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Angeles University Foundation
Angeles City
COLLEGE OF NURSING
Family Case Analysis
Barangay Lourdes Sur East, Angeles City
In Partial Fulfillment of the Requirements in
Related Learning Experience
For the Degree of Bachelor of Science in Nursing
Submitted by:
Group 46
BSN II-8
Submitted to:
I. Introduction
“The hygiene was the most important thing there as far as keeping
everyone healthy”
-Chris Lane
Nurses help in the rehabilitation of the sick but their primary focus is the
prevention of illnesses. They can do such preventions by doing health teachings to
the family. One of these health teachings is maintaining the environment clean. In
addition to this, nurses also encourage the patient or the family to maintain good
personal hygiene. If done properly, these techniques can be a great help in
preventing illnesses or diseases that may alter the health status and the normal
functioning of the family member.
Community is composed of group of families living together as one and

sharing common goals. It is also defined by its geographic boundaries, and primarily
composed of institutions organized into social systems with the institutions and
organizations that are linked together.
Family is the basic unit of the society. It is composed of a man and woman
that are bonded by marriage and this man and woman must have an offspring.
Therefore, as community health nurses, our primary goal is to enhance the health
conditions of the families. The health of the community is dependent on the health
of the families that are living in a specific community.
The essence of Community Health Nursing is not only taking care for the
individuals, but also for the families living in the community. It is a service rendered
by a professional nurse with the community, groups, and families at home, in health
centers, in clinics, in places of work for the promotion of health, prevention of
illness, care for the sick at home and rehabilitation. Promoting and protecting the
health of the community is the unique role that is needed to be fulfilled by
community health nurses.
There are communities in our country that are being congested because of
overpopulation. If a community is said to be congested, we may think that this
community has poor ventilation. Therefore, we can say that communicable diseases
within congested communities can be easily transferred from an individual to the
other. Poor health in these communities can be the result of this phenomenon. This
is where community health nursing will take place. The lives of the families in these
kind of communities will be uplifted through the community health nurses.
With the aid of Family Case Analysis, we would be able to understand the
health status and present conditions of our adopted family. In addition to this, it is
also through family case analysis that we can identify the problems present in the
family and we could determine certain interventions that the family needs.
The group made sure that the family that they would choose has at least two
children whose ages would range from zero to two years of age. The group also
noticed that the household of the family has an obvious need of help in environment
and that made the group adopt this family.
The group adopted the Ice Cream family when they had their exposure in the
community. The data that the group would be able to gather would be part of their
family case analysis ( FCA ).
A. Objectives
1. Student centered
• Short term
At the end of 1-2 home visits, the group shall have:
 Familiarized themselves from the physical setting of their

adopted community – Brangay Lourdes Sur East
 Chosen a family that would fit into the criteria of FCA
 Introduced their selves to the adopted family
 Established rapport with the family
 Observed the general conditions and identified problems of

the family
 Explained the importance of having home visits
 Informed the family about the different programs offered by

the barangay health center
 Acquired important information about the family (eg., history

of present illness, family background, socio economic status,
etc.,)
 Conducted physical assessment for the family
• Long term
At the end of 3-5 home visits, the group shall have:
 Provided different health teachings that could help the family
 Prioritized health and health-related problems identified

together with the family
 Formulated family nursing care plans that is well suited for

the family for the provision of care and service to the
problems identified
 Implemented different nursing interventions to alleviate or
minimize the identified problems of the family
 Encouraged the family to put in to practice what they have

learned during the home visits
 Encouraged the family to participate in the promotion and

maintenance of health
 Evaluated the interventions done for the family and the

improvements in the family’s condition from the initial home
visit to the last home visit
2. Family centered
• Short term
At the end of 1-2 home visits, the family shall have:
 Been familiarized with the members of the group
 Established rapport with the group
 Identified problems present within their family with the help

of the student nurses
 Understood the importance of having home visits
 Provided important information about their family
 Understood the programs offered in the barangay health

center
 Participated in the physical assessment conducted by the

group
• Long term
At the end of 3-5 home visits, the family shall have:
 Gained knowledge on how to recognize and meet the family’

health needs
 Understood and have complied to the health teaching

provided by the student nurses
 Participated in the prioritization of problems with the group
 Carried out appropriate actions for the problems as a result

of nursing interventions done by the student nurses
 Developed and maintained a home environment that would

be conducive to health development
 Utilized available resources in the community to promote

health and to prevent illnesses
3. Research centered
After doing the Family Case Analysis, the group shall have:
 Identified factors that affect the development of health and

environmental problems
 Introduced appropriate health teachings and interventions to

specific problems
 Imparted knowledge to the family that would make them

self-reliant and independent in managing their own health
conditions
Entry, Climate of acceptance, First few words, Number of home visits

Home visits or ocular visits are one of the very most essential tools in order to assess,
gather and to implement data’s in order for the complete success of the family case analysis
that has been conducted by the group. It also serves as a bridge in establishing rapport so that
questions and other important data’s that are being collected are accurate and correct so it can
serve as a baseline data.
Last June 23,2009, the student nurses were given a chance to look for a family to adopt
for their Family Case Analysis. The criteria set were that a family must have a minimum of five
(6) members and there should be a child below 5 years old. The student nurse started to find
one and luckily they were able to find their family for the study.
First home visit
June 23, 2009 (Tuesday): 8:30 am to 11:00 am
A sunny morning then, the group went to the house of the Ice cream Family and asked
permission to conduct their studies that involves their family. The student nurses asked and said
to the mother, “Magandang umaga po, mga estudyante po kami ng Angeles University
Foundation, naghahanap po kasi kami ng palmiya na pwede naming tulungan, kung okay lang
po ba na tuwing martes dinadalaw namin kayo? Titingnan po namin kung may depekto ang mga
anak ninyo. The mother replied, “ah, okey lang naman”. The student nurses replied,” tutulong
lang po kami dito sa bahay, sa pagaalaga ng mga anak ninyo, kung okay lang po sana, kung
bibigyan nyo po kami ng pahintulot. At first the mother was hesitant to accept the student nurses
but upon explaining the purpose and importance of FCA, she accepted the permission of the
group to conduct their FCA to their family. As the family welcomed the group, the group
introduced themselves individually, informed the family about the frequency, duration and
purpose of the home visit and started to establish rapport. The group established rapport to their
adopted family by introducing themselves to the family to make the family members comfortable
with the group.
Second home visit
June 30, 2009 (Tuesday): 9:00 am to 11:00 am
On the second day, it was a hot morning then. The student-nurses returned to the
family's house. The group greeted the mother and started to conduct interviews to obtain
essential information. Also the student- nurses were able to asses the family members who are
present at the moment, they are the mother, the 3rd and 4th child, and the youngest child. The
mother said that the other three children have gone to school while the father is working as soft
drink dealer.
In addition, the group attained measurements of the house, door and window to compute
for the total floor area and to determine the status of ventilation since the group first impression
is that it is inadequate. Finally they inspect for the toilet facility.
Third Home Visit
July 7, 2009 ( Tuesday) 8:30 am to 12:00 pm
During the third day of home visit the student nurse continued to perform their vital signs
taking, and together with the family identified the problems and what plans which can solve or
even eliminate the problems. The problems identified are the following:
 Presence of cough and colds

 Fire hazards
 Self medication
 Inadequate family income
 Inadequate living space
 Inadequate light and ventilation
Fourth home visit
July 14, 2009 (Tuesday) 8:30 am to 12:00 pm
On the hot morning, the family had welcomed the group willingly. The group has given
health teachings about the importance of good ventilation, proper food handling and having an
over all clean environment. The group taught the two mother how to wash hands and gave its
importance especially during cooking and serving food to the family. The two mother listened
and verbalized agreement and willingness regarding the health teachings being imparted.
Fifth home visit
July 21, 2009 (Tuesday) 8:00 am to 12:00 pm
It was a sunny morning. On the final visit of the group, it was the most memorable part
among the total home visits. The group has extended the warmest gratitude for the good
accommodation and treatment. On the other hand, the group encouraged the mother to utilize
programs about health available at the health center such as seminars, mother's class, family
planning methods, check-up and complete immunization.
The group evaluated the family’s progress in maintaining home environment conducive
to health as the result of the health teachings given by the student nurses with regards to the
identified problems.
The family has verbalized understanding about the health teachings that the group has
given as evidenced by frequent inquiry of the parents about health.
II. FAMILY CONSTELLATION
Family Constellation is where the family members are presented by their position in the
family and it also includes the initial appearances of the family member from the first visit. The
group’s chosen family was named the “Ice Cream Family” which is an extended type of family
composed of 13 members. The members of the first family are Mr. Ube (father), Mrs. Strawberry
(mother), Buko Pandan (eldest), Rocky Road, Mocha, Pistachio, Vanilla, and Mango (youngest).
The members of the second family are Mr. Double Dutch (father), Mrs. Caramel (mother),
Cookies and Cream (eldest), Coffee Crumble and Chocolate (youngest). They are presented by
their position and ages for them to be easily identified and distinguished from one another, it
also provides important demographic data that are deemed significant in assessing family’s
health status. It includes age, gender and overview of the member’s present health status based
from the assessment done by the student nurses.
NAME AGE POSITION SEX EDUCATIONA PRESENT HEALTH

L STATUS
STATUS
Mr. Ube was seen

wearing black shorts
Mr. Ube 37 Father Male Not going to
and not wearing top
(head of the school –
years old shirt. He stands 168
family) Vocational -
cm weighting 52 kg. He
Aircraft is thin and has dark
Birthday: Mechanic complexion. He has
long black hair. With
February
presence of
25, 1972
discoloration of the
teeth. His fingernails
and toenails are long
and dirty.
Vital Signs as follows:
• Temperature:
37.1oC
• Pulse rate: 58
bpm
• Respiratory
rate: 22 cpm
• Blood Pressure:
140/100 mmHg
Height: 1.68 m
Weight: 52 kg
BMI:18.5
UNDERWEIGHT
Mrs. 39 years old Mother Female Not going to Mrs. Strawberry was
Strawberry school – seen wearing green
shirt and white shorts.
Medical
Birthday: She has black short
Secretary
hair. She has fair
November
complexion. With
25, 1969
presence of scars on
right leg.
• Temperature:
37.6oC
• Pulse rate: 75
bpm
• Respiratory
rate: 21cpm
• Blood Pressure:
100/70 mmHg
Height: 1.57 m
Weight: 54 kg
BMI: 21.8
NORMAL
Buko 13 years old Eldest Son Male Going to Not seen through out
Pandan school – the home visits.
Highschool –
Birthday:
(2nd year)
July
24,1995
Rocky 11 years old Second Male Going to Rocky Road was seen
Road eldest Son school – wearing his white polo
and black pants
Highschool
Birthday: uniform. He has colds
(1styear)
and non productive
August 12,
cough. He has a dark
1997
complexion. He has
long and dirty
fingernails.
• Temperature:
37.0oC
• Pulse rate: 73
bpm
• Respiratory
rate: 17cpm
Height: 1.45 m
Weight: 32 kg
BMI: 15.3
UNDERWEIGHT
Mocha 10 years old Third eldest Female Going to Mocha was seen
daughter school – wearing blue sando
and short. Her hair was
Elementary
Birthday: long and ponytailed.
(Grade 5)
She has dark
January 23,
complexion and her lips
1999
is pale and dry. With
presence of colds. She
has long and dirty
fingernails and toenails.
• Temperature:
36.8oC
• Pulse rate: 100
bpm
• Respiratory
rate: 19cpm
Height: 1.48 m
Weight: 36 kg
BMI: 16.6
UNDERWEIGHT
Pistachio 8 years old Third Male Going to Pistachio was seen

