
the anterior two thirds of the
tongue
VIII: Vestibulocochlear/
Acoustics
Type: Sensory
Function: Hearing and
Equilibrium
steady and follow movement of the eye movements and
the thermometer thermometer. able to follow the
direction. movement of the
thermometer.
Ask the client to The client will be Lola Beauty was able
smile, frown, raise able to smile, to smile, frown, raise
frown, raise eyebrow, puff the
cheeks and show eyebrow, puff the cheeks and show
teeth. Ask the cheeks and show teeth.
client to identify teeth. The client
the different tastes will be able to
(sugar) placed on identify the sugar
the anterior 2/3 of placed on the
the tongue. anterior 2/3 of the
tongue.
Have the client to The client will be Lola Beauty was able
walk with both able to walk with to walk with both
eyes close and both eyes close eyes close and repeat
repeat the and repeat the the whispered few
whispered few whispered few words whispered to
words at the words at the him. She was also
client’s back. client’s back. The able to perform
Allow client to client will be able Romberg’s Test with
stand with feet to perform equilibrium.
together and arms Romberg’s Test
resting at the sides, with equilibrium.
first with eyes open
and then closed
(Romberg’s Test).
IX: Glossopharyngeal
Type: Motor and Sensory
Function: Swallowing, gag
reflex, pharyngeal movement
and sense of taste of the
posterior one-third of the
tongue
X: Vagus
Type: Motor
Function: Swallowing and
Speaking
XI: Accessory
Type: Motor
Function: Movement of
shoulder muscles
XII: Hypoglossal
Type: Motor
Function: Movement and
strength of tongue
HISTORY OF PAST AND PRESENT ILLNESS
Ask the client to Client will elicit Lola Beauty was able
swallow then open gag reflex. The to elicit gag reflex.
mouth widely and client will be able And the uvula moved
say “Ah”. Ask the to identify the upward upon saying
client to identify taste of sugar “Ah”.
the taste (sugar) placed on
placed on posterior posterior tongue.
tongue.
Ask client to cough The client will be Lola Beauty had an
and say its name. able to state his effective coughing
name without and was able to state
hoarseness of her name without
voice. hoarseness of voice.
Ask client to The client will be Lola Beauty was able
elevate shoulders able to elevate to elevate shoulders
against the gravity shoulders against against the gravity
and turn head from the gravity and and turn head from
side to side. turn head from side to side.
side to side.
Ask the client to The client will be Lola Beauty was able
protrude the tongue able to protrude to protrude her
and move in his tongue and tongue and move in
different directions. move in different different directions.
directions.
 Currently, Lola Beauty is not experiencing any illness. He often acquired some
colds, cough and even fever. There are times when her blood pressure is high, but has
medicines to lower it down.

ACTIVITIES OF DAILY LIVING

TIME ACTIVITIES
7:00 am Wakes up
7:00-8:00 am Cleans the house and cooks breakfast
8:00-11:00 am Takes care of her grandchildren
11:00-12:00pm Prepares lunch
12:00-1:00 pm Eats lunch
1:00-5:30 pm Takes care of her grandchildren
5:30-6:30pm Prepares dinner
6:30-7:00 Eats dinner
7:00-9:00pm Watching TV with family
9:00 pm Rest and Goes to sleep

Eating pattern

Lola Beauty eats thrice daily. She eats whatever is available.

Sleeping pattern

Lola Beauty wakes up at 7:00 am and sleeps at 9:00 pm. She sleeps in the living
room by herself. She sleeps 10 hours a day.

Leisure time activities

When Lola Beauty has leisure time, she utilizes it for watching TV, listening to
the radio, cleaning the house or chatting with neighbors.

2. Papa King (Father)

Initial Assessment (July 9, 2010---Friday)

General Appearance

Upon initial assessment, Papa King was conscious and oriented as to date, time
and place. He was wearing long maong shorts, has no top, and with slippers. His mood
was appropriate to the situation, he was cooperative, and has coordinated movements,
straight posture and good muscle tone.