Youngest school – wearing white sando
Son and short. His hair is
Elementary
Birthday: black. He is afraid of
(Grade 2) talking to strangers. He
February
has long and dirty
16, 2001
fingernails.
• Temperature:
37.5oC
• Pulse rate: 81
bpm
• Respiratory
rate: 24 cpm
Height: 1.15 m
Weight: 22 kg
BMI: 16.6
UNDERWEIGHT
Vanilla 5 years old Second Female Going to Vanilla was seen

Youngest school – wearing pink sando
Daughter and black shorts. She
Daycare
Birthday: has a fair complexion.
(DSWD)
She has a black
January 27,
straight long hair and
2004
no presence of
dandruff. She has long
and dirty fingernails.
• Temperature:
37.5OC
• Pulse rate: 87
bpm
• Respiratory
rate: 20cpm
Height: .97 m
Weight: 16 kg
BMI: 16.8
UNDERWEIGHT
Mango 2 years old Youngest Male Never been Mango was seen
Son to school wearing white sando
and shorts. He was
Birthday: seen breastfeeding to
his mother. He was not
April 25,
wearing slippers inside
2007
the house. He has a
fair complexion. He has
long and dirty
fingernails.
• Temperature:
37.1oC
• Pulse rate:76
bpm
• Respiratory
rate: 27cpm
Height: 0.87 m
Weight: 12kg
BMI: 15.8
UMDERWEIGHT
Mr. Double 40 years old Father Male Not going to Not seen through out
Dutch school – the home visits
(head of
the family) Vocational-
Birthday:
Electrician
December
15, 1968
Mrs. 35 years old Mother Female Not going to Mrs. Caramel was seen
Caramel school – wearing her white shirt
Undergradua and blue shorts. She
Birthday: te- has a long ponytailed
hair. She has a dark
January 06, (First year
complexion. She also
1974 College)
has incomplete teeth.
She has long and dirty
fingernails.
• Temperature:
37.4oC
• Pulse rate: 65
bpm
• Respiratory
rate: 15cpm
• Blood Pressure:
110/70mmHg
Height: 1.62 m
Weight: 57 kg
BMI: 22.3
NORMAL
Cookies 12 years old Eldest Female Going to Cookies and Cream
and Cream daughter school - was seen wearing
white blouse and green
Birthday: skirt uniform. Her hair
High School is long and wavy. She
November
has dark complexion
19, 1996 (1st year)
and her lips is pale and
dry. Her Blood
Pressure begin to
fluctuate when she was
9yrs. old until now. Vital
Signs as follows:
• Temperature:
37.0oC
• Pulse rate: 75
bpm
• Respiratory
rate: 19cpm
Height: 1.65 m
Weight: 43 kg
BMI: 16.3
UNDERWEIGHT
Coffee 7 years old Middle Male Going to Coffee Crumble was

Crumble Son school – seen wearing white
shirt and blue shorts.
Elementary
Birthday: His hair is black. He is
(Grade 2) has a fever. He has
February
long and dirty
14,2001
fingernails.
• Temperature:
38oC
• Pulse rate: 89
Chocolate 9 mos. old Youngest Male Never been Chocolate was seen
Son to school wearing her white
sando and not wearing
Birthday: shorts. No presence of
teeth yet. He has a fair
September
complexion. His hair is
18, 2008
evenly distributed.
• Temperature:
37.6oC
• Pulse rate: 87
bpm
• Respiratory
rate: 29cpm
Height: 0.75 m
Weight: 13 kg
BMI: 23.2
NORMAL
III. HEALTH ASSESSMENT
The nursing process hinges on assessment of the client to provide baseline data.
Assessment enhances identification of physical and psychological needs. The amount, depth,
and level of assessment skills vary with the nurse’s knowledge and expertise. The family health
assessment helps to identify family-linked diseases that affect health status and risk for potential
problems. Data about the present condition or status of the family was compare against norms
or standards of problems.
INITIAL ASSESSMENT
Name: Mr. Ube (Father)
Date: July 14, 2009
General Description:
Mr. Ube is 37 years old. He is conscious and coherent. He was wearing shorts, not
wearing any top shirt and he is wearing slippers . He stands 1.68 m and weighs 52 kg with a
BMI of 18.5 which is underweight. He was born February 25, 1972.
Vital signs:
Body temperature: 36.1°C
Pulse rate: 58 bpm
Respiratory rate: 22 cpm
Blood pressure: 140/100mmHg
Physical Assessment
Appearance and Mental status
Mr. Ube has small built and coordinated movements. He is cooperative upon doing client
care and interventions and assessment.
Integumentary System:
He has a fair complexion, and no body odor. Mr. Ube has a normal skin turgor as
evidenced by skin goes back to its previous state immediately when pinched, his temperature is
within the normal limit and no edema.
Nails:
Mr. Ube has a dirty long fingernails and toenails, no presence of clubbing; convex
curve, smooth and intact epidermis, capillary refill prompt return to usual color in less than 3
seconds
Head:
Mr. Ube has an evenly distributed long hair, no presence of patches or hair loss with a
variable amount of hair.
Mr. Ube skull is normal and cephalic; there is no presence of nodules and masses, no
tenderness palpated. Facial features and facial movements are symmetrical.
Eyes and Vision:

His eyelashes are equally distributed. No abnormal protrusion noted. No discharges on
both eyes, his eyebrows are evenly distributed and symmetrically aligned. His eyelids; skin is
intact, there were no discharges and no discoloration; lid close symmetrically; involuntary blinks.
Pupils are black with equal on size. Palpebral conjunctiva is shiny, smooth and pink. His bulbar
conjunctiva is transparent, and sclera appears white. No edema or tenderness over the lacrimal
gland, lacrimal sac and nasolacrimal duct; No edema nor tearing.
Ears
Mr. Ube’s ears (auricles) are symmetrical in size. His pinna recoils after it is folded, firm
and without tenderness upon palpation. External ear canal contains minimal amount of dry
cerumen.
Nose and Facial Sinuses:

His nose is symmetrical and uniform in color; there are no discharges or flaring. Not
tender and no lesions. Air moves freely as the client breathes through nares by asking him to
exert pressure on one nares, and breathe through the opposite nares. Facial sinuses are not
tender.
Mouth and Throat:
Mr. Ube has symmetrical lips, able to purse lips, with discoloration of the teeth. No
sore throat. No sign of gum bleeding. His tongue is pinkish in color, moves without restraint, no
tenderness and no lesions. Uvula is positioned in the middle of the soft palate.
Lymph nodes, Thyroid gland and Neck:
Mr. Ube has proper neck contour. There is no difficulty with neck mobility and
movements are coordinated, smooth and no discomforts and equal in size. There is resistance
when neck has applied with pressure. Muscle strength is equal strength by letting the client to
turn one head on one side against the nurse’s hand’s resistance. Lymph nodes are not
palpable, not tender and no enlargement in submandibular, post-auricular, and submental area.
Upon assessing the thyroid gland the student nurse asked client to drink water and to swallow it.
Gland ascends while swallowing. Carotid artery has symmetric pulse volume. Neck veins are
not visible, jugular veins are not distended.
Chest and Thorax:

Chest wall is intact and symmetric in volume, no tenderness and masses, full and
symmetric lung expansion, and resonant sound upon percussion over the lungs and no
adventitious breath sounds. Breathing pattern is normal with symmetrical chest movement
noted on anterior thorax. He has a regular heart beat pattern. Spine is vertically aligned. Skin is
intact and uniform temperature. Thorax is symmetric, with bilateral symmetry of vocal fremitus
and with normal breath sounds.
Abdomen:
His abdomen is uniform in color, not distended, rounded symmetric contour and
movements upon by respiration and with audible bowel sounds (10-15 bowel sounds per 5
minutes), tympani over the stomach and no evidence of enlargement of liver and spleen.
Upper Extremities and Lower Extremities:

There are no nodules, masses or tenderness noted. Both upper and lower extremities
are symmetrical in contour. The bones and joints in both upper and lower extremities have no
deformities and no pain felt. The client’s gait and balance is stable. Mr. Ube can walk in a
straight line and able to maintain balance with eyes closed using one foot.
Cranial Nerves Test Expected Result Actual Result
I. Olfactory Ask the client to smell Client must be able Able to differentiate
and identify an to identify the scent odor such as
aromatic, nonirritating of an object when cologne and coffee.
odor with each nostrils asked to smell it.
separately and with
the eyes closed.
II. Optic Snellen's chart or Client can read Able to read at a

newspaper. newspaper at a distance of 12
distance of 12
inches. inches.
III. Oculomotor Test for Pupils equally Eyes must follow the Able to raise eyelids
round reactive to light direction of normally. Pupils
and accommodation movement of ball constrict when
(PERRLA). Can pen. In light dim exposed to light
perform 4 out of 6 environment, the (PERRLA). Can
Cardinal gazes. pupils of the eyes perform 4 expected
are dilated upon cardinal gazes.
introduction of light
to the eyes, pupils
constricted. Ask the
client to follow the
direction of the
ballpen to the upper
right corner, upper
left corner, lower
right corner and
lower left corner.
IV. Trochlear Ask the client to follow Eyes must follow the Coordinated eye
the lateral and downward and movements of both
downward movement lateral movement of eyes move in
of the ballpen with his object without unison.
eyes. difficulty.
V. Trigeminal Ask the client to look Client must blink and Presence of blinking
upward then lightly able to clench her reflex and able to
touch lateral sclera of jaw. clench her jaw while
the eye to elicit blink the student nurse
reflex and ask the tries to pen his jaw.
patient to clench the
jaw while the student
nurse tries to open the
jaw.
VI. Abducens Ask the client to follow The client must He has unison
the movement of the follow the movement lateral eye
penlight with his eyes. of the penlight movements.
laterally.
VII. Facial Ask the patient to Client’s muscle of Able to smile, puff
smile, puff cheeks and facial expression cheeks and raise
raise his eyebrows should work. Able to eyebrows in unison.
and other facial identify the various He can identify the
expressions. Ask the tastes. sweet taste of the
client to identify some candy, sour taste of
sweet, salty, and sour calamansi juice, and
foods or condiments. salty taste of table
salt.
VIII. Ask the client to Must be able to Able to identify

Glossopharyngeal identify bitter foods or distinguish the taste coffee through taste.
condiments. of coffee powder.
IX. Accessory Ask the client to The client must be Can move/ rotate
elevate shoulders, turn able to shrug his head from side to
the head side to side, shoulders against side and shrug
and push the head resistance. shoulders both
forward against against resistance.
resistance.
X. Hypoglossal Ask the client to Tongue should Able to stick out

protrude tongue at move without tongue and move to
midline and then move difficulty. all direction.
it side to side
FINAL ASSESSMENT
Name: Mr. Ube (Father)
Date: July 21, 2009

Vital signs:
Pulse rate: 87 bpm
Physical Assessment
He has a fair complexion, and no body odor. Mr. Ube has a normal skin turgor as
Nails:
Mr. Ube has a clean fingernails and toenails, no presence of clubbing; convex curve,
smooth and intact epidermis, capillary refill prompt return to usual color in less than 3 seconds.
Head:
Mr. Ube has an evenly distributed and short hair, no presence of patches or hair loss
with a variable amount of hair.
Mr. Ube skull is normal and cephalic; there is no presence of nodules and masses, no
Eyes and Vision:

Ears
Mr. Ube ears (auricles) are symmetrical in size. His pinna recoils after it is folded, firm
and without tenderness upon palpation.

tender.
Mouth and Throat:
Mr. Ube has symmetrical lips, able to purse lips, with discoloration of the teeth. No
sore throat. No sign of gum bleeding. His tongue is pinkish in color, moves without restraint, no
tenderness and no lesions. Uvula is positioned in the middle of the soft palate. With presence of
gag reflex.
Mr. Ube has proper neck contour. There is no difficulty with neck mobility and
Chest and Thorax:

Abdomen:

deformities and no pain felt. The client’s gait and balance is stable. Mr. Ube can walk in a
Name: Mrs. Strawberry (Mother)
Date: July 14, 2009
Mrs. Strawberry is 39 years old. She is conscious and coherent. She was wearing a
black sando and short and wearing her slippers. She stands 1.57 m and weighs 54 kg with a
BMI of 21.8 which is normal. She was born November 25, 1969.
Vital signs:
Pulse rate: 75 bpm
Physical Assessment

Mrs. Strawberry has a small built and coordinated movements. She is cooperative upon
doing client care and interventions and assessment.
She has a fair complexion and no body odor. Mrs. Strawberry has a normal skin turgor
as evidenced by skin goes back to its previous state immediately when pinched, her
temperature is within the normal limit and no edema.
Nails:
Mrs. Strawberry has a dirty long fingernails but clean toenails, no presence of
clubbing; convex curve, smooth and intact epidermis, capillary refill prompt return to usual color
in less than 3 seconds.
Head:
Mrs. Strawberry has an evenly distributed, uncombed short thick dry hair no presence
of patches or hair loss with a variable amount of hair
Mrs. Strawberry’s skull is normal and cephalic with a smooth skull contour; there is no
presence of nodules and masses, no tenderness palpated. Facial features and facial
movements are symmetrical.
Eyes and Vision:

Her eyelashes are equally distributed. No abnormal protrusion noted. No discharges on
both eyes, her eyebrows are evenly distributed and symmetrically aligned. Her eyelids, skin is
Pupils are black with equal on size. Palpebral conjunctiva is shiny, smooth and pink. Her bulbar
Ears:
Mrs. Strawberry’s ears (auricles) are symmetrical in size. Her pinna recoils after it is
folded, firm and without tenderness upon palpation. External ear canal contains minimal
amount of dry cerumen.

Her nose is symmetrical and uniform in color; there are no discharges or flaring. Not
tender and no lesions. Air moves freely as the client breathes through nares by asking her to
tender.
Mouth and Throat:
Mrs. Strawberry has symmetric lips, able to purse lips, with discoloration of the teeth.
No sore throat. No sign of gum bleeding. Her tongue is pinkish in color, moves without restraint,
no tenderness and no lesions. Uvula is positioned in the middle of the soft palate. With
presence of gag reflex.
Mrs. Strawberry has proper neck contour. There is no difficulty with neck mobility and
Chest and Thorax:

noted on anterior thorax. She has a regular heart beat pattern. The carotid, brachial and radial
arteries have symmetrical pulse volume. Spine is vertically aligned. Skin is intact and uniform
temperature. Thorax is symmetric, with bilateral symmetry of vocal fremitus and with normal
breath sounds.
Abdomen:
Her abdomen is uniform in color, not distended, rounded symmetric contour and

deformities and no pain felt. The client’s gait and balance is stable. Mrs. Strawberry can walk in
a straight line and able to maintain balance with eyes closed using one foot.
CRANIAL NERVE ASSESSMENT
separately and with
the eyes closed.

distance of 12 inches.
inches.
to the eyes, pupils
direction of the
right corner, upper
left corner, lower
right corner and
lower left corner.
of the ballpen with her object without unison.
eyes. difficulty.
reflex and ask the tries to pen her jaw.
jaw.
VI. Abducens Ask the client to follow The client must She has unison
laterally.
and other facial identify the various She can identify the
salt.

IX. Accessory Ask the client to Must be able to Can move/ rotate
elevate shoulders, turn shrug her shoulders head from side to
the head side to side, against resistance.. side and shrug
and push the head shoulders both
resistance.

it side to side
FINAL ASSESSMENT
Vital signs:
Pulse rate: 66 bpm
Nutritional status by age, weight and height
Age: 39 y/o
Weight: 54 kg
Height: 1.57 m
BMI: 21.8
Nutritional Status: normal
BMI interpretation
< 18.5 underweight
18.6-22.9 healthy weight

> 23.0 overweight
23.0-24.9 at risk
25.0-29.9 obese I
> 30.0 obese II
History of past and present illness
According to Mrs. Strawberry, she was only hospitalized during her delivery with her
children. She had 6 children which are born with normal spontaneous delivery. Aside from that,
Mrs. Strawberry didn’t experience any illness that requires hospitalization. As of now, it was
seen with her daily vital signs that she is healthy and normal.
Activities of Daily Living
Mrs. Strawberry wakes up at around 5 am and preparing to cook food by that time. She
usually spends her morning roaming around their place and chatting with his friends. By 11:00
am, She is starting to prepare the lunch of the family. Then at 12 noon, she takes her lunch
together with Mrs. Caramel and Mr. Ube. After taking her lunch, she usually spends her time
sleeping or watching TV. By 7 pm, she takes her dinner together with her family. She usually
sleeps at around 11 pm or 12 pm.
Name: Buko Pandan (eldest son)
* Never been seen throughout the home visits.
Name: Rocky Road (2nd eldest son)
Date: July 14, 2009
Rocky Road is 11 years old. He is conscious and coherent. He was wearing a wearing
his white polo and black pants uniform. He stands 1.45 m. and weighs 32 kg. A BMI result of
15.3 and it is underweight. He was born August 12, 1997.
Vital signs:
Body temperature: 37°C
Pulse rate: 73 bpm
Physical Assessment

Rocky Road has good built and coordinated movements. He is cooperative upon doing
client care and interventions and assessment
He has a dark complexion and no body odor. Rocky Road has a normal skin turgor as
evidenced by skin goes back to its previous state immediately when pinched, her temperature is
Nails:
Rocky Road has a dirty long fingernails but clean toenails, no presence of clubbing;
convex curve, smooth and intact epidermis, capillary refill prompt return to usual color in less
than 3 seconds.
Head:
Rocky Road has an evenly distributed, no presence of patches or hair loss with a
variable amount of hair
Rocky Road’s skull is normal and cephalic with a smooth skull contour; there is no
Eyes and Vision:

both eyes, his eyebrows are evenly distributed and symmetrically aligned. His eyelids, skin is
Ears:
Rocky Road’s ears (auricles) are symmetrical in size. His pinna recoils after it is folded,
firm and without tenderness upon palpation. External ear canal contains minimal amount of
dry cerumen.

His nose is symmetrical and uniform in color; with presence of clear discharges. Not
tender and no lesions.
Mouth and Throat:
Rocky Road has symmetrical lips, able to purse lips. No sore throat. No sign of gum
bleeding. His tongue is pinkish in color, moves without restraint, no tenderness and no lesions.
Uvula is positioned in the middle of the soft palate.
Rocky road has proper neck contour. There is no difficulty with neck mobility and
Chest and Thorax:

symmetric lung expansion.He has a regular heart beat pattern. Spine is vertically aligned. Skin
is intact and uniform temperature. Thorax is symmetric.
Abdomen:
movements upon by respiration.
deformities and no pain felt. The client’s gait and balance is stable. Rocky Road can walk in a
and identify an to identify the scent odor such as cologne
aromatic, nonirritating of an object when and coffee.
separately and with the
eyes closed.

inches.
Cardinal gazes. pupils of the eyes are perform 4 expected
dilated upon cardinal gazes.
introduction of light to
the eyes, pupils
direction of the
right corner, upper
left corner, lower
right corner and
lower left corner.
eyes. difficulty.
jaw.
laterally.
salt.
resistance.

it side to side
FINAL ASSESSMENT
Vital signs:
Pulse rate: 69 bpm
Physical Assessment
He has a dark complexion, and no body odor. Rocky Road has a normal skin turgor as
Nails:
Rocky Road has a clean fingernails and toenails, no presence of clubbing; convex curve,
Head:
Rocky Road has an evenly distributed, no presence of patches or hair loss with a
Rocky Road skull is normal and cephalic; there is no presence of nodules and masses,
no tenderness palpated. Facial features and facial movements are symmetrical.
Eyes and Vision:

Ears
Rocky Road’s ears (auricles) are symmetrical in size. His pinna recoils after it is folded,
firm and without tenderness upon palpation.

tender.
Mouth and Throat:
Rocky Road has symmetrical lips, able to purse lips. No sore throat. No sign of gum
Rocky Road has proper neck contour. There is no difficulty with neck mobility and
Chest and Thorax:
Abdomen:

deformities and no pain felt. The client’s gait and balance is stable. Ham can walk in a straight
line and able to maintain balance with eyes closed using one foot.
Age: 11 y/o
Weight: 32 kg
Height: 1.45 m
BMI: 15.3
FNRI: Underweight
According to Mrs. Strawberry, Rocky Road didn’t experience diseases that require
hospitalization. He only experience fever, cough and colds during his childhood years. For fever,
he takes paracetamol and for coughs and colds, he drinks calamansi juice made by Mrs.
Strawberry.