Vital Signs

BP= 130/100 mmHg

T= 37.2ºC/axilla
P= 98 bpm
R= 20 bpm

Physical Assessment

Skin
Papa King has dark complexion, with evenly distributed body hair consistent from
head, neck, arms down to the legs and with other parts upon inspection. No edema and no
lesions noted upon inspection. He has a good skin turgor as evidenced by when the skin
was pinched at the arm, the skin goes back to its previous state.

Hair and Scalp

Papa King has a short black hair and it is evenly distributed upon
inspection. Has no dandruff and infestations of lice, no evidence of flaking and no areas
of hair loss. The scalp is smooth upon palpation.

Nails
Nails are pinkish, convex curve with 160° angle, long and dirty. Has a normal
capillary refill time which is 2 seconds.

Skull
Skull is round and there are no presence of nodules and masses.

Face

Facial movement has coordination and has balanced facial features. There is
absence of edema.
Eyes and Vision

Eyebrows evenly distributed, eyelids close symmetrically approximately 16

blinks per minute, white sclera, pink palpebral conjunctiva and transparent bulbar
conjunctiva, pupils are well rounded and reactive to light and accommodation, absence of
abnormal secretions. During the Corneal Sensitivity Test, client blinks when cornea is
touched indicating that he has intact cranial nerve no. 5 (trigeminal). He can see and read
newsprint clearly.

Ears and Hearing

No abnormal discharges noted, ears are on the level of outer canthus of the eye,
has dark pinna and recoil after it is folded, with minimal cerumen. During the Whisper
test, the client is able to hear normal voice tone at a distance of 1-2 inches.

Nose

Air moves freely as Daddy Jon breaths through his nares, nasal septum intact and
in midline, no swellings and lesions, absence of abnormal discharges.

Lips

Dark pink in color, moist and smooth, able to purse lips, symmetry of contour.

Tongue

Central position, pink, moist, slightly rough, no lesions, with raised papillae,
moves freely, not tender, no palpable nodules.

Neck

Papa King’s sternocleidomastoid and trapezius muscles are equal in size, head
centered, coordinated smooth movements with no discomforts, equal muscle strength, is
able to turn the head to one side against the resistance of our hands, able to shrug
shoulders against the resistance of our hands, no palpable lymph nodes, trachea is on the
midline of the neck upon inspection, thyroid gland not visible on inspection, full
pulsation and symmetric pulse volume of the carotid artery, jugular vein not distended,
no enlargement of lymph nodes.

Lungs and Thorax

Spine vertically aligned, spinal column is straight, full and symmetric chest
expansion, with normal breath sounds, no tenderness or masses noted upon palpation.

Heart

Normal heart sound (lub-dub upon auscultation), has a normal heart rate of 98
beats per minute and has regular rhythm and has a BP of 130/100 mmHg, no murmurs
heard upon auscultation.

NEUROLOGICAL ASSESSMENT
• Mental Status - conscious, awake; knows his name; where he is currently and
who he is at the moment; answers questions asked to him accordingly; uses
Kapampangan whenever he answers the questions asked.
• Sensory Function - able to distinguish a light touch using tip of cotton; able to
distinguish hot from cold water; pointed the place where the pricking pain was
pointed; can readily determine the position of fingers and toes.
• Motor Function- has upright position and gait steady with opposing arm
swinging; walks unaided maintaining balance; can alternately supinate and
pronate at rapid pace; moves smoothly and coordinately.