Rocky Road usually wakes up at around 6 in the morning to prepare for school. By 6:30 am, he
takes her breakfast and go to school afterwards. He spends most of her time in the school, from
7 am up to 4 pm. He takes his lunch at around 12 noon. When he arrives at their house after
school, he takes her rest first then go outside to play with his playmates. By 7 or 8 pm, he takes
his dinner with his family. He sleeps at around 9 pm.
Name: Mocha (Third eldest daughter)
Date: July 14, 2009
Mocha is 10 years old. She is conscious and coherent. She was wearing a blue sando
and short and wearing her slippers. She stands 1.48 m. and weighs 36 kg. According to FNRI a
BMI of 16.6 is underweight for the age. She was born January 23, 1999.
Vital signs:
Pulse rate: 100 bpm
Physical Assessment

Mocha has a small built and coordinated movements. She is cooperative upon doing
She has a fair complexion and no body odor. Mocha has a normal skin turgor as
Nails:
Mocha has a dirty long fingernails but clean toenails, no presence of clubbing; convex
seconds.
Head:
Mocha has an evenly distributed, no presence of patches or hair loss with a variable
amount of hair
Mocha’s skull is normal and cephalic with a smooth skull contour; there is no presence
of nodules and masses, no tenderness palpated. Facial features and facial movements are
symmetrical.
Eyes and Vision:

Ears:
Mocha’s ears (auricles) are symmetrical in size. Her pinna recoils after it is folded, firm

Her nose is symmetrical and uniform in color; with presence of clear discharges. Not
Mouth and Throat:
Mocha has symmetrical lips, able to purse lips. No sore throat. No sign of gum bleeding.
Her tongue is pinkish in color, moves without restraint, no tenderness and no lesions. Uvula is
positioned in the middle of the soft palate.

Mocha has proper neck contour. There is no difficulty with neck mobility and
Chest and Thorax:

symmetric lung expansion. She has a regular heart beat pattern. Spine is vertically aligned. Skin
Abdomen:
movements upon respiration.

deformities and no pain felt. The client’s gait and balance is stable. Mocha can walk in a straight
FINAL ASSESSMENT
Vital signs:
Pulse rate: 65 bpm
Physical Assessment
She has a fair complexion, and no body odor. Mocha has a normal skin turgor as
Nails:
Mocha has a clean fingernails and toenails, no presence of clubbing; convex curve,
smooth and intact epidermis, capillary refill prompt return to usual color in less than 3 seconds
Head:
Mocha has an evenly distributed, combed long thick dry hair, no presence of patches or
hair loss with a variable amount of hair
Mocha’s skull is normal and cephalic with a smooth skull contour; there is no presence
symmetrical.
Eyes and Vision:

Ears:
Mocha’s ears (auricles) are symmetrical in size. Her pinna recoils after it is folded, firm
cerumen.

tender.
Mouth and Throat:
Mocha has a symmetrical lips, able to purse lips. No sore throat. No sign of gum
bleeding. Her tongue is pinkish in color, moves without restraint, no tenderness and no lesions.
Mocha has proper neck contour. There is no difficulty with neck mobility and
Chest and Thorax:

noted on anterior thorax. She has a regular heart beat pattern. Spine is vertically aligned. Skin is
Abdomen:

Age: 10 y/o
Weight: 36 kg
Height: 1.48 m
BMI: 16.6
FNRI: Underweight
Upon home visit, Mocha had verbalized that she had not suffered any serious illness.
She only experienced the usual cough, colds and fever in different intervals. At present, she has
non productive cough.
Mocha usual waking hour is around 5:30 am and then takes her breakfast. After taking
her breakfast, she is ready to go to school. By lunch time, she will go home and eat lunch with
her mother and father. After eating, she will take her rest then afterwards, she will come back at
the school again. She go home at 3 pm. At around 7 or 8 pm, she will take her dinner and
sleeps at 8:30 to 9 pm.
Name: Pistachio (3rd youngest son)
Date: July 14, 2009
Pistachio is 8 years old. He is conscious and coherent. He was wearing a wearing his
white polo and black pants uniform. He stands 1.15 m. and weighs 22 kg. A BMI result of 16.6
and it is underweight. He was born February 16, 2001.
Vital signs:
Pulse rate: 81 bpm
Physical Assessment
Pistachio has good built and coordinated movements. He is cooperative upon doing
He has a dark complexion and no body odor. Pistachio has a normal skin turgor as
Nails:
Pistachio has a dirty long fingernails but clean toenails, no presence of clubbing;
than 3 seconds
Head:
Pistachio has an evenly distributed, no presence of patches or hair loss with a variable
amount of hair
Pistachio’s skull is normal and cephalic with a smooth skull contour; there is no presence
symmetrical.
Eyes and Vision:

Ears:
Pistachio’s ears (auricles) are symmetrical in size. His pinna recoils after it is folded, firm
cerumen.
His nose is symmetrical and uniform in color. Not tender and no lesions.
Mouth and Throat:
Pistachio has symmetrical lips, able to purse lips. No sore throat. No sign of gum
Pistachio has proper neck contour. There is no difficulty with neck mobility and
Chest and Thorax:

symmetric lung expansion..He has a regular heart beat pattern. Spine is vertically aligned. Skin
Abdomen:

deformities and no pain felt. The client’s gait and balance is stable. Rocky Road can walk in a
eyes closed.

inches.
the eyes, pupils
direction of the
right corner, upper
left corner, lower
right corner and
lower left corner.
eyes. difficulty.
jaw.
laterally.
salt.

resistance.

it side to side
FINAL ASSESSMENT
Vital signs:
Pulse rate: 72 bpm
Physical Assessment
He has a dark complexion, and no body odor. Pistachio has a normal skin turgor as
Nails:
Pistachio has a clean fingernails and toenails, no presence of clubbing; convex curve,
Head:
Pistachio has an evenly distributed, no presence of patches or hair loss with a variable
amount of hair.
Pistachio skull is normal and cephalic; there is no presence of nodules and masses, no
Eyes and Vision:

Ears
Pistachio’s ears (auricles) are symmetrical in size. His pinna recoils after it is folded, firm

tender.
Mouth and Throat:
Pistachio has a symmetrical lips, able to purse lips. No sore throat. No sign of gum
Pistachio has proper neck contour. There is no difficulty with neck mobility and
Chest and Thorax:

Abdomen:

Age: 8 y/o
Weight: 22 kg
Height: 1.15 m
BMI: 16.6
FNRI: Underweight
According to Mrs. Strawberry, Pistachio didn’t experience diseases that require

hospitalization. He only experience fever, cough and colds during his childhood years. For fever,
he takes paracetamol and for coughs and colds, he drinks calamansi juice made by Mrs.
Strawberry.
Pistachio usually wakes up at around 8:00 in the morning to prepare for school. By 10
am, he takes her breakfast and go to school afterwards. He will go home at 4 pm. When he
arrives at their house after school, he takes her rest first then go outside to play with his
playmates. By 7 or 8 pm, he takes his dinner with his family. He sleeps at around 9 pm.
Name: Vanilla (2nd youngest daughter)
Date: July 14,2009
Vanilla is 5 years old. She is conscious and coherent. She was wearing a pink sando
and black shorts. She stands 0.97 cm. and weighs 16 kg. A BMI result of 16.8 and it is
underweight. She was born January 27, 2004.
Vital signs:
Pulse rate: 87 bpm
Physical Assessment

Vanilla has good built and coordinated movements. She is cooperative upon doing client
care and interventions and assessment
She has a fair complexion and no body odor. Rice cake has a normal skin turgor as
Nails:
Vanilla has a dirty long fingernails but clean toenails, no presence of clubbing; convex
seconds.
Head:
Vanilla has an evenly distributed, no presence of patches or hair loss with a variable
amount of hair
Vanilla’s skull is normal and cephalic with a smooth skull contour; there is no presence
symmetrical.
Eyes and Vision:

Ears:
Vanilla’s ears (auricles) are symmetrical in size. Her pinna recoils after it is folded, firm
cerumen.

Her nose is symmetrical and uniform in color; Not tender and no lesions.
Mouth and Throat:
Vanilla has symmetrical lips, able to purse lips. No sore throat. No sign of gum bleeding.
Her tongue is pinkish in color, moves without restraint, no tenderness and no lesions. Uvula is
positioned in the middle of the soft palate. With presence of gag reflex.
Vanilla has proper neck contour. There is no difficulty with neck mobility and
Chest and Thorax:

symmetric lung expansion, rales auscultated on both lung fields. She has a regular heart beat
pattern. Spine is vertically aligned. Skin is intact and uniform temperature. Thorax is symmetric.
Abdomen:

deformities and no pain felt. The client’s gait and balance is stable. Vanilla can walk in a straight
separately and with
the eyes closed.

inches.
to the eyes, pupils
direction of the
right corner, upper
left corner, lower
right corner and
lower left corner.
eyes. difficulty.
jaw.
laterally.
VII. Facial Ask the patient to smile, puff cheeks and Able to smile, puff
raise his eyebrows and other facial cheeks and raise
expressions. Ask the client to identify some eyebrows in unison.
sweet, salty, and sour foods or condiments. She can identify the
sweet taste of the
Client’s muscle of facial expression should
candy, sour taste of
work. Able to identify the various tastes.
calamansi juice, and
salty taste of table
salt.

IX. Vagus Ask the client to Must be able to Has normal

swallow amount of swallow small swallowing and (+)
water and used the amount of water and gag reflex.
tongue depressor to demonstrate gag
elicit gag reflex. reflex.

it side to side
FINAL ASSESSMENT
Vital signs:
Pulse rate: 64 bpm
Physical Assessment
She has a fair complexion, and no body odor. Vanilla has a normal skin turgor as
Nails:
Vanilla has a clean fingernails and toenails, no presence of clubbing; convex curve,
Head:
Vanilla has an evenly distributed, combed long thick dry hair, no presence of patches or
hair loss with a variable amount of hair.
Vanilla’s skull is normal and cephalic with a smooth skull contour; there is no presence
symmetrical.
Eyes and Vision:

Ears:
Vanilla’s ears (auricles) are symmetrical in size. Her pinna recoils after it is folded, firm

tender.
Mouth and Throat:
Vanilla has a symmetrical lips, able to purse lips. No sore throat. No sign of gum
bleeding. Her tongue is pinkish in color, moves without restraint, no tenderness and no lesions.
Vanilla has proper neck contour. There is no difficulty with neck mobility and
Chest and Thorax:

Abdomen:
deformities and no pain felt. The client’s gait and balance is stable. Rice cake can walk in a
Age: 5 y/o
Weight: 16 kg
Height: 0.97 m
BMI: 16.8
Nutritional Status: underweight
History of present and past illness
According to Mrs. Strawberry, Vanilla didn’t experience diseases that require

hospitalization. She only experience fever, cough and colds during her childhood years. For
fever, she takes paracetamol and for coughs and colds, she drinks calamansi juice made by
Mrs. Strawberry just like her other brothers do.
Vanilla usually wakes up at around 9 in the morning to prepare for school. She eats her
breakfast after she wakes up. Her class will start at 11 and she will go home at 4 in the
afternoon. She usually plays wth her playmates after schooling. By 7 or 8 pm, she takes her
dinner with her family. She sleeps at around 8:30 pm.
Name: Mango (youngest son)
Date: July 14, 2009
Mango is 2 years old. He is conscious and coherent. He was wearing white sando and
shorts. He stands 0.87 m. and weighs 12 kg and according to FNRi, his weight is 12.8
underweight for his age. He was born April 25, 2007.
Vital signs:
Pulse rate: 76 bpm
Physical Assessment

Mango has small built and coordinated movements. He is cooperative upon doing client
care and interventions and assessment
He has a fair complexion, and no body odor. Mango has a normal skin turgor as
Nails:
Mango has a dirty long fingernails and toenails, no presence of clubbing; convex
seconds.
Head:
Mango has an evenly distributed hair, no presence of patches or hair loss with a variable
amount of hair
Mango’s skull is normal and cephalic; there is no presence of nodules and masses, no
Eyes and Vision:

Ears
Mango’s ears (auricles) are symmetrical in size. His pinna recoils after it is folded, firm
cerumen.

tender.
Mouth and Throat:
Mango has a symmetrical lips, able to purse lips. No sore throat. No sign of gum
Mango has proper neck contour. There is no difficulty with neck mobility and
when neck has applied with pressure.
Chest and Thorax:

noted on anterior thorax. He has a regular heart beat pattern. Skin is intact and uniform
temperature.
Abdomen:
deformities and no pain felt. The client’s gait and balance is stable. Mango can walk in a straight
FINAL ASSESSMENT
Vital signs:
Pulse rate: 76 bpm
Physical Assessment
He has a fair complexion, and no body odor. Mango has a normal skin turgor as
Nails:
Mango has a clean fingernails and toenails, no presence of clubbing; convex curve,
Head:
Mango has an evenly distributed, no presence of patches or hair loss with a variable
amount of hair.
Mango skull is normal and cephalic; there is no presence of nodules and masses, no
Eyes and Vision:

Ears
Mango’s ears (auricles) are symmetrical in size. His pinna recoils after it is folded, firm

tender and no lesions. Air moves freely as the client breathes through the opposite nares.
Mouth and Throat:
Mango has symmetrical lips, able to purse lips. No sore throat. No sign of gum bleeding.
His tongue is pinkish in color, moves without restraint, no tenderness and no lesions.

Mango has proper neck contour. There is no difficulty with neck mobility and
Chest and Thorax:

noted on anterior thorax. He has a regular heart beat pattern.
Abdomen:

deformities and no pain felt. The client’s gait and balance is stable. Mango can walk in a straight
Age: 2 y/o
Weight: 12 kg
Height: 0.87 m
FNRI: Underweight

According to Mrs. Strawberry, Mango didn’t experience diseases that require
hospitalization. He only experience fever, cough and colds. For fever, he takes paracetamol ang
for colds Mrs. Strawberry make calamansi juice for Mango.
Mango usually wakes up at around 7 in the morning. He eats his breakfast after waking up.
Then he likes watching tv and playing with his cousins. He usually sleeps at 8 in the evening.
* Second Family
Name: Mr. Double Dutch (father)
* Never been seen throughout the home visits.
Name: Mrs. Caramel (mother)
Mrs. Caramel is 35 years old. She is conscious and coherent. She was wearing a white
shirt and blue shorts. She stands 1.62 m and weighs 57 kg with a BMI of 22. which is healthy
weight. She was born January 06.1974.
Vital signs:
Pulse rate: 75 bpm
Physical Assessment

Mrs. Caramel has a small built and coordinated movements. She is cooperative upon
doing client care and interventions and assessment.
She has a fair complexion and no body odor. Mrs. Caramel has a normal skin turgor as
Nails:
Mrs. Caramel has a dirty long fingernails but clean toenails, no presence of clubbing;
than 3 seconds.
Head:
Mrs. Caramel has an evenly distributed, ponytailed hair no presence of patches or hair
loss with a variable amount of hair
Mrs. Caramel’s skull is normal and cephalic with a smooth skull contour; there is no
Eyes and Vision:

Ears:
Mrs. Caramel’s ears (auricles) are symmetrical in size. Her pinna recoils after it is folded,

tender.
Mouth and Throat:
Mrs. Caramel has symmetric pale lips, able to purse lips, with discoloration of the
teeth. No sore throat. No sign of gum bleeding. Her tongue is pinkish in color, moves without
restraint, no tenderness and no lesions. Uvula is positioned in the middle of the soft palate.
Mrs. Caramel has proper neck contour. There is no difficulty with neck mobility and
Chest and Thorax:

noted on anterior thorax. She has a regular heart beat pattern. The carotid, brachial and radial
arteries have symmetrical pulse volume. Spine is vertically aligned. Skin is intact and uniform
temperature. Thorax is symmetric, with bilateral symmetry of vocal fremitus and with normal
breath sounds.
Abdomen:

deformities and no pain felt. The client’s gait and balance is stable. Mrs. Caramel can walk in a
CRANIAL NERVE ASSESSMENT
separately and with
the eyes closed.

inches.
to the eyes, pupils
direction of the
right corner, upper
left corner, lower
right corner and
lower left corner.
eyes. difficulty.
jaw.
laterally.
and other facial identify the various She can identify the
salt.

IX. Accessory Ask the client to Must be able to Can move/ rotate
elevate shoulders, turn shrug her shoulders head from side to
the head side to side, against resistance.. side and shrug
and push the head shoulders both
forward against
resistance. against resistance.

it side to side
FINAL ASSESSMENT
Vital signs:
Pulse rate: 61 bpm
Age: 35 y/o
Weight: 57 kg
Height: 1.22 m
BMI: 22.3
Nutritional Status: healthy weight
According to Mrs. Caramel, she was only hospitalized during her delivery with her
children. She had 3 children which are born via normal spontaneous delivery. Aside from that,
Mrs. Caramel didn’t experience any illness that requires hospitalization. As of now, it was seen
with her daily vital signs that she is healthy and normal.
Mrs. Caramel wakes up at around 6 am and preparing to cook food by that time. She
usually spends her morning roaming around their place and chatting with his friends. By 11:00
am, she is starting to help Mrs. Strawberry prepare the lunch of the family. Then at 12 noon, she
takes her lunch together with Mrs. Strawberry and Mr. Ube. After taking her lunch, she usually
spends her time sleeping or watching TV. By 7 pm, she takes her dinner together with her
family. She usually sleeps at around 11 pm or 12 pm.
Name: Cookies and Cream (Eldest daughter)
Date: July 14, 2009
Cookies and cream is 12 years old. She is conscious and coherent. She was wearing
white blouse and green skirt uniform. She stands 1.65 m. and weighs 43kg. According to FNRI
a BMI of 16.3 is underweight for the age. She was born November 19, 1996.
Vital signs:
Pulse rate: 75 bpm
Physical Assessment

Cookies and Cream has a small built and coordinated movements. She is cooperative
upon doing client care and interventions and assessment
She has a fair complexion and no body odor. Cookies and cream has a normal skin
turgor as evidenced by skin goes back to its previous state immediately when pinched, her
Nails:
Cookies and has a dirty long fingernails but clean toenails, no presence of clubbing;
than 3 seconds.
Head:
Cookies and cream has an evenly distributed, no presence of patches or hair loss with a
Cookies and Cream’s skull is normal and cephalic with a smooth skull contour; there is
no presence of nodules and masses, no tenderness palpated. Facial features and facial
Eyes and Vision:

Ears:
Cookies and Cream’s ears (auricles) are symmetrical in size. Her pinna recoils after it is
folded, firm and without tenderness upon palpation.