Cranial Nerves

CRANIAL NERVE ASSESSMENT EXPECTED ACTUAL

TECHNIQUE OUTCOME FINDINGS
I: Olfactory Ask the client to The client will be Papa King was able
Type: Sensory identify aromas able to identify to identify the
Function: Smell like cologne, different aromas aromas of cologne,
alcohol and like cologne, alcohol and vinegar.
vinegar, with each alcohol snd
nostril separately vinegar, unless
with eyes close. such condition
like cold is
present.
II: Optic Ask the client to The client will be Papa King was able
Type: Sensory read words on a able to read the to read the articles in
Function: Vision piece of paper with words at 12-14 the newspaper at 12-
each eye first then inches. 14 inches.
both eyes at 12-14
inches.
III: Oculomotor Ask client to look The client’s eyes Papa King had a
Type: Motor straight ahead then will have a normal reaction to
Function: Upward and approach the pupil normal reaction PERRLA.
downward movement of pupils with a penlight and for PERRLA.
observe for pupil
constriction.
IV: Trochlear Ask client to hold The client will be Papa King has good
Type: Motor the head still and able to follow the coordination of eye
Function: Extra-ocular follow the movement of the movements and able
movement of eyes in oblique thermometer as it thermometer. to follow the
movement moves in the six movement of the
cardinal eye thermometer.
movements.
V: Trigeminal Ask the client to The client will be Papa King was able
Type: Motor and Sensory make chewing able to make to make chewing
Function: Sensation of cornea, movements, open chewing movements, open the
skin of face and jaw movement the mouth against movements, open mouth against
resistance, move the mouth against resistance, move jaw
jaw from side to resistance, move from side to side and
 side and open jaw from side to open mouth widely.
mouth widely. side and open
mouth widely. Blinking Reflex was
Cotton is wisp at noted to Papa King.
the side of the Blinking Reflex
client’s eyes. was noted.
VI: Abducens Have the client to The client will be Papa King has good
Type: Motor hold his head able to follow the coordination of eye
Function: Extra-ocular steady and follow movement of the movements and able
movement of eyes in a lateral the thermometer thermometer. to follow the
movement direction. movement of the
thermometer.
VII: Facial Ask the client to The client will be Papa King was able
Type: Motor and Sensory smile, frown, raise able to smile, to smile, frown, raise
Function: Movement of facial eyebrow, puff the frown, raise eyebrow, puff the
muscles and sense of taste on cheeks and show eyebrow, puff the cheeks and show
the anterior two thirds of the teeth. Ask the cheeks and show teeth. He was also
tongue client to identify teeth. The client able to identify the
the different tastes will be able to taste of sugar on the
(sugar) placed on identify the sugar anterior 2/3 of his
the anterior 2/3 of placed on the tongue.
the tongue. anterior 2/3 of the
tongue.
VIII: Vestibulocochlear/ Have the client to The client will be Papa King was able
Acoustics walk with both able to walk with to walk with both
Type: Sensory eyes close and both eyes close eyes close and repeat
Function: Hearing and repeat the and repeat the the whispered few
Equilibrium whispered few whispered few words whispered to
words at the words at the him. He was also
client’s back. client’s back. The able to perform
Allow client to client will be able Romberg’s Test with
stand with feet to perform equilibrium.

IX: Glossopharyngeal
Type: Motor and Sensory
Function: Swallowing, gag
reflex, pharyngeal movement
and sense of taste of the
posterior one-third of the
tongue
X: Vagus
Type: Motor
Function: Swallowing and
Speaking
XI: Accessory
Type: Motor
Function: Movement of
shoulder muscles
XII: Hypoglossal
Type: Motor
Function: Movement and
strength of tongue
together and arms Romberg’s Test
resting at the sides, with equilibrium.
first with eyes
open and then
closed (Romberg’s
Test).
Ask the client to Client will elicit Papa King was able
swallow then open gag reflex. The to elicit gag reflex.
mouth widely and client will be able And the uvula
say “Ah”. Ask the to identify the moved upward upon
client to identify taste of sugar saying “Ah”. He was
the taste (sugar) placed on also able to identify
placed on posterior posterior tongue. the taste of sugar
tongue. placed on his
posterior tongue.
Ask client to The client will be Papa King had an
cough and say its able to state his effective coughing
name. name without and was able to state
hoarseness of his name without
voice. hoarseness of voice.
Ask client to The client will be Papa King was able
elevate shoulders able to elevate to elevate shoulders
against the gravity shoulders against against the gravity
and turn head from the gravity and and turn head from
side to side. turn head from side to side.
side to side.
Ask the client to The client will be Papa King was able
protrude the able to protrude to protrude his
tongue and move his tongue and tongue and move in
in different move in different different directions.
directions. directions.
HISTORY OF PAST AND PRESENT ILLNESS

Currently, Papa King is not experiencing any illness. He often acquired some
colds, cough and even fever.