Her nose is symmetrical and uniform in color; with presence of clear discharges. Not
Mouth and Throat:

Cookies and Cream has symmetrical lips, able to purse lips. No sore throat. No sign of
gum bleeding. Her tongue is pinkish in color, moves without restraint, no tenderness and no
lesions. Uvula is positioned in the middle of the soft palate.
Cookies and Cream has proper neck contour. There is no difficulty with neck mobility
and movements are coordinated, smooth and no discomforts and equal in size. There is
resistance when neck has applied with pressure.
Chest and Thorax:

symmetric lung expansion. She has a regular heart beat pattern. Spine is vertically aligned. Skin
Abdomen:
FINAL ASSESSMENT
Vital signs:
Pulse rate: 72 bpm
Physical Assessment
She has a fair complexion, and no body odor. Mocha has a normal skin turgor as
Nails:
Cookies and Cream has a clean fingernails and toenails, no presence of clubbing;
than 3 seconds.
Head:
Cookies and Cream has an evenly distributed, combed long thick dry hair, no presence
of patches or hair loss with a variable amount of hair
Cookies and Cream’s skull is normal and cephalic with a smooth skull contour; there is
no presence of nodules and masses, no tenderness palpated. Facial features and facial
Eyes and Vision:

Ears:
Cookies and cream’s ears (auricles) are symmetrical in size. Her pinna recoils after it is

tender.
Mouth and Throat:
Cookies and Cream has symmetrical lips, able to purse lips. No sore throat. No sign of
gum bleeding. Her tongue is pinkish in color, moves without restraint, no tenderness and no
lesions. Uvula is positioned in the middle of the soft palate.
Cookies and cream has proper neck contour. There is no difficulty with neck mobility
and movements are coordinated, smooth and no discomforts and equal in size. There is
resistance when neck has applied with pressure. Muscle strength is equal strength by letting the
client to turn one head on one side against the nurse’s hand’s resistance. Lymph nodes are not
Chest and Thorax:

Abdomen:

deformities and no pain felt. The client’s gait and balance is stable. Cookies and Cream can
walk in a straight line and able to maintain balance with eyes closed using one foot.
Age: 12 y/o
Weight: 43 kg
Height: 1.65 m
BMI: 16.3
FNRI: Underweight
Upon home visit, Cookies and Cream had verbalized that she had not suffered any
serious illness. She only experienced the usual cough, colds and fever in different intervals. At
present, she has non productive cough.
Cookies and cream’s usual waking time is around 8 am and then takes her breakfast.
After taking her breakfast, she is ready to go to school. She will go home at 3 pm. At around 7
or 8 pm, she will take her dinner and sleeps at 8:30 to 9 pm
Name: Coffee Crumble (middle son)
Date: July 14, 2009
Coffee Crumble is 8 years old. He is conscious and coherent. He was wearing white
shirt and blue shorts. He stands 104 cm and weighs 18 kg. A BMI result of 17.2 and it is
underweight. He was born February 14, 2002.
Vital signs:
Pulse rate: 89 bpm
Physical Assessment
Coffee Crumble has good built and coordinated movements. He is cooperative upon
doing client care and interventions and assessment
He has a dark complexion and no body odor. Coffee Crumble has a normal skin turgor
as evidenced by skin goes back to its previous state immediately when pinched, her
Nails:
Coffee Crumble has a dirty long fingernails but clean toenails, no presence of
clubbing; convex curve, smooth and intact epidermis, capillary refill prompt return to usual color
in less than 3 seconds.
Head:
Coffee Crumble has an evenly distributed, no presence of patches or hair loss with a
Coffee Crumble’s skull is normal and cephalic with a smooth skull contour; there is no
Eyes and Vision:

Ears:
Coffee Crumble’s ears (auricles) are symmetrical in size. His pinna recoils after it is
His nose is symmetrical and uniform in color; with presence of clear discharges. Not
Mouth and Throat:
Coffee Crumble has symmetrical lips, able to purse lips. No sore throat. No sign of gum
Coffee Crumble has proper neck contour. There is no difficulty with neck mobility and
Chest and Thorax:

symmetric lung expansion.He has a regular heart beat pattern. Spine is vertically aligned. Skin
Abdomen:

deformities and no pain felt. The client’s gait and balance is stable. Coffee Crumble can walk in
a straight line and able to maintain balance with eyes closed using one foot.
eyes closed.

inches.
the eyes, pupils
direction of the
right corner, upper
left corner, lower
right corner and
lower left corner.
eyes. difficulty.
jaw.
laterally.
salt.

resistance.
it side to side
FINAL ASSESSMENT
Vital signs:
Pulse rate: 86 bpm
Physical Assessment
He has a dark complexion, and no body odor. Coffee Crumble has a normal skin turgor
as evidenced by skin goes back to its previous state immediately when pinched, his
Nails:
Coffee Crumble has a clean fingernails and toenails, no presence of clubbing; convex
seconds.
Head:
Coffee Crumble has an evenly distributed, no presence of patches or hair loss with a
Coffee Crumble’s skull is normal and cephalic; there is no presence of nodules and
masses, no tenderness palpated. Facial features and facial movements are symmetrical.
Eyes and Vision:

Ears
Coffee Crumble’s ears (auricles) are symmetrical in size. His pinna recoils after it is
folded, firm and without tenderness upon palpation.

tender.
Mouth and Throat:
Coffee Crumble has symmetrical lips, able to purse lips. No sore throat. No sign of gum
Coffee Crumble has proper neck contour. There is no difficulty with neck mobility and
Chest and Thorax:

Abdomen:

Age: 7 y/o
Weight: 18 kg
Height: 1.15 m
BMI: 17.2
FNRI: Underweight
According to Mrs. Caramel, Coffee Crumble didn’t experience diseases that require
hospitalization. He only experience fever, cough and colds but not severe cases that needs to
be hospitalized.
Name: Chocolate (youngest son)
Date: July 14, 2009
Chocolater is 9 mos. old. He is conscious and coherent. He was wearing white sando
and not wearing shorts. He stands 0.75 m. and weighs 13 kg and according to FNRi, his weight
is 23.2 normal for his age. He was born September 18, 2008.
Vital signs:
Pulse rate: 83 bpm
Physical Assessment

Chocolate has small built and coordinated movements. He is cooperative upon doing
He has a fair complexion, and no body odor. Chocolate has a normal skin turgor as
Nails:
Chocolate has a clean and short fingernails and toenails, no presence of clubbing;
than 3 seconds.
Head:
Chocolate has an evenly distributed hair, no presence of patches or hair loss with a
Chocolate’s skull is normal and cephalic; there is no presence of nodules and masses,
no tenderness palpated. Facial features and facial movements are symmetrical.
Eyes and Vision:

Ears
Chocolate’s ears (auricles) are symmetrical in size. His pinna recoils after it is folded,
firm and without tenderness upon palpation. External ear canal contains minimal amount of
dry cerumen.

tender.
Mouth and Throat:
Chocolate has symmetrical lips, able to purse lips. No sore throat. No sign of gum
Chocolate has proper neck contour. There is no difficulty with neck mobility and
Chest and Thorax:

noted on anterior thorax. He has a regular heart beat pattern. Skin is intact and uniform
temperature.
Abdomen:

deformities and no pain felt. The client’s gait and balance is stable. Chocolate can walk in a
FINAL ASSESSMENT
Vital signs:
Pulse rate: 87 bpm
Physical Assessment
He has a fair complexion. Chocolate has a normal skin turgor as evidenced by skin goes
back to its previous state immediately when pinched, his temperature is within the normal limit
and no edema.
Nails:
Chocolate has maintained his clean fingernails and toenails, no presence of clubbing;
than 3 seconds.
Head:
Chocolate has an evenly distributed, no presence of patches or hair loss with a variable
amount of hair.
Chocolate skull is normal and cephalic; there is no presence of nodules and masses, no
Eyes and Vision:
Ears
Chocolate’s ears (auricles) are symmetrical in size. His pinna recoils after it is folded,

tender and no lesions. Air moves freely as the client breathes through the opposite nares.
Mouth and Throat:
Chocolate has symmetrical lips, able to purse lips. No sore throat. No sign of gum
Chocolate has proper neck contour. There is no difficulty with neck mobility and
Chest and Thorax:

noted on anterior thorax. He has a regular heart beat pattern.
Abdomen:
deformities and no pain felt. The client’s gait and balance is stable.
Age: 9 mos/o
Weight: 13 kg
Height: 0.75 m
FNRI: Normal
According to Mrs. Caramel, Chocolate didn’t experience diseases that require

hospitalization. He only experience fever, cough and colds. For fever, he takes paracetamol and
if the fever is not gone after three days, they will immediately consult to the doctor.
Chocolate usually wakes up at around 9 in the morning. He takes his breakfast after waking up.
Then he likes watching tv and playing with his cousins. He also takes his nap during the
afternoon 3 hours approximately. He usually sleeps at 10 in the evening.
IV. Socioeconomic, cultural, and environmental

assessment
Ice cream family belongs to the extended type of family wherein two sets of family are
living together. The first set of family is composed of Daddy Ube and Mommy Strawberry living
together with their children Buko Pandan, Rocky road, Mocha, Pistachio, Vanilla, and Mango
while the second set of family is represented by: Daddy Double Dutch and Mommy Caramel,
also living together with their children namely Cookies and Cream, Coffee Crumble and
Chocolate (taking into consideration that Daddy Ube and Daddy Double Dutch are brothers).
The family members were close with each other and they have harmonious relationship with
each other. With regards to decision making, both daddies and mommies decide on what to do.
Both couple shared the responsibility of taking care of their children. In terms of health care, the
two daddies make most of the decisions. Both of them, makes sure that in every decision they
make, it would benefit the whole family and at the same time, it would be for the best interest of
all the family members.
As of now, both daddies are the breadwinner of the family. Daddy Ube works as a soft
drink dealer and earns 300php per day making it 9,300php per month. While Daddy Double
Dutch works as a maintenance In PAG-IBIG and earns 300php per day making it 9,300php per
month. The family’s income is allotted mainly for food, electric bill and other basic expenses.
Breakdown of expenses are the following:
Apartment 2,000php/month
Food 9,300php/month
Toiletries 600php/month
Electric Bills 800php/month
Other basic expenses such as: baon of the 4,650php/month
children
Total expenses: P 17, 350.00
According to NEDA, each member of the family must be allotted at least