ACTIVITIES OF DAILY LIVING

TIME ACTIVITIES
6:30 am Wakes up
7:00-9:00 am Works as a street sweeper
9:00-12nn Rest and goes to sleep
12:00-1:00 pm Eats Lunch
1:00-2:00pm Get ready for work
2:30-10:00 pm Works as a Guard Vendor
10:30 pm Goes home
11:00 pm Rest and goes to sleep

Eating pattern

Papa King eats thrice daily. He eats whatever is available.

Sleeping pattern

Papa King wakes up at 6:30 am and sleeps at 11:00 pm. He sleeps with his wife and 2
children. He sleeps 7 ½ hrs a day.

Leisure time activities

When Papa King has leisure time, he utilizes it for sleep, rest, watching TV, listening
to the radio, playing basketball or with the kids.

3. Mama Queen (Mother)

Initial Assessment (July 9, 2010---Friday)

General Apperance
 Upon initial assessment, Mama Queen was conscious and oriented as to date,
time, and place. She was wearing a t-shirt, pants, and shoes ready to go to work. Her
mood was appropriate to the situation, she was cooperative, and coordinated movements.

Vital Signs

BP= 110/90 mmHg

T= 35.8 ºC/axilla
P= 70 bpm
R= 16 bpm

Skin

Mama Queen has brown complexion, with evenly distributed body hair consistent
from head, neck, arms down to the legs and with other parts upon inspection. No edema
and no lesions noted upon inspection. Her skin is moist with the same temperature on
upper and lower extremities upon palpation. She has a good skin turgor as evidenced by
when the skin was pinched at the arm, the skin goes back to its previous state.

Hair and Scalp

Mama Queen has a straight long dark brown hair and it is evenly distributed upon
inspection. Has no dandruff and infestations of lice, no evidence of flaking and no areas
of hair loss. The scalp is smooth upon palpation.

Nails

Nails are pinkish, convex curve with 160° angle, short and clean. Has a normal
capillary refill time which is 2 seconds.

Skull

Skull is round and there are no presence of nodules and masses.

Face

Facial movement has coordination and has balanced facial features. There is
absence of edema.

Eyes and Vision

Eyebrows evenly distributed, eyelids close symmetrically approximately 17

blinks per minute, white sclera, pink palpebral conjunctiva and transparent bulbar
conjunctiva, pupils are well rounded and reactive to light and accommodation, absence of
abnormal secretions. During the Corneal Sensitivity Test, client blinks when cornea is
touched indicating that she has intact cranial nerve no. 5 (trigeminal). She can see and
read newsprint clearly.

Ears and Hearing

No abnormal discharges noted, ears are on the level of outer canthus of the eye,
has brown pinna and recoil after it is folded, with minimal cerumen. During the Whisper
test, the client is able to hear normal voice tone at a distance of 1-2 inches.

Nose

Air moves freely as Mommy Mariel breaths through her nares, nasal septum
intact and in midline, no swellings and lesions, absence of abnormal discharges.

Lips

Pink in color, moist and smooth, able to purse lips, symmetry of contour.

Tongue

Central position, pink, moist, slightly rough, no lesions, with raised papillae,
moves freely, not tender, no palpable nodules.

Neck
 Mama Queen’s sternocleidomastoid and trapezius muscles are equal in size, head
centered, coordinated smooth movements with no discomforts, equal muscle strength, is
able to turn the head to one side against the resistance of our hands, able to shrug
shoulders against the resistance of our hands, no palpable lymph nodes, trachea is on the
midline of the neck upon inspection, thyroid gland not visible on inspection, full
pulsation and symmetric pulse volume of the carotid artery, jugular vein not distended,
no enlargement of lymph nodes.