P2,768.60/individual in order to consider the family having sufficient income.
Ice cream family is considered poor since each member is allotted for only
P1,430.77/individual compared to the standard. In order for the family to meet the standard
income for each member, the family should need to have an income of at least
P36,000.00/month.
Ice cream’s family income is just enough for their basic needs. The family usually does
not have savings in case of emergency and often they borrow money from their relatives
specifically, the mother of Mommy Strawberry.
Daddy Ube and Daddy Double Dutch work from 8am – 5pm. Mommy Strawberry and
Mommy Caramel stays at home to look after their children.
Tracing their ethnical background, Daddy Ube and Daddy Double Dutch is a native from
Pampanga. On the other hand, Mommy Strawberry grew up in City of San Fernando,
Pampanga while Mommy Caramel is a native from Nueva Ecija. Both couple got married and
reside first to the mother of Daddy Ube and Daddy Double Dutch. They resided at Barangay
Lourdes Sur East in Angeles City at the year 1999. The family is affiliated to Roman Catholic.
The family attends the mass every Sunday.
According to Mommy Strawberry, her mother helps them with their financial needs and
in case of emergency, she is also the one who helps them.
The Ice Cream family avails the services of the health center. The family practices self
medication like the use of paracetamol when one of the members has a fever. They usually use
herbal medicines such as calamansi juice for cough and colds. They also believe in herbolarios.
According to Mommy Strawberry and Mommy Caramel, they do not believe that it is not
advisable to take a bath during menstruation or even eating sour foods.
According to Mommy Caramel, they are aware with the community activities but they do
not have time to involve themselves with the activities. The family utilizes the community
resources like the nearest elementary school in their barangay wherein Mocha, Pistachio, and
Coffee Crumble are currently enrolled.
The Ice Cream family lives at Barangay Lourdes Sur East, Angeles City. The family’s
house is a combination of cement blocks and woods; therefore, it is categorized as concrete-
wood (mixed) which measures 4.5m length, 2.0m in width and 2.50m in height. The house
where they live in has two stories with two rooms on the 2nd floor. The 2 families occupy each
room. In addition to this, there is also room on the first floor but they use this room as a bodega.
Both family only sleep on the floor. Based from the National Building Code of the Philippines
( 2005 ), one can determine the adequacy of living space of a certain house by getting the total
floor area plus the height which is the estimated length times the width times the height of the
house and then getting the total space requirement of the family.
Total living space area = L x W x H
= 4.5 x 2.0 x 2.50
= 22.50 cubic meters
Impression: inadequate living space ( 1.73 cubic meters per family member )
Their living space according to the data that were gathered by the student nurses is
inadequate as supported by the National Building Code of the Philippines which mention that an
area of 14 cubic meters should be allotted per family member.
The family’s source of lighting is electricity. They only utilize one light bulb with 25 watts.
Based on the information, the family’s lighting at night is considered as inadequate since the
accepted measurement is 20-40 watts per fluorescent bulbs and 50 watts for incandescent
bulbs. Though the light bulb they use is a 25-watt bulb, still it is not sufficient enough to light the
whole house. During daytime, there is poor lighting because of the size of the window.
According to Daddy Ube, there are insects like house flies and rodents in their house
such as rats and cockroaches. When it comes to their furniture, they have one table, six mono
block chairs, and a cabinet. They also have television and radio. Since they have poor lighting,
risk for accident inside the house may occur. The family uses physical method in killing the
cockroach.
Accident hazards were also observed during the home visits. The family uses stove as a
means of cooking their food which is within the reach of children. Utensils are also within the
reach of the children. With regards to their sleeping arrangement, all of the family members
sleep together in the floor so there is a high risk of spreading infection and diseases if one of the
family member is sick. In the first story, there is only one window which measures 1.09m x
1.12m. on the 2nd story, there are four windows which measure 1.10m x 1.07m. the ventilation in
the first story is considered to be inadequate. As stated in the COPAR, to determine if the
ventilation is adequate, the following computations should be done:
1. compute for the area of the window/s
Window: 1.09 x 1.12 = 1.22 square meters (first story)
1.10x 1.07 = 1.18 square meters (second story)
2. apply the formula: ventilation = total window opening / total floor area x 100
= 1.22/9 x 100
= 13.56 %
3. Consider the following critera:
 > 20 % = satisfactory
 19 – 18 % = fair
 <18 % = poor
Impression: poor
When it comes to their food source, Daddy Ube and Daddy Double Dutch tends to buy
their food in the market. Sometimes, the family just buys cooked viand from the nearby
carinderia. Most of the time, the family uses stove as means of cooking their food. They store in
a plate or casserole and cover it. Usually, there is no left over foods because they only buy
which is enough for the whole family. If there is left over foods, they cover it with plates.
The family’s water supply is coming from the faucet. With their drinking water, the family
avails NAWASA’s services.
The family has own toilet facilities. According to Mommy Caramel, it is a toilet facility
water carriage that can be manually flushed.
With their drainage system, the family has an open type drainage system. The condition
of their drainage system is flowing and does not have any foul odor. In addition to this, Daddy
Double Dutch makes it a point to always clean this open drainage system to prevent the
breeding sites for mosquitoes.
The family has complete access to the social and health facilities near their residence.
There is a church near the house, a public school, a basketball court, and a health center which
are just few steps away.
The family speaks the national language Filipino and Kapampangan dialect. The family
has no telephone (or landline) but they have cellular phones for their communication. Their
means of transportation is by riding public jeepneys and tricycles.
Problem Identification
List of Problems Score

Problem1. Presence of colds and cough 5
Problem2: lack of food storage 4.17
Problem3: Presence of Breeding sites 3.84
Problem4: Inadequate family resources 3.17
beyond family can adequately give
Problem5: inadequate living space 2.5
Problem6: poor personal hygiene 2.34
Problem7: poor ventilation 2
Problem8: poor lighting during daytime 2
Problem9: presence of fire hazards 2
Problem no. 1: presence of cough and colds as a health threat
CRITERIA COMPUTATION SCORE JUSTIFICATION
NATURE OF THE
PROBLEM
Health Deficit It is a health deficit because cough

and colds should not be present on
a healthy individual. Cough occurs
3/3x1 1
Health Threat in many of the acute infectious
diseases, including the common
cold (viral infection).
Foreseeable
The problem is easily modifiable
MODIFIABILITY OF THE
PROBLEM
• The family knows that the
Easily Modifiable presence of cough and
colds is a problem as
evidenced by the mother’s
verbalization of “Sisipun
Partially Modifiable ampo manguku I Rocky
Road and Mocha”
Not modifiable • The family has the means

to eradicate the problem
such as: knowledge on how
Current to deal with cough and
knowledge, √ colds, which includes
technology, 2/2x2 2 increasing fluid intake.
and
interventions
to manage the • Health teachings provided
problem such as the importance of
Resources of early management of cough
the family √ and colds and consultation
-physical, to the health center. The
financial, student nurses also
manpower emphasized the importance
Resources of of continuing an increase in
the nurse √ fluid intake to help manage
-knowledge, the condition.
skills, time
Community √ • The health center is

Resources available for check up and
gives free medicines for
cough and colds.
PREVENTIVE 3/3x1 1 The problem has a moderate
POTENTIAL preventive potential
High
• The gravity of the problem

Moderate is low because only Rocky
Road and Mocha has
cough and colds. They
have not also manifested
Low an alteration in breathing
pattern respiratory effort.
Gravity or √
severity of the • Mrs, Strawberry increased
problem Rocky Road and Mocha’s
water intake.
Duration of √
the problem
• All the family members are
Current √ at risk of having cough and
Management colds because they have
direct contact with Chestnut
Exposure of √ and Rice cake everyday.
any high risk
group
SALIENCE
A serious problem.
Attention needed.
The family considered it as a
problem needing immediate
attention as evidenced by early
2/2x1 1
A problem but not management of the condition such
needing immediate as increasing Rocky Road and
attention. Mocha’s water intake.
Not a problem
Total 5
Problem no. 2: Poor home environment specifically lack of food storage

COMPUTATION SCORE JUSTIFICATION
CRITERIA
NATURE OF THE It is a health threat since
PROBLEM leftover food especially those
uncovered can be
contaminated w/
Health Deficit
microorganisms that can bring
disease to the family esp. to
children
Health Threat 2/3x1 0.67
Foreseeable
MODIFIABILITY OF THE In terms of modifiability of the

PROBLEM problem it is considered as
easily modifiable
Easily Modifiable
• Current knowledge: The

family has current
Partially Modifiable knowledge about the
problem and their doing
their best to somehow
2/2x2 2 prevent problems that may
Not modifiable
arise from it.
Current • Resources of the family

knowledge, √ such as manpower
technology,
and
interventions to • Resources of the student-
manage the nurse: knowledge, skills and
problem attitude through health
Resources of teachings.
the family √
-physical,
financial, • Community resources: not
manpower available
Resources of
the nurse √
-knowledge,
skills, time
Community x
Resources
PREVENTIVE Inadequate food storage

POTENTIAL facility is classified under
moderate preventive potential
High
Problem no. 3 : Poor Environmental Sanitation specifically presence of breeding places
of Insects.
NATURE OF THE
PROBLEM
It is a health threat because

Health Deficit it can cause insect bites and
infection to the family. One of
the most common diseases
2/3x1 0.67
Health Threat caused by an insect bite if
dengue hemorrhagic fever
brought by the aedes aegypti
mosquito.
Foreseeable
MODIFIABILITY OF THE 2/2x2 2 The problem is easily

PROBLEM modifiable
Easily Modifiable
• The family knows that

the presence of these
Partially Modifiable breeding places is a
problem as
evidenced by the
Mrs. Strawberry
Not modifiable verbalization of “Ating
marakal lamok king
bale mi.”
Current
knowledge, √
technology, • The family has the
and means to eradicate
interventions to the problem such as
manage the cleaning materials to
problem aide in eliminating the
Resources of breeding places of
the family √ insects.
-physical,
financial,
manpower • Health teachings
Resources of provided such as
the nurse √ frequent cleaning of
-knowledge, the house and canal
skills, time and to rearrange the
furniture of the house
Community √ to eliminate breeding
Resources places of insects.
• The community has

fumigation services to
help eliminate the
breeding places of
insects.
PREVENTIVE 2/3x1 0.67 The problem has a moderate
High
• The gravity of the

Moderate problem is low
because the insects
are few in number
and there is no
Low history of disease
occurred in the family
related to insect bite.
Gravity or x
severity of the
problem • The problem has
existed before the
Duration of the √ student nurses’ home
problem visits.
Current √
Management • The family utilizes
manual killing of
Exposure of √ insects and
any high risk frequently cleans
group their house and
canal.
• All the family
members are at risk
for insect.
SALIENCE
A serious problem.
The family considered it as a
Attention needed.
problem needing immediate
attention as evidenced by
utilizing ways to eliminate the
2/2x1 0.5
A problem but not insects such as manual
needing immediate killing of insects and frequent
attention. cleaning of the house and
canal.
Not a problem
Total 3.84
Problem no. 4: Family resources beyond family can adequately give as a health threat
CRITERIA COMPUTATIONSCORE JUSTIFICATION

NATURE OF THE The problem is a health threat
PROBLEM because the family doesn’t have
the money allotted to medical
expenses in case any of the
Health Deficit
members get sick. Food is also
limited since the family has a low
income and they have to divide it to
Health Threat their other expenses.
2/3x1 0.67
Foreseeable
MODIFIABILITY OF THE The problem is considered partially
PROBLEM modifiable.
Easily Modifiable
• Current knowledge: the family
has knowledge about the
problem but they can’t do
Partially Modifiable anything about it since both
parents don’t have work and the
only breadwinner is Macaroni.
Not modifiable 1/2x2 1
• Family resources: inadequate,
considering the fact that the only
Macaroni serves as the family’s
Current
breadwinner
knowledge, √
technology,
and
• Resources of the student
interventions to
nurses: they can help the family
manage the
on proper budgeting and assist
problem
them in understanding the
Resources of
importance of medical
the family √
management.
-physical,
financial,
manpower
• Community resources are
Resources of
available but the family doesn’t
the nurse √
make use of it, as they seldom
-knowledge,
go to the health center.
skills, time
Community x
•
Resources
PREVENTIVE The problem is moderately
POTENTIAL preventive
High
• Severity: it is not severe since
the family could still cope and
could adequately provide other
Moderate family needs
2/3x1 0.67
• Duration: The problem has
Low existing for long time now
• Current management: the
Gravity or √ problem can be solved through
severity of the proper budgeting and
problem prioritization of needs. The
family resources and skills to
Duration of the x solve the problem are limited.
problem • Exposure: There is presence of
high risk group since medical
Current x needs are not properly provided.
Management
Exposure of √
any high risk
group
The family considers it as problem