Lungs and Thorax

Spine vertically aligned, spinal column is straight, full and symmetric chest
expansion, with normal breath sounds, no tenderness or masses noted upon palpation.

Heart

Normal heart sound (lub-dub upon auscultation), has a normal heart rate of 80
beats per minute and has regular rhythm and has a BP of 110/90 mmHg, no murmurs
heard upon auscultation.
NEUROLOGICAL ASSESSMENT
• Mental Status - conscious, awake; knows her name; where she is currently and
who she is at the moment; answers questions asked to her accordingly; uses
Kapampangan whenever she answers the questions asked.
• Sensory Function - able to distinguish a light touch using tip of cotton; able to
distinguish hot from cold water; pointed the place where the pricking pain was
pointed; can readily determine the position of fingers and toes.
• Motor Function- has upright position and gait steady with opposing arm
swinging; walks unaided maintaining balance; can alternately supinate and
pronate at rapid pace; moves smoothly and coordinately.

Cranial Nerves

CRANIAL NERVE ASSESSMENT EXPECTED ACTUAL

 TECHNIQUE OUTCOME FINDINGS
I: Olfactory Ask the client to The client will be Mama Queen was
Type: Sensory identify aromas able to identify able to identify the
Function: Smell like cologne, different aromas aromas of cologne,
alcohol and like cologne, alcohol and vinegar.
vinegar, with each alcohol and
nostril separately vinegar, unless
with eyes close. such condition
like cold is
present.
II: Optic Ask the client to The client will be Mama Queen was
Type: Sensory read words on a able to read the able to read the
Function: Vision piece of paper with words at 12-14 articles in the
each eye first then inches. newspaper at 12-14
both eyes at 12-14 inches.
inches.
III: Oculomotor Ask client to look The client’s eyes Mama Queen had a
Type: Motor straight ahead then will have a normal reaction to
Function: Upward and approach the pupil normal reaction PERRLA.
downward movement of pupils with a penlight and for PERRLA.
observe for pupil
constriction.
IV: Trochlear Ask client to hold The client will be Mama Queen has
Type: Motor the head still and able to follow the good coordination of
Function: Extra-ocular follow the movement of the eye movements and
movement of eyes in oblique thermometer as it thermometer. able to follow the
movement moves in the six movement of the
cardinal eye thermometer.
movements.
V: Trigeminal Ask the client to The client will be Mama Queen was
Type: Motor and Sensory make chewing able to make able to make
Function: Sensation of cornea, movements, open chewing chewing movements,
skin of face and jaw movement the mouth against movements, open open the mouth
resistance, move the mouth against against resistance,
jaw from side to resistance, move move jaw from side
side and open jaw from side to to side and open
mouth widely. side and open mouth widely.
mouth widely.
Blinking Reflex
was noted.
Cotton is wisp at Blinking Reflex was
the side of the noted to Mama
client’s eyes. Queen.
VI: Abducens Have the client to The client will be Mama Queen has
Type: Motor hold his head able to follow the good coordination of
Function: Extra-ocular steady and follow movement of the eye movements and
movement of eyes in a lateral the thermometer thermometer. able to follow the
movement direction. movement of the
thermometer.
VII: Facial Ask the client to The client will be Mama Queen was
Type: Motor and Sensory smile, frown, raise able to smile, able to smile, frown,
Function: Movement of facial eyebrow, puff the frown, raise raise eyebrow, puff
muscles and sense of taste on cheeks and show eyebrow, puff the the cheeks and show
the anterior two thirds of the teeth. Ask the cheeks and show teeth. She was also
tongue client to identify teeth. The client able to identify the
the different tastes will be able to taste of sugar on the
(sugar) placed on identify the sugar anterior 2/3 of her
the anterior 2/3 of placed on the tongue.
the tongue. anterior 2/3 of the
tongue.
VIII: Vestibulocochlear/ Have the client to The client will be Mama Queen was
Acoustics walk with both able to walk with able to walk with
Type: Sensory eyes close and both eyes close both eyes close and
Function: Hearing and repeat the and repeat the repeat the whispered
Equilibrium
IX: Glossopharyngeal
Type: Motor and Sensory
Function: Swallowing, gag
reflex, pharyngeal movement
and sense of taste of the
posterior one-third of the
tongue
X: Vagus
Type: Motor
Function: Swallowing and
Speaking
whispered few whispered few few words whispered
words at the words at the to her. She was also
client’s back. client’s back. The able to perform
Allow client to client will be able Romberg’s Test with
stand with feet to perform equilibrium.
together and arms Romberg’s Test
resting at the sides, with equilibrium.
first with eyes
open and then
closed (Romberg’s
Test).
Ask the client to Client will elicit Mama Queen was
swallow then open gag reflex. The able to elicit gag
mouth widely and client will be able reflex. And the uvula
say “Ah”. Ask the to identify the moved upward upon
client to identify taste of sugar saying “Ah”. She
the taste (sugar) placed on was also able to
placed on posterior posterior tongue. identify the taste of
tongue. sugar placed on her
posterior tongue.
Ask client to The client will be Mama Queen had an
cough and say its able to state his effective coughing
name. name without and was able to state
hoarseness of her name without
voice. hoarseness of voice.
XI: Accessory Ask client to The client will be Mama Queen was
Type: Motor elevate shoulders able to elevate able to elevate
Function: Movement of against the gravity shoulders against shoulders against the
shoulder muscles and turn head from the gravity and gravity and turn head
side to side. turn head from from side to side.
side to side.

XII: Hypoglossal
Type: Motor
Function: Movement and
strength of tongue
Ask the client to The client will be Mama Queen was
protrude the able to protrude able to protrude her
tongue and move his tongue and tongue and move in
in different move in different different directions.
directions. directions.

MOTHER’S OBSTETRICAL HISTORY

Mama Queen has been living with Papa King for 4 years now. Her Obstetric
History is G4P4 (4004). She started having her menstrual cycle when she was 12 years
old. All of her children were born via normal delivery and they were all delivered at the
hospital. According to her, she had completed her tetanus toxoid vaccine.

HISTORY OF PAST AND PRESENT ILLNESS

Currently, Mama Queen is not experiencing any illness. She often acquired some
colds, cough and even fever several times due to some factors that are still unknown over
the past years according to her; she just acquired it sometimes when her other family
members have it.

Eating pattern

Mama Queen eats thrice daily. She eats whatever is available.

Sleeping pattern
 Mama Queen wakes up at 6:00 am and sleeps at 11:00 pm. She sleeps with her
husband and 2 children. She sleeps 7 hours every a day.

Leisure time activities

She utilizes it for sleep, rest, watching TV, listening to the radio, or chatting
with neighbors.
IV. Socio-Economic, Cultural, and Environmental Assessment

A. Type of Family Structure

The Royale Family is an extended type of family, composed of parents: Papa
King and Mama Queen, children: 4-year old Brother Prince and 1-year old Sister
Princess, and Lola Beauty living with them. When Papa Prince and Mama Princess are at
work, Lola Beauty is the one taking care of their kids. Although the family is not lucky
enough to have a wealthy and comfortable living, they still manage to surpass every
challenging situation that they encounter by having a positive outlook in life.

B. Dominant family members in terms of decision making especially to health care

In terms of decision making, whether related to health care or not, Papa King and
Mama Queen are the decision makers in the family.

C. Source of Income, Expenditures

The family’s source of income is Papa King’s wage from being a street sweeper
and a barangay tanod in their community and Mama Queen’s wage from being a
saleslady at LCN Enterprises. The family has adequate financial for the basic needs of the
family. In case of emergency, they use the money that the mother had kept/saved.

D. Working hours
Papa Prince works from 7 am to 9 am as a street sweeper, 2 hours a day, 2pm-
10pm as a guard vendor, and 10 pm to 6 am as a barangay tanod while Mama Queen
works from 8 am to 5 pm as a saleslady at LNC Enterprises.

E. Ethnic background and Religious Affiliation

The family’s religion is Roman Catholic, so very few restrictions are being
implemented. They don’t attend the Holy Mass often.

F. Significant other’s role in the family life

Lola Beauty is taking care of the kids whenever Papa King and Mama Queen are
not around.
G. Health habits/beliefs
The family resorts to herbal medicines such as lagundi for colds and they usually
go to herbolarios(herb doctors) before going to the hospital. These health beliefs and
customs are considered factors that may greatly affect the children’s upbringing and
health status.

H. Family’s involvement in community activities

According to Lola Beauty, Papa King often joins in the Barangay Basketball
League.

I. Family’s utilization of Community Resources

Community resources in the barangay include the health center. The family does
not utilize community resources. They visit the hospital for consultation, check-ups, and
emergency especially when Sister Princess is having an asthma attack.

J. Housing Condition
The Royale Family lives in a one-bedroom shack. In the front yard, there is a
drainage system where it is very dirty and has moles and mud surrounding it. Then
there’s a 3-step stairs down the front porch. On the right of the front porch, one can see a
pile of charcoal which the family uses for cooking when they don’t have money to buy
gas for their stove. Before entering the house, there is a wood/boarding in front of the
door for the kid’s safety and the kids wouldn’t be able to go outside without their Lola
Beauty knowing. There is a big closet that separates the living room and the bedroom. In
the living room, the family has TV for entertainment and a cardboard and pillow for Lola
Beauty to sleep on. The living room has no furniture for them to sit on while watching
TV. Instead, the family sits on the floor or uses the chairs that they have borrowed from
the community. The bedroom has the largest area in the house with wooden bed. Mama
Queen, Brother King, and Sister Princess sleep on the bed while Papa Prince prepares his
bed with foam on the floor. The dining area is on the right side of the bedroom where two
refrigerators and a table are located. One refrigerator is used by Lola Beauty for selling
ice and ice water while the other refrigerator is for their food storage. There is also a
cabinet for medicines, plates, and glasses. At the back of their house is where the kitchen
and bathroom are located. There are presence of ants, spiders, and cockroaches. For the
lighting conditions, the family use incandescent bulbs as their source of light during
evenings. However, inadequacy in daytime lighting is very evident, as there is only one
window.

K. Food sources, storage, and cooking facilities

The family usually buys cooked food at the carinderia while Lola Beauty prepares
the rice. They seldom cook for their own food. When they ran out of gas for their stove,
Lola Beauty prepares rice in the front porch where the pile of charcoal is used. Food
storage comprises of food covered in plates.

L. Water Supply (source, ownership, portability, storage)

The family has a level 3 water system. They own such water supply facility. For
the kids, they boil the water first before they let the kids drink it while the adults in the
family drink the water from the household tap. The type of water storage is pitchers or
jars with cover.

M. Toilet facility (type, ownership, sanitary condition)

Their toilet facility is at the back of the house. The family has a septic tank
without water carriage so it has to be mechanically flushed by pouring water in it. It is in
good condition because the surrounding area of the bowl is clean and no discoloration or
foul odor is evident.

N. Drainage system (type, sanitary, condition)

Their drainage system is located on the front yard of the house. Its type is of open
and flowing nature. The garbage disposal container is sack and it is uncovered.

O. Social and health facilities available

The community where the family resides has various social and health facilities.
They have a basketball court wherein certain activities such as sports fest are being
carried out and the Barangay San Remedios Health Center which offers an array of
services such as immunization, family planning programs, and prenatal care.

P. Communication and transportation facilities

In the family, Papa King and Mama Queen have cell phones for communication.
The family commutes by riding a tricycle or public utility jeepney to go to places. They
can also walk if the destination is just considerably near.