SALIENCE
but they feel that they cannot do
much about it especially now that
only Macaroni earns for the family.
A serious problem.
Attention needed.
1/2x1 0.5
A problem but not needing

immediate attention.
Not a problem
TOTAL= 3.17
Problem no. 5: Poor home condition specifically ventilation

NATURE OF THE
PROBLEM It is a health threat because
inadequate ventilation means
there is inadequate exchange
Health Deficit of air. It can be detrimental
especially if a communicable
2/3 x 1 0.67 disease is present resulting to
Health Threat the bacteria staying in the
house.
Foreseeable Crisis
The problem is partially

modifiable
• Current knowledge: The

MODIFIABILITY OF THE family recognizes the
PROBLEM problem since they can feel
1/2x2 1 the hotness when inside
the house.
Easily Modifiable
• Family resources: the
family doesn’t have enough
resources since they have
Partially Modifiable financial constraints.
Not Modifiable • Resources of the student-

nurse- The group can
provide health teachings to
allow adequate surrounding
Current air to move freely inside the
knowledge, √ house, such as-
technology, rearranging the furniture,
and and other household stuff,
interventions to and opening the window
manage the everyday.
problem
Resources of
the family x • Community resources:
-physical, There is no facility in the
financial, community that could help
manpower with the problem.
Resources of
the nurse √
-knowledge,
skills, time
Community x
Resources
PREVENTIVE The problem has a low

High
• Severity: the problem is
severe since the
windows are small and
Moderate because of the location
of the house.
1/3x1 0.33
Low • Duration: The problem

has been existed for long
time now
Gravity or x • Current management:

severity of the the family is doing
problem nothing about it since
they can’t modify the
Duration of the x window structure in the
problem first place
Current x
Management • Exposure: They are
prone to acquire airborne
diseases, cross-
Exposure of √
contamination or there is
any high risk
spread of diseases.
group
SALIENCE
A serious problem. 1/2x1 0.5 The family recognizes the

Attention Needed problem but is not giving it
attention because of financial
constraints and lack of time to
perform action to alleviate the
A problem but not needing problem.
immediate attention
Not a problem
TOTAL 2.5
Problem no. 6: Unhealthful lifestyle and personal habits specifically poor personal
hygiene

NATURE OF THE 2/3x1 0.67 The problem is considered as a
PROBLEM health threat because failure to
maintain cleanliness through
good personal hygiene will
Health Deficit
predispose the family to
acquiring diseases and will
facilitate easy spread of
Health Threat infection to all the members of
the family.
Foreseeable
MODIFIABILITY OF THE 1/2x2 1 The problem is partially

PROBLEM modifiable.
Easily Modifiable • The family is not really

aware of the problem.
• The family has

Partially Modifiable resources such as nail
cutter, soap, toothbrush,
and tooth paste which
are essential in
Not modifiable
maintaining good
hygiene.
Current
knowledge, x • The student nurses
technology, provided health
and teachings about the
interventions to importance of
manage the maintaining proper
problem hygiene.
Resources of
the family √ • The community doesn’t
-physical, have the facilities or
financial, organization regarding
manpower this problem.
Resources of
the nurse √
-knowledge,
skills, time
Community x
Resources
PREVENTIVE POTENTIAL 2/3 X 1 0.67 The problem preventive
High potential is moderate.
Moderate • The problem is not

categorized as severe
since the health of the
family has not been
Low affected yet with any
illness by the problem.
Gravity or √
severity of the • The problem is already
problem experienced for an
extended period of time.
Duration of the x
problem
• No interventions are
Current x acted by the family
Management since they still have
untrimmed and untidy
Exposure of √ fingernails and toenails.
any high risk
group
• A high risk group is
exposed since improper
hygiene would facilitate
faster transmission of
microorganism from one
member to another.
SALIENCE
0/2x1 0 The problem is not recognized
by the family as a problem and
as of now, no interventions are
A serious problem. done.
Attention needed.
A problem but not

needing immediate
attention.
Not a problem
TOTAL 2.34
Problem no. 7 : Poor home condition specifically poor lighting during daytime

NATURE OF THE It is a health threat because having
PROBLEM inadequate lighting during the day
can alter some activities that can
be done. Objects that may harm
Health Deficit
the family such as pointed objects
are not well seen and can cause
injury.
Health Threat 2/3 x 1 0.67
Foreseeable
MODIFIABILITY OF THE It is partially modifiable

PROBLEM
Easily Modifiable • Current knowledge: The

knowledge and interventions in
order to keep adequate lighting
during the day is not attainable
Partially Modifiable by the family because they do
not do anything to have an
1/2 x 2 1 adequate lighting during the day.
• Family resources: like
Not modifiable physical and manpower
resources are attainable by the
family.
• Resources of the nurse:
Current
The student nurses provided
knowledge, x
health teachings on the
technology,
importance of lighting in the
and
performance of some activities.
interventions to
manage the • Community resources: The
problem community resources are not
available.
Resources of
the family √
-physical,
financial,
manpower
Resources of
the nurse √
-knowledge,
skills, time
Community x
Resources
PREVENTIVE It is low preventive potential
POTENTIAL
High • Severity: the severity of the

problem can threaten the health
of the family because of the
pointed objects that are not well
Moderate 1/3 x 1 0.33 seen.
• Duration: the family experienced
the problem for the long time
now. They got used to having
Low inadequate light during the day.
• Current management: They do
not do anything to solve this kind
of problem.
Gravity or • Exposure: All family members
severity of the are at risk.
problem
Duration of the
problem
Current
Management
Exposure of √
any high risk
group
SALIENCE The family does not recognize this
as a problem since they don’t do
necessary actions to alleviate this
and they got used to it.
A serious problem.
Attention needed.
0/2 x 1 0
immediate attention.
Not a problem
TOTAL 2
Problem no. 8 : Accidental hazards specifically fire hazards

NATURE OF THE It is a health threat since accident
PROBLEM hazard such as cooking facilities
such as the charcoal and kerosene
are within the reach of children,
Health Deficit
which could lead to injuries.
Health Threat 2/3 x 1 0.67
Foreseeable
MODIFIABILITY OF THE It is classified under not modifiable
PROBLEM
Easily Modifiable • Current knowledge: the family

lacks knowledge about the
problem as seen by cooking
facilities within the reach of
Partially Modifiable children
• Family Resources: the family

Not modifiable 0/2 x 2 0 can’t afford to buy cooking
facility that is much safer. The
charcoal and kerosene can be
kept out of reach of children but
Current the family didn’t do so.
knowledge, x
technology,
and • Resources of the nurse: such as
interventions to knowledge, skills and time are
manage the present.
problem
Resources of
the family x • Community resources: the
-physical, community could not provide
financial, resources about the problem
manpower
Resources of
the nurse √
-knowledge,
skills, time
Community x
Resources
In terms of preventive potential, the
PREVENTIVE problem is considered as low
POTENTIAL because
• Gravity: the problem is

High moderately severe since all of
the family members can be
affected
1/3 x 1 0.33
Moderate
• Duration; the problem has long
been existing
Low
• Current management: the family

do nothing about it as seen by
cooking facility is within the
Gravity or x reach of the children
severity of the
problem
• Exposure: there is presence of
Duration of the x high risk group
problem
Current x
Management
Exposure of √
any high risk
group
SALIENCE
A serious problem.
Attention needed.

immediate attention. The family doesn’t recognize it as a
problem.
Not a problem
0/2 x 1 0
TOTAL 2

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Angeles University Foundation

Family Case Analysis

Barangay Lourdes Sur East, Angeles City

In Partial Fulfillment of the Requirements in

Related Learning Experience

For the Degree of Bachelor of Science in Nursing

Community is composed of group of families living together as one and

At the end of 1-2 home visits, the group shall have:

 Familiarized themselves from the physical setting of their

 Chosen a family that would fit into the criteria of FCA

 Introduced their selves to the adopted family

 Established rapport with the family

 Observed the general conditions and identified problems of

 Explained the importance of having home visits

 Informed the family about the different programs offered by

 Acquired important information about the family (eg., history

 Conducted physical assessment for the family

At the end of 3-5 home visits, the group shall have:

 Provided different health teachings that could help the family

 Prioritized health and health-related problems identified

 Formulated family nursing care plans that is well suited for

 Encouraged the family to put in to practice what they have

 Encouraged the family to participate in the promotion and

 Evaluated the interventions done for the family and the

At the end of 1-2 home visits, the family shall have:

 Been familiarized with the members of the group

 Established rapport with the group

 Identified problems present within their family with the help

 Understood the importance of having home visits

 Provided important information about their family

 Understood the programs offered in the barangay health

 Participated in the physical assessment conducted by the

 Gained knowledge on how to recognize and meet the family’

 Understood and have complied to the health teaching

 Participated in the prioritization of problems with the group

 Carried out appropriate actions for the problems as a result

 Developed and maintained a home environment that would

 Utilized available resources in the community to promote

 Identified factors that affect the development of health and

 Introduced appropriate health teachings and interventions to

 Imparted knowledge to the family that would make them

Entry, Climate of acceptance, First few words, Number of home visits

First home visit

June 23, 2009 (Tuesday): 8:30 am to 11:00 am

June 30, 2009 (Tuesday): 9:00 am to 11:00 am

Third Home Visit

July 7, 2009 ( Tuesday) 8:30 am to 12:00 pm

 Presence of cough and colds

July 14, 2009 (Tuesday) 8:30 am to 12:00 pm

Fifth home visit

July 21, 2009 (Tuesday) 8:00 am to 12:00 pm

II. FAMILY CONSTELLATION

NAME AGE POSITION SEX EDUCATIONA PRESENT HEALTH

Mr. Ube was seen

Vital Signs as follows:

Vital Signs as follows:

Vital Signs as follows:

Vital Signs as follows:

Pistachio 8 years old Third Male Going to Pistachio was seen

Vital Signs as follows:

Vanilla 5 years old Second Female Going to Vanilla was seen

Vital Signs as follows: