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I. INTRODUCTION

To put the world right in order, we must first put the nation in order; to put the nation in

order, we must first put the family in order; to put the

family in order, we must first cultivate our personal life;

we must first set our hearts right.

- Confucius

The first steping stone in order for people to develop into the next level it is

necessary to create a more peaceful and unified society, each individual must

understand his own capabilities ofhaving motivation to share goodly with other people in

order tap into their core of potential and achieve a level of self-realization and

improvement, which is the ultimate key to creating a better community. These works and

ways will now be a bigger and greater leap as a group. Then, with a small group, you

can create a bigger one, an organization, a league, a society and community, a nation,

and a world. Every member of this team must work hand in hand with one another and

let others realize their own abilities of changing the world for the better. It may be a

simple start yet a unified one. A small step yet deeper. This goes with any precious and

crucial events in life, such is health. Healthy family come up with a healthy community

and healthy community builds a healthy nation and a healthy nation is the world that

everyone dreams of.

No two communities are alike. A nurse exposed in the community learns how

to interact and adapt to different kinds of people. The family is considered as the basic

unit of care in community health nursing. It is in the family where a member develops

his health values, beliefs and practices. It is a major influence in the health behaviors

of an individual. With this, it is important that families in a community are aware of the

things and practices pertaining to theirhealth.

A community is defined as a social group of people interacting with each other,

determined by geographic boundaries, living together to attain certain and commongoals, sharing the same interest, belief, intent, resources and preference. It is a group of

families sharing others lives and resources through collaboration, cooperation and

intense participation to stand and be of aid to all persons living in it. Together, with these

persons, the health care team is in one with the mission and purpose of improving and

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enhancing ones health throughhealth promotion, disease prevention, and treatment o

provide all their needs and concerns regarding health matters.

Community Health Nursing (CHN) is a synthesis of nursing practice and public

health practice applied to promoting and preserving the health of populations. The

nature of this practice is general and comprehensive. It is not limited to a particular age

or diagnostic group. It is not continuing, not episodic. The dominant responsibility is to

the population as a whole. Therefore, nursing directed to individuals, families or groups

contributes to the health of the total population. Health promotion, health maintenance,

health education, coordination, and continuity of care are utilized in a holistic approach

to the family, group and community. The nurses actions acknowledge the need for

comprehensive health planning recognize the influences of social and ecological issues,

give attention population at risk, and utilize the dynamic forces which influence change.

(Benson and McDevitt, 1980).

The focus of community health nursing is more on health promotion and is

extended to benefit not only the individual but the whole family as mentioned and

community. Since health promotion is the primary focus in community health nursing;

nurses turn out to be educator by imparting health teachings to the family. It also help

communities and families to cope with the discontinuities in health and threats in such a

way as to maximize their potential for high level wellness, as well as to promote

reciprocally supportive relationship between people and their physical and social

environment.

According to Maglaya (2004), the family is defined as the unit of the society

which sets up the most basic values since it is where an individual first attaches and

where he learns to love. It is a very important social institution which performs two major

functions, reproduction and socialization. It is generally considered as a basic unit of

community health nursing in a way that the family is the most basic group that builds up

the community and in initiating a health changing action, the nurses must find their way

first in promoting the family.

According to National Statistical Coordination Board (NSCB) of 2009, about 47

percent of the household heads interviewed representative of about 8.7 million families

considered themselves poor. Twenty six percent said that they were not poor, and 27

percent considered themselves on the borderline (Philippine Daily Inquirer, 2009).

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Family case analysis is a means by which student nurses feel the pulse of the

community through its basic structure, the family. It is a way of assessing persons within

a family and plan for individualized care for each. The nursing process which includes

assessment, diagnosis, planning, implementation and evaluation are important factors

for the student nurses to accomplish the FCAs goals which are geared towards the

familys optimum level of functioning in order for them to be productive and self-reliant

members of the society in which they belong. In this way and approach, student nurses

would help the community in general to further enhance theirhealth condition and raise

standards on health. And by the end of their exposure they have touched other peoples

lives and have shared what they have to them.

Prior to these, the group must be proficient to choose an assigned family for the

case analysis. Some standards must be considered before selecting a family. These

include: (a) a deprived family, (b) a family with four or more children, with at least 1 or 2

belonging to the 0 to 5 age bracket, (c) a family with visible poor environmental condition

and (d) a family that gives permission to be taken as a case for the FCA project.

The criteria mentioned were eventually met by the group and adopted a family at

the Balibago, Pampanga. The family consists of six members including the mother

together withher four children and their grandmother. With this, the group decided to

use a pseudo name to respect the confidentiality and identity of each family member.

The groups adopted family is named as the Fantacia Family . The home visits

conducted by the group started from September 6, 2010 up to September 14, 2010,

utilizing two days each week, therefore having a total of fourhome visits.

The student nurses are challenged to take part in providing quality, appropriate

nursing care. The student nurses must be able to be the familys partner in promoting

and maintaining health. The goal of this study is to help the family achieve competence

in health maintenance and in managing health crisis through acquisition of knowledge

from the student nurses. The goal is not only centered in the family, but also in the

student nurses as it aims to enrich and broaden their knowledge by providing an actual

and hands-on experience in family health care.

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Family-centered

i. Short Term

After 1-2 days of home visits, the family should have:

y Established a good relationship with the student.

y Demonstrated approval in conducting home visits.

y Gained trust and confidence with the student nurses.

y Verbalized understanding regarding the purpose of home visits and the

succeeding activities necessary to accomplish the Family Case Analysis.

y Show cooperation in giving necessary information regarding their demographic,

socio-economic ad health status.

y Expressed different problems that they encounter.

y Gained the necessary knowledge as they interrelate with student nurses.y Determined their present and potential health needs of the family.

y Understood health teachings regarding identified problems and needs.

ii. Long Term

After 3-5 home visits, the family should have:

y Verbalized understanding of the rationale behind each intervention that the

student nurses have planned to intervene.

y Participated in the implementation phase of nursing intervention the family

members and student nurses decided to worked on

y Carried out planned interventions

y Recognized the importance of good sanitary environment to the promotion and

maintenance ofhealth and prevention of illness.

y Developed awareness regarding health seeking behaviors and how they promote

and maintain health.

y Verbalized understanding of the health teachings imparted to them.

y Appreciated and practiced the various nursing measures taught to them by the

student nurse like intake of inexpensive but nutrition foods, good personal

hygiene, etc.

y Performed suitable actions toward health problems in response to the nursing

interventions rendered.

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Research-Centered

Specifically, the Family Case Analysis will aim to answer the following

1. How may the physical profile of the family be described as to:

a. Type of family

b. Composition of family

2. How may the profile of the family members described as to:

a. Age

b. Sex

c.O

rdinal position

d. Educational attainment

e. Present health status

3. How may the health profile of the family be assessed:

a. Physical status

b. History of past and present health illness

c. Activities of daily living

d. Nutritional status

4. How may the growth and development of children be assessed:

a. Eric Ericksons Concept

b. Sigmund Freuds Concept

5. How may be the obstetrical history of the mother been described?

6. How may the family be assessed as to:

a. Socio-economic status

b. Cultural status

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c. Environmental sanitation

7. How may the health problems be prioritized?

8. How may the significance of the following factors to the health status of the family

be described?

a. Physical profile of the family

b. Profile of the members

c. Health profile of the members

d. Growth and development of the children under 6 years of age

e.Immunization status of t

he infant

9. How may the family nursing care plan of the family based on the analysis of data

collected be described?

10. How may the plans made with the family be implemented?

11. How may the effectiveness of the plan be implemented?

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A. Entry, Climate of Acceptance and First Few Words

On September 6, 2010, a group of 10 student nurses were tasked to have

a duty in Balibago Health Center. It was their first exposure with the families in the

community. They made rounds to the community where they are assigned to and to look

for a family who will qualify to the criteria that was instructed to them. It was not easy to

find a family especially in a place which they are not familiar with.

On their first day in the community, they had an orientation about their

requirements and tasks that they will have to accomplish within 4 weeks and the student

nurses were given the chance to look for a family to be adopted for the Family Case

Analysis (FCA) at around 10:00 in the morning .

The family that the group has chosen was very accommodating and welcoming.

The group had chosen this family because the family is deprived with monetary

resources, knowledge about health care. The family speaks Tagalog, which is their

dialect, and they conversed with the group with ease and confidence.

As the group entered the house, MotherYuna guided them to theirhouse. She

preparing their food for their lunch and their children were playing when the student

nurses arrived. They greeted MotherYuna and Grandma Tifa, Magandang umaga po

(GoodMorning)while carrying smiles in their faces and the mother replied, Magandang

umaga din (GoodMorning), tuloy kayo (come in). With those words, the group saw the

humility of the family and its ability to welcome visitors; therefore, the group showed

respect to the mother and to theirhouse. The group introduced themselves, and said

their purpose.

There are three student nurses assigned to the Fantacia Family. One of which

stayed inside the house to assess the house condition while the other two stayed

outside to assess the families and for data gathering. The children were unresponsive at

first because they still do not have trust with the student nurses. However, the mother

was very comfortable with the presence of the other student nurses making it easy for

the exchange of information.

The group stayed at familys house for about 3 hours. They told the mother that

they will be visiting again in the following week hoping for the cooperation of the whole

mother especially their children.

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II. FAMILY CONSTELLATION: The Fantacia Family

A family constellation is attached in a Family Case Analysis and is presented to contain

and provide a view of the crucial information that needs to be highlighted for the convenience of

the critics. This data takes hold of the respective names of the family members which are to be

kept of great confidentiality and are to be substituted by pseudonyms. Their respective ages,

positions in the family, sexes, educational status and present health status will also be reflected

on this report. Moreover, this file carefully examined to provide an overview or a brief summary

of what is to be expected from the outcome of the entire Family Case Analysis.

Name: Tifa

Age: 81 years old

Position in the Family: Grandmother

Gender: Female

Educational Status: Grade 6 (not going toschool)

Present Health Status: During the

assessment at Day 1, Tifa was seen smoking;

however she immediately threw her cigarette

upon seeing the student nurses. She wears a

white shirt and dark blue pants. She has

wrinkles on her cheeks and fore head. She has

been noticed coughing. She consumes half

pack of cigarette every day. She has dirty

finger nails and toe nails. She has a short,

black and white, soft hair and slightly oily.

She was unable to read a print 14 inches

apart. She was unable to hearthe whispered

words. The lips have symmetrical contour, no

pallor noted but dark in colorand smooth and

has the ability to purse lips. She has dentures.

Her tongue is dry.

Vital signs:

T: 36.3C/axilla

P: 86 bpm

R: 22 cpm

BP: 130/90 mm Hg

Nutritional status:

Wt: 37 kg

HT: 1.57 m

BMI: 15.04 kg/m2

(underweight)

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Name: Yuna

Age: 42 years old

Position in the Family: Mother

Gender: Female

Educational Status: Grade 6 (not going toschool)

Present Health Status: During the

assessment at Day 1, Mother Yuna was

wearing white sando and khaki shorts. She

was carrying Tidus when the student nurses

arrived. She looks tired because she just

finished their laundry. She has a slouched

posture, skinny, has fair complexion and was

noted to have untrimmed finger and toe nails

as well as presence of pediculosis with

untidy appearance. Her teeth are yellow in

color and there is presence of tooth decay

and halitosis. There is noticed presence of

dry lesions and rashes on her upper limb.

Vital signs:

T: 36.5C/axilla

P: 85 bpm

R: 21 cpm

BP: 100/70 mm Hg

Nutritional status:

Wt: 35 kg

HT: 1.5 m

BMI:15.56kg/m2

(underweight)

Name: Zidhaine

Age: 13 years old

Position in the Family: Third child

Gender:Male

Educational Status: Grade 3 (going to school)

Present Health Status: Seen on the 2nd day

of home visit (Sept 7, 2010) wearing striped

shirt, blue shorts and with slippers on. He has a

fair complexion. He has no missing tooth but

has tooth decays. He has 4 tooth decays: 2

on his right mandible, 2 on his right

maxillary. He has dirty and long nails on hisfeet and hands. His feet are also notably

dirty.

Vital signs:

T: 36.9C/axilla

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P: 88 bpm

R: 18 cpm

Nutritional status:

Wt: 36 kg

Ht: 1.49 m

BMI: 16.22 kg/m2

(underweight)

Name: Cloud

Age: 10 years old

Position in the Family: Fourth child

Gender:Male


Present Health Status: During the first home

visit, he was wearing white t-shirt with black

pants. He has a fair complexion. Have long

and dirty fingernails. He had a presence of

clear nasal discharge was noted. He has

coughs and colds; with obstructed nasalairway passage. Has a dental decay.

Vital signs:

Temperature: 36.8oC / axilla

Pulse Rate: 82 bpm

Respiratory Rate: 21 cpm

Nutritional status:

Weight: 25 kg

Height: 42 (1.28 m)

BMI: 15.26 kg/m2

(Underweight)Name:Aerith

Age: 8 years old

Position in the Family: Fifth child

Gender: Female


Seen on the first day of home visit (Sept 6,

2010) wearing orange shirt and black shorts.

She has short, slightly curly hair. Fair

complexion. She has tooth decay on her

frontal incisors. 1 missing tooth and 6 dental

carries. She showed loss of appetite,

untrimmed nails, scars in the legs, withinfestation of hair.She has long fingernails.

She has dirty feet and nails. She has been

coughing for one week on the first day of

home visit.

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Vital signs:

T: 36.5C/axilla

P: 89 bpm

R: 21 cpm

Nutritional status:

Wt: 19 kg

Ht: 1.19 m

BMI: 13.48 kg/m2

(underweight)

Name: Tidus

Age: 2 years old

Position in the Family: Youngest child

Gender:Male

Educational Status: Not going to school

Present Health Status: During the first home

visit, he was wearing sando only. He has long

and dirty fingernails. He had a presence of

clear nasal discharge was noted. He has

also coughs and colds; with obstructed

nasal airway passage. Has a dental decay

and missing teeth.

Vital signs:

Temperature: 36.3oC / axilla

Pulse Rate: 92 bpm

Respiratory Rate: 26 cpm

Nutritional status:

Weight: 10 kg

Height: 29 (0.88 m)

FNRI Weight Classification: Underweight

The other two eldest children were not seen during the visits because according

to the mother, they dont live with them and they both have their own families.

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III.HEALTH ASSESSMENT

MRS. TIFA

(Grandmother)

(Initial home visit: September 6, 2010)

APPEARANCE AND MENTAL STATUS

Mrs. Tifa is 70 years old. She has a short, black and white, soft hair and slightly

oily. She was wearing a white shirt, dark blue pajama pants and rubber slippers. Her skin is

smooth, brown complexion, sweaty and wrinkled skin. Herfingernails and toenails are

untrimmed. Upon interview, she is oriented to time, date, place and person and coherent in

answering questions. Herheight is 154 cm and weighs 33 kg and her initial vital signs are

T=36.3C, PR= 86 bpm, RR=22 cpm and BP= 130/90 mmHg

PHYSICAL ASSESSMENT:

SKIN: Mrs. Tifa has brown, uniform complexion with moist and wrinkled skin. There are no

lesions and wound found. The skin is smooth and warm to touch and the skin turgor is good.

NAILS:Upon inspecting the nails, fingernails are untrimmed. Her nails were pink in color and

smooth in texture and with a capillary refill of less than 2 seconds.

HAIR: The hair is short, black and white, soft and evenly distributed with no presence of

dandruff. There is no presence of infestations.

SKULL AND FACE: Skull is round and smooth in contour without presence of nodules or

masses. The color ofher face is symmetrical to the skin. Facial features are symmetrical and

facial movements.

EYES: Eyebrows are evenly distributed and symmetrically aligned with equal movements.

Eyelashes are also equally distributed and curled slightly outward and upward. Eyelids close

symmetrically with skin intact and no discharge or discoloration. Bulbar conjunctiva is

transparent and sclera appears white. Palpebral conjunctiva is shiny, smooth and pink in color.

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Lacrimal ducts have no edema or tearing upon palpation. Cornea is transparent, shiny and

smooth with visible details of iris. Client blinks when the cornea is touched with the use of

cotton. Pupils are equally round and reactive to light and accommodation. Client can see

objects in the periphery when looking straight ahead and unable to read a print 14 inches

apart.

EARS:The color of the auricle is the same as the facial skin color, symmetrical in size and the

position of both auricles is at the level of the eye. It is elastic and the pinna recoil when folded.

There are no lesions found and no tenderness noted.

NOSE:The nose is symmetric, straight and cleardischarges found in nares. The color of the

nose is the same as the facial skin, no abnormalities of the shape can be seen. The air moves

freely when she breaths on both nares and the nasal septum is in between the nasal chambers.

There are no masses or swellings are palpated in maxillary and frontal sinuses.

MOUTH AND OROPHARYNX:The lips have symmetrical contour, no pallor noted but dark in

colorand smooth and has the ability to purse lips. She has dentures. Her tongue is dry, pink in

color, at the central position, no lesions observed and moves freely. The soft palate is light pink

and smooth while the hard palate is lighter pink. The uvula is positioned on the midline of soft

palate. The oropharynx is smooth and pink and the tonsils have no discharges.

NECK: The neck is wrinkled and the color is the same as the facial skin and no lesions seen in

the neck. There are no lymph nodes palpable. She is able to shrug her shoulder and turn her

neck against the student nurse resistance. The trachea is in the center.

THORAX AND LUNGS: Skin is evenly distributed skin color, skin intact with uniform

temperature. The chest shape and size is symmetrical and the anterior-posterior and transverse

diameter in ratio of 1:2. The lungs are full and symmetric in expansion, quiet rhythmic sound

and there is effortless respiration.

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HEART:Mrs. Tifas heart has no vibrations or pulsations are palpated on the aortic, pulmonic or

tricuspid area. There is no presence of swishing sound like murmurs. Has regular rate and

rhythm. And has identical pulse in radial and apical pulse.

ABDOMEN:There is no blemished in the skin, no pulsation, masses and no tenderness. The

skin is intact and warm to touch.

UPPER EXTREMITIES: The arm has brown complexion, no lesions or wounds found and soft

to touch. Has smooth coordinated movement. No tenderness or swelling of muscles and bones

noted. Has normal radial and brachial pulse.

> Fine Sensory Test

The touch sensation is normal. She was able to discriminate sharp and dull

sensations. She can also determine hot and cold sensations.

> Fine Motor Test

Finger to Nose Test: Can repeatedly and rhythmically touchher nose.

Supination and Pronation of the Hand: Can alternately supinate and pronate

herhands at rapid pace.

Fingers to Fingers: Can perform with accuracy and rapidity.

LOWER EXTREMITIES: The legs are warm, brown in complexion and smooth in texture. The

toenails are untrimmed, convex in curvature and the result for capillary refill is normal. The

toenails are convex in curvature. There are no lesions found in both feet. There is no presence

of contractures or deformities. The muscles have equal strength.

> Gait and Balance

The client was able to maintain balance (Walking Gait). When she was asked to

stand with feet together and arms resting at the sides, first with eyes open then closed.

Client was able to maintain upright posture and foot stance (Romberg Test).

She can also maintain heel-toe walking along a straight line.

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> Fine Motor Test

She was able to maintain bilateral equal coordination. She can also move

smoothly with coordination.

CRANIAL NERVE ASSESSMENT

CranialNerve

Type andFunction

AssessmentProcedure

ExpectedResult

ActualResult

CranialNerveNumber 1:

OlfactoryNerve

Type:SensoryFunction:Smell

The student nurseasked the patient toclose both ofher eyesand asked to identifydifferent aromas suchas perfume andvinegar.

Client will beable to identifythe differentodors presentedwith eyes closed.

The pt. was ableto identify the mildaromas correctly.


OpticNerve

Type:SensoryFunction:Vision

The student nurseasked the client toread some printedwords from a paper14 inches apart andidentify some colors.

Client will beable to read whatwas written onthe paper 14inches apart andable to seeobjects andidentify colors.

The pt. wasunable to readand identify thepicture shown toher at 14 inchesapart.


Occulomo-tor Nerve

Type:MotorFunction:Extra-ocularmovementof pupils

The client was askedto look at the straightdirection. Then withthe use of a penlight,light was focused onthe right eye and wasremoved to determineany changes on thepupil size. Sameassessment was doneto the left eye.

Pupils will reactto light andaccommodation,able to close andopen eyelids.

The pt. was ableto follow the peneasily andcorrectly. Herpupil performedconstriction anddilation. Her pupilswere round andequally reactive tolight andaccommodation.


TrochlearNerve

Type:MotorFunction:Extra-ocular

movementof eyes indownwardand inwardmovement.

The client was askedto follow the directionof the penlight in anupward and

downward movementwithout moving hishead.

The client will beable to moveeyes on anupward and

downwarddirection withoutmoving the head.

The pt. was ableto perform theocular movementswithout moving

the head.

CranialNerveNumber5:

Type: Motorand SensoryFunction:

Student nurse madeuse of a clean cottonwisp and gently

Client will beable to elicitcorneal reflex

The pt. was ableto blink aftercotton touched

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CranialNerve

Type andFunction

AssessmentProcedure

ExpectedResult

ActualResult

TrigeminalNerve

Sensation ofcornea, skinof face, and

jawmovement.

stroked client'seyelashes to elicitcorneal reflex. Also,

the student nurseasked the client toclose his eyes todetermine if the objectis sharp or dull uponintroducing to face.The nurse also askedthe client to move his

jaw from side to sideand chew.

and identify thesensation of dullor sharp objects.

The client mustbe able to closeand open, moveside to side his

jaw and makesomemastication.

her eyes; she feltthe cotton; andshe also identified

if the object issharp or blunt.She can alsomove her jaw sideto side and chew.

CranialNerve

Number 6:

AbducensNerve

Type:MotorFunction:

Extra-ocularmovementof eyes in alateralmovement

Student nurse askedthe client to follow the

direction of thepenlight in a lateralmovement.

The clients eyeswill be able to

move in lateralmovementwithout movingthe head.

The pt. was ableto move her eyes

symmetrically.


FacialNerve

Type: Motorand SensoryFunction:Movementof facialmuscles andsense oftaste on theanterior two-thirds of thetongue

Student nurse askedthe client to raise hiseyebrows, smile,frown, show teeth,and to puff out hischeeks and to identifyvarious taste on thetip of the tongue likesweet and salty.

Client will beable to raiseeyebrows, frown,smile, showteeth, puff outcheeks, andidentify varioustaste on the tip oftongue likesweet and salty.

The client wasable to raiseeyebrows, frown,smile, show teeth,puff out cheeks,and identifiedvarious taste onthe tip of tonguelike sweet andsalty.


Vestibulo-cochlear or

Acoustics

Type:SensoryFunction:Hearing andequilibrium

Student nurse placeda second-hand watchnear the ears andasked the client if hecould hear the watchtick. Then, he wasalso asked to stand

on his own for severalseconds.

The client will beable to hear theticking watch andwill be able toshow balance.

The pt. was

unable to hear

the whispered

words. She is able

to show balance.


Glossopha-ryngeal

Type: Motorand sensoryFunction:Swallowingand Gagreflex,

Student nurse askedthe client to say AH;pressed the posteriortongue with a tonguedepressor. Introducedthe vinegar to the

The client will beable to elicitupwardmovement of softpalate whenmouth is opened,

The client elicitedupward movementof soft palatewhen mouth isopened, identifiedsour taste, and

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CranialNerve

Type andFunction

AssessmentProcedure

ExpectedResult

ActualResult

pharyngealmovementand sense

of taste onthe posteriorone-thirds ofthe tongue

tongue with eyesclosed. Lastly, thestudent nurse asked

the patient to swallow.

identify sourtaste, and able toswallow.

was able toswallow.


VagusNerve

Type: Motorand SensoryFunction:Swallowingandspeaking

Student nurse askeda question, andelicited gag reflex.

The client will beable to speakwithouthoarseness, andwill elicit gagreflex.

The client spokewithouthoarseness, andelicited gag reflex.

Cranial

NerveNumber 11:

AccessoryNerve

Type:Motor

Function:Movement

of shoulderblades

Student nurse asked

th

e client to moveh

erhead from side to sideand asked to elevateher shoulders againstthe resistanceintroduced by thestudent nurse.

The client will be

able to sh

rugshoulders andmove head fromside to sideagainst appliedresistance.

The client was

able to sh

rugshoulders andmoved head fromside to sideagainst appliedresistance.


Hypoglossa

l Nerve

Type:MotorFunction:Movementand strengthof tongue

Student nurse askedthe client to movetongue from side toside and in and out.

The client will beable to protrudetongue andmove it from sideto side.

The client wasable to protrudetongue andmoved it from sideto side.

(Final home visit: September 21, 2010)


Mrs. Tifa was wearing a blue shirt with blue pants and slippers are on. Her

hair is loose, soft and equally distributed. Her skin appears sweaty, with good skin

turgor. Her nails are trimmed and clean. Upon interview, she is oriented to time, date,

place and person and is coherent in answering the question. H iernitial vital signs were

taken and recorded as follows:T=36.5 oC, PR=88bpm, RR= 24 cpm, BP=120/80 mmHg

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SKIN: Mrs. Tifa has brown, uniform complexion with moist and wrinkled skin. There are no

lesions and wound found. The skin is smooth and warm to touch and the skin turgor is good.

NAILS:Upon inspecting the nails, fingernails are trimmed. Her nails were pink in color and

smooth in texture and with a capillary refill of less than 2 seconds.

HAIR: The hair is short, black and white, soft and evenly distributed with no presence of

dandruff. There is no presence of infestations.



facial movements.








objects in the periphery when looking straight ahead and unable to read a print 14 inches

apart.




NOSE:The nose is symmetric, straight and no discharge found in nares. The color of the nose

is the same as the facial skin, no abnormalities of the shape can be seen. The air moves freely

when she breaths on both nares and the nasal septum is in between the nasal chambers. There

are no masses or swellings are palpated in maxillary and frontal sinuses.

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> Fine Motor Test

Finger to Nose Test: Can repeatedly and rhythmically touchhis nose.








> Gait and Balance





> Fine Motor Test




CranialNerve

Type andFunction

AssessmentProcedure

ExpectedResult

ActualResult


Olfactory

Nerve


The student nurseasked the patient toclose both ofher eyesand asked to identifydifferent aromas such

as perfume andvinegar.


The pt. was ableto identify the mildaromas correctly.


OpticNerve



Client will beable to read whatwas written onthe paper 14inches apart andable to see

The pt. wasunable to readand identify thepicture shown toher at 14 inchesapart.

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CranialNerve

Type andFunction

AssessmentProcedure

ExpectedResult

ActualResult

objects andidentify colors.

Cranial

NerveNumber 3:

Occulomo-tor Nerve

Type:Motor

Function:Extra-ocularmovementof pupils

The client was asked

to look at the straightdirection. Then withthe use of a penlight,light was focused onthe right eye and wasremoved to determineany changes on thepupil size. Sameassessment was doneto the left eye.

Pupils will react

to light andaccommodation,able to close andopen eyelids.

The pt. was able

to follow the peneasily andcorrectly. Herpupil performedconstriction anddilation. Her pupilswere round andequally reactive tolight andaccommodation.

Cranial

NerveNumber 4:

TrochlearNerve

Type:M

otorFunction:Extra-ocularmovementof eyes indownwardand inwardmovement.

The client was asked

to follow the directionof the penlight in an

upward anddownward movementwithout moving hishead.

The client will be

able to moveeyes on anupward anddownwarddirection withoutmoving the head.

The pt. was able

to perform theocular movements

without movingthe head.


TrigeminalNerve

Type: Motorand SensoryFunction:Sensation of

cornea, skinof face, and

jawmovement.

Student nurse madeuse of a clean cottonwisp and gentlystroked client's

eyelashes to elicitcorneal reflex. Also,the student nurseasked the client toclose his eyes todetermine if the objectis sharp or dull uponintroducing to face.The nurse also askedthe client to move his


Client will beable to elicitcorneal reflexand identify the

sensation of dullor sharp objects.The client mustbe able to closeand open, moveside to side his


The pt. was ableto blink aftercotton touchedher eyes; she felt

the cotton; andshe also identifiedif the object issharp or blunt.She can alsomove her jaw sideto side and chew.


AbducensNerve

Type:MotorFunction:Extra-ocularmovementof eyes in alateralmovement

Student nurse askedthe client to follow thedirection of thepenlight in a lateralmovement.

The clients eyeswill be able tomove in lateralmovementwithout movingthe head.

The pt. was ableto move her eyessymmetrically.

Cranial Type: Motor Student nurse asked Client will be The client was

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CranialNerve

Type andFunction

AssessmentProcedure

ExpectedResult

ActualResult

NerveNumber 7:

FacialNerve

and SensoryFunction:Movement

of facialmuscles andsense oftaste on theanterior two-thirds of thetongue

the client to raise hiseyebrows, smile,frown, show teeth,

and to puff out hischeeks and to identifyvarious taste on thetip of the tongue likesweet and salty.

able to raiseeyebrows, frown,smile, show

teeth, puff outcheeks, andidentify varioustaste on the tip oftongue likesweet and salty.

able to raiseeyebrows, frown,smile, show teeth,

puff out cheeks,and identifiedvarious taste onthe tip of tonguelike sweet andsalty.


Vestibulo-

cochlear orAcoustics


Student nurse placeda second-hand watchnear the ears andasked the client if hecould hear the watch

tick. Then, he wasalso asked to standon his own for severalseconds.


The pt. was

unable to hear

the whispered

words. She is able

to show balance.


Glossopha-ryngeal

Type: Motorand sensoryFunction:Swallowingand Gagreflex,pharyngealmovementand senseof taste onthe posteriorone-thirds ofthe tongue

Student nurse askedthe client to say AH;pressed the posteriortongue with a tonguedepressor. Introducedthe vinegar to thetongue with eyesclosed. Lastly, thestudent nurse askedthe patient to swallow.

The client will beable to elicitupwardmovement of softpalate whenmouth is opened,identify sourtaste, and able toswallow.

The client elicitedupward movementof soft palatewhen mouth isopened, identifiedsour taste, andwas able toswallow.


VagusNerve




The client spokewithouthoarseness, andelicited gag reflex.


AccessoryNerve

Type:MotorFunction:Movementof shoulderblades

Student nurse askedthe client to move herhead from side to sideand asked to elevateher shoulders againstthe resistanceintroduced by thestudent nurse.

The client will beable to shrugshoulders andmove head fromside to sideagainst appliedresistance.

The client wasable to shrugshoulders andmoved head fromside to sideagainst appliedresistance.

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CranialNerve

Type andFunction

AssessmentProcedure

ExpectedResult

ActualResult


Hypoglossal Nerve

Type:MotorFunction:Movement

and strengthof tongue

Student nurse askedthe client to movetongue from side to

side and in and out.

The client will beable to protrudetongue and

move it from sideto side.

The client wasable to protrudetongue and

moved it from sideto side.

Nutrition Status:

At the age of 81 y/o, Mrs. Tifa has a height of52 (1.57m) and a weighs 33 kg.

BMI = weight in kg

height in m

= 37kg

(1.57m)2

= 15.04 kg/m2

Asia-Pacific Obesity Guidelines

BMI Interpretation

< 18.5 Underweight

18.6 22.9 Healthy Weight

> 23.0 Overweight

23.0 24.9 At risk

25.0 29.9 Obese I

> 30.0 Obese II

Mrs. Tifas BMI is 15.04 kg/m2which is interpreted as Underweight according to the

parameter of the Asia-Pacific Obesity Guidelines.

History of Past Illness

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Mrs. Tifa experienced cough and colds, fever and chicken pox for the past years. She

takes Paracetamol when she had fever and no medication for her cough and colds. She

managed her cough by stopping smoking and eating candies and then she would resume

smoking. According to Mrs. Yuna, even she was a child, her mother always does this. She also

used herbal medicines like Oregano to manage her cough sometimes. She prepares oregano

throughBoiling one cup of fresh leaves in 3 cups of water for 10 to 15 minutes. And then

drinking the cup for about three times a day.

History of Present Illness

Mrs. Tifa was suffering productive cough and colds for about a week during the first

home visit (September 6, 2010). She was not taking any medications for her cough but she

uses other alternatives like drinking lots of water. She still didnt visit the health center to have a

check up about her cough and colds.

Activities of Daily Living

Mrs. Tifa usually gets up at 6 am and helps Mrs. Yuna in preparing the breakfast. After

breakfast, she usually smokes or cleans the house. After that she will wonder around the

community, sometimes going to the internet to have a contact to her son in abroad or just visit

some neighbors. In the middle of the day, she usually comes back at lunch to see her

grandchildren eat their lunch before going to school. She either eat lunch or not and then go

back to sleep. About 1:30 or 2:00, she will stay in the house watching TV or keeping an eye to

her grandchildren. At night, she will watchTV orhave conversation to her family or neighbors

and after taking her dinner, she will go to sleep at 10 pm.

Mrs. Tifa smokes and she can consume half packet of cigarette a day. She started

smoking at the age of24. Therefore, there is a total of57 pack years.

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MRS. YUNA



MotherYuna, age 42 y/o, female, Filipino, affiliated under Roman Catholic, born March

8, 1968, stands 150cm and weighs 35kg. On the first day of assessment, MotherYuna was

seen carrying baby Tidus and wearing a loose white shirt paired with khaki shorts. She just

finished washing clothes. Her posture is slouched in standing. She answers queries with

appropriate response and affect. After assessment, mother was noted to have untrimmed

finger and toe nails as well as presence of pediculosis with untidy appearance. Her vital

signs were taken and recorded as follows: T=36.5rC, PR=85 bpm, RR=21 cpm,

BP=100/70mmHg


SKIN: MotherYunas skin color is fair. There is no edema and inflammations present. There is

noticed presence of dry lesions and rashes on her upper limb. Her skin is warm to touch,

slightly dry and with a good skin turgor.

NAILS:She has dirty untrimmed finger and toe nails. But smooth in texture and nail beds

are pink with good capillary refill. Nail beds returns to pink after blanching in 2 seconds.

HAIR: Herhair is evenly distributed, and black in color. There is presence of dandruff on

scalp, pediculosis on uncombed hair.

SKULL AND FACE: Her skull is rounded, normocephalic and with normal contour, smooth skull

contour, no lesions and masses noted. She has symmetrical face features and no lesions or

masses noted.

EYES: Her eyebrows are symmetrically aligned and evenly distributed with eyelashes curled,

outward and long. The eyelids are intact without secretions or discharges. The bulbar

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conjunctiva is transparent, the palpebral conjunctiva is shiny, smooth and pink in color and shiny

with flat iris. Can move eyes and see objects in the periphery when looking straight.

EARS: Her auricles are symmetrical and have same color as the face. It is aligned with the

outer canthus of the eye. Ear canals are seen withlittle amounts of dry cerumen. Not tender

upon palpation, Pinna recoils after it is folded.

NOSE: Her nose is in proportion, uniform in color and no lesions. Sinuses are not tender when

palpated and no discharge is noted.

MOUTH AND OROPHARYNX: Her lips are slightly brown in color, smooth in texture and elastic

texture. She has pink tongue and moves freely. The palates and uvula are color pink with uvula

at the midline. There are no discolorations and irritations and the oropharynx tonsils are pink in

color. Herteeth are yellow in color and there is presence of tooth decay and halitosis.

NECK: Her neck is uniform in color, with coordinate smooth movement with equal muscle

strength. Herhead was able to move against resistance.

THORAX AND LUNGS:Skin is intact with uniform color. No inflammation, lesions, deformities,

masses and tenderness noticed. She has no difficulty in breathing and has regular breathing

pattern of quiet and rhythmic respiration. Chest has no masses or tenderness. Breathing pattern

and heart beat are normal. Spine is aligned vertically. Her composure is slightly slouched due

to household chores. Her back is uniform in color. Both shoulders are aligned.

HEART:She has a normal pulse of 85 bpm with full pulsation of the carotid artery upon

palpation.

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ABDOMEN:Skin in her abdomen is uniform and rounded. With presence of tympanic sound

over the stomach, with audible bowel sounds of 23 per min. upon auscultation, does not

complain tenderness and pain upon palpation.




> Fine Sensory Test



> Fine Motor Test






toenails are untrimmed and dirty, convex in curvature and the result for capillary refill is

normal. The toenails are convex in curvature. There are no lesions found in both feet. There is

no presence of contractures or deformities. The muscles have equal strength.

> Gait and Balance





> Fine Motor Test



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CranialNerve

Type andFunction

AssessmentProcedure

ExpectedResult

ActualResult


OlfactoryNerve




The pt. was ableto identify the mildaromas correctly

CranialNerve

Number 2:

OpticNerve

Type:Sensory

Function:Vision

The student nurseasked the client to

read some printedwords from a paper14 inches apart andidentify some colors.

Client will beable to read what

was written onthe paper 14inches apart andable to seeobjects andidentify colors.

The pt. was ableto read the text

sh

own toher.


Occulomo-tor Nerve


The client was askedto look at the straightdirection. Then withthe use of a penlight,light was focused onthe right eye and was

removed to determineany changes on thepupil size. Sameassessment was doneto the left eye.


The pt. was ableto follow the peneasily andcorrectly. Herpupil performedconstriction and

dilation. Her pupilswere round andequally reactive tolight andaccommodation.


TrochlearNerve

Type:MotorFunction:Extra-ocularmovementof eyes indownwardand inwardmovement.

The client was askedto follow the directionof the penlight in anupward anddownward movementwithout moving hishead.

The client will beable to moveeyes on anupward anddownwarddirection withoutmoving the head.

The pt. was ableto perform theocular movementswithout movingthe head.


TrigeminalNerve

Type: Motorand SensoryFunction:Sensation ofcornea, skinof face, and

Student nurse madeuse of a clean cottonwisp and gentlystroked client'seyelashes to elicitcorneal reflex. Also,

Client will beable to elicitcorneal reflexand identify thesensation of dullor sharp objects.

The pt. was ableto blink aftercotton touchedher eyes; she feltthe cotton; andshe also identified

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CranialNerve

Type andFunction

AssessmentProcedure

ExpectedResult

ActualResult

jawmovement.

the student nurseasked the client toclose his eyes to

determine if the objectis sharp or dull uponintroducing to face.The nurse also askedthe client to move his


The client mustbe able to closeand open, move

side to side his jaw and makesomemastication.

if the object issharp or blunt.


Abducens

Nerve

Type:MotorFunction:Extra-ocularmovementof eyes in a

lateralmovement


The clients eyeswill be able tomove in lateralmovementwithout moving

the head.



FacialNerve




The pt. was ableto do all activities

The pt. was ableto identify alltasted foodappropriate orcorrectly.



Acoustics


Student nurse placeda second-hand watchnear the ears andasked the client if hecould hear the watchtick. Then, he wasalso asked to standon his own for severalseconds.


The pt. was ableto correctly repeatthe whisperedwords.

Cranial

NerveNumber 9:

Glossopha-ryngeal

Type: Motor

and sensoryFunction:Swallowingand Gagreflex,pharyngealmovementand sense

Student nurse asked

the client to say AH;pressed the posteriortongue with a tonguedepressor. Introducedthe vinegar to thetongue with eyesclosed. Lastly, thestudent nurse asked

The client will be

able to elicitupwardmovement of softpalate whenmouth is opened,identify sourtaste, and able toswallow.

The pt. was able

to do allmovement easily.

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CranialNerve

Type andFunction

AssessmentProcedure

ExpectedResult

ActualResult

of taste onthe posteriorone-thirds of

the tongue



VagusNerve




The pt. was ableto speak clearlyand did not have adifficulty inswallowing.


AccessoryNerve

Type:MotorFunction:Movementof shoulder

blades

Student nurse askedthe client to move herhead from side to sideand asked to elevateh

er shoulders againstthe resistance

introduced by thestudent nurse.

The client will beable to shrugshoulders andmove head from

side to sideagainst appliedresistance.

The pt. was ableto shrugs hershoulder. Sheturned his head in

all movement.


Hypoglossal Nerve




The pt. was ableto do allmovementinstructed.




During the final assessment, MotherYuna was seen on the yard carrying Tidus. She

was wearing a white t-shirt with red pajamas and slippers on. We observed that she already has

trimmed nails both on hands and feet, has a neat appearance withherhair fixed and ponytailed

and answers our queries accordingly. Her vital signs taken and recorded as follows :T=36.2rC,

PR=87 bpm, RR=23 cpm, BP=100/80mmHg

SKIN: MotherYunas skin color is fair. There is no edema and inflammations present. There is

noticed presence of dry lesions and rashes on her upper limb. Her skin is warm to touch,

slightly dry and with a good skin turgor.

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NAILSShe has trimmed finger and toe nails. But smooth in texture and nail beds are pink with

good capillary refill. Nail beds returns to pink after blanching in 2 seconds.

HAIR: Herhair is evenly distributed, and black in color. There is presence of dandruff on

scalp, pediculosis on uncombed hair.

SKULL AND FACE: Her skull is rounded, normocephalic and with normal contour, smooth skull

contour, no lesions and masses noted. She has symmetrical face features and no lesions or

masses noted.

EYES: Her eyebrows are symmetrically aligned and evenly distributed with eyelashes curled,

outward and long. The eyelids are intact without secretions or discharges. The bulbar

conjunctiva is transparent, the palpebral conjunctiva is shiny, smooth and pink in color and shiny

with flat iris. Can move eyes and see objects in the periphery when looking straight.

EARS: Her auricles are symmetrical and have same color as the face. Ear canals are seen with

little amounts of dry cerumen. It is mobile, firm, and not tender.

NOSE: Her nose is in proportion, uniform in color and no lesions. Sinuses are not tender when

palpated and no discharge is noted.

MOUTH AND OROPHARYNX: Her lips are slightly brown in color, smooth in texture and elastic

texture. She has pink tongue and moves freely. The palates and uvula are color pink with uvula

at the midline. There are no discolorations and irritations and the oropharynx tonsils are pink in

color. Herteeth are slightly yellow in color and there is presence of tooth decay.

NECK: Her neck is uniform in color, with coordinate smooth movement with equal muscle

strength. Herhead was able to move against resistance.

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THORAX AND LUNGS:Skin is intact with uniform color. No inflammation, lesions, deformities,

masses and tenderness noticed. She has no difficulty in breathing and has regular breathing

pattern of quiet and rhythmic respiration. Chest has no masses or tenderness. Breathing pattern

and heart beat are normal. Spine is aligned vertically. Her composure is slightly slouched due

to household chores. Her back is uniform in color. Both shoulders are aligned.

HEART:She has a normal pulse of 87 bpm with full pulsation of the carotid artery upon

palpation.

ABDOMEN:Skin in her abdomen is uniform and rounded. With presence of tympanic sound

over the stomach and gas fluid sound upon percussion, does not complain tenderness and pain

upon palpation.




> Fine Sensory Test



> Fine Motor Test






toenails are trimmed, convex in curvature and the result for capillary refill is normal. The toenails

are convex in curvature. There are no lesions found in both feet. There is no presence of

contractures or deformities. The muscles have equal strength.

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> Gait and Balance





> Fine Motor Test




CranialNerve

Type andFunction

AssessmentProcedure

ExpectedResult

ActualResult


OlfactoryNerve




The pt. was ableto identify the mildaromas correctly


OpticNerve



Client will beable to read whatwas written onthe paper 14inches apart andable to seeobjects andidentify colors.

The pt. was ableto read the textshown to her.


Occulomo-tor Nerve

Type:MotorFunction:Extra-ocular

movementof pupils

The client was askedto look at the straightdirection. Then with

the use of a penlight,light was focused onthe right eye and wasremoved to determineany changes on thepupil size. Sameassessment was doneto the left eye.

Pupils will reactto light andaccommodation,

able to close andopen eyelids.

The pt. was ableto follow the peneasily and

correctly. Herpupil performedconstriction anddilation. Her pupilswere round andequally reactive tolight andaccommodation.

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CranialNerve

Type andFunction

AssessmentProcedure

ExpectedResult

ActualResult


TrochlearNerve

Type:MotorFunction:

Extra-ocularmovementof eyes indownwardand inwardmovement.

The client was askedto follow the directionof the penlight in an

upward anddownward movementwithout moving hishead.

The client will beable to moveeyes on an

upward anddownwarddirection withoutmoving the head.

The pt. was ableto perform theocular movements

without movingthe head.


TrigeminalNerve


jawmovement.

Student nurse madeuse of a clean cottonwisp and gentlystroked client'seyelashes to elicitcorneal reflex. Also,

the student nurseasked the client toclose his eyes todetermine if the objectis sharp or dull uponintroducing to face.The nurse also askedthe client to move his


Client will beable to elicitcorneal reflexand identify thesensation of dullor sharp objects.

The client mustbe able to closeand open, moveside to side his


The pt. was ableto blink aftercotton touchedher eyes; she feltthe cotton; andshe also identified

if the object issharp or blunt.


AbducensNerve






FacialNerve

Type: Motorand SensoryFunction:Movementof facialmuscles and

sense oftaste on theanterior two-thirds of thetongue

Student nurse askedthe client to raise hiseyebrows, smile,frown, show teeth,and to puff out hischeeks and to identify

various taste on thetip of the tongue likesweet and salty.

Client will beable to raiseeyebrows, frown,smile, showteeth, puff outcheeks, and

identify varioustaste on the tip oftongue likesweet and salty.

The pt. was ableto do all activities

The pt. was ableto identify all

tasted foodappropriate orcorrectly.


Type:SensoryFunction:

Student nurse placeda second-hand watchnear the ears and

The client will beable to hear theticking watch and

The pt. was ableto correctly repeatthe whispered

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CranialNerve

Type andFunction

AssessmentProcedure

ExpectedResult

ActualResult


Acoustics

Hearing andequilibrium

asked the client if hecould hear the watchtick. Then, he was

also asked to standon his own for severalseconds.

will be able toshow balance.

words.


Glossopha-ryngeal

Type: Motorand sensoryFunction:Swallowingand Gagreflex,pharyngealmovementand sense

of taste onthe posteriorone-thirds ofthe tongue

Student nurse askedthe client to say AH;pressed the posteriortongue with a tonguedepressor. Introducedthe vinegar to thetongue with eyesclosed. Lastly, thestudent nurse asked


The client will beable to elicitupwardmovement of softpalate whenmouth is opened,identify sourtaste, and able toswallow.

The pt. was ableto do allmovement easily.


VagusNerve




The pt. was ableto speak clearlyand did not have adifficulty inswallowing.

Cranial

NerveNumber 11:

AccessoryNerve

Type:Motor

Function:Movementof shoulderblades

Student nurse asked

the client to move herhead from side to sideand asked to elevateher shoulders againstthe resistanceintroduced by thestudent nurse.

The client will be

able to shrugshoulders andmove head fromside to sideagainst appliedresistance.

The pt. was able

to shrugs hershoulder. Sheturned his head inall movement.


Hypoglossa

l Nerve




The pt. was ableto do allmovementinstructed.

Mothers Obstetrical history

MotherYunas obstetric record is G6P6 (T6P0A0L6M0), with termed pregnancies of 6, no

preterm pregnancy, no aborted fetus, six living children and no multiple pregnancies. She had

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her first menstrual period when she was twelve years old. She has irregular menstruation which

often lasts for 3 days. She consumes two pads per day when she has menstruation. She usually

experiences menstrual cramps.

During her first pregnancy, MotherYuna told the student nurses that she did not have a

hard time. She mostly craved for fruits like apples and bananas all the time. She delivered all

her six children via normal delivery at home. In every pregnancy that she went through, she

avoided drinking carbonated beverages like softdrinks, and she didnt eat salty food. She went

forher pre-natal check-ups and she completed herTetanus Toxoid vaccine.

Nutritional Status

MotherYuna, age 42 y/o has a height of 150cm and weighs 35kg.

BMI = weight in kg_

(height in m)

= 35 kg __

2.25 m

= 15.56kg/m


BMI Interpretation

< 18.5 Underweight


> 23.0 Overweight

23.0 24.9 At risk

25.0 29.9 Obese I

> 30.0 Obese II

Based from the results ofherBMI computation, MotherYuna is considered under the

classification ofunderweight.

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Mother Yuna did not experience any serious illness since childhood. She verbalized

having common colds, cough, fever, chicken pox and measles when she was young.

Sometimes, she uses herbal medicines such as Lagundi and Oregano. If she experiences

cough or colds, she self-medicates by drinking OTC medicine. She does not often go for a

check-up.


Mother Yuna is not presently diagnosed of any disease condition since she doesnt

really go often for check-ups. She verbalized experiences ofDOB, dysphagia and chest pain.


MotherYuna wakes up at 6AM. Then she proceeds to making coffee for her

breakfast or bread whenever its available, clean the house and fix her childrens things. After

that, she takes care of Tidus. At 10:30 AM, she cooks lunch and then after that, if she has

enough time, she watches television. At noon, she eats lunch. After lunch time, either she

prepares her kids to shool or she does the laundry. At around 6 pm or 7 pm, she prepares

dinner, and after preparing and cooking, they eat dinner. After eating, she rests and watches TV

with the whole family. After relaxing, she fixes all the things and approximately at 10:00PM she

heads off to sleep.

Zidhaine


He is not able to assess during the home visit because he had his class that morning.

(Second home visit: September 7, 2010)


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Zidhaine is the eldest among the four children of the family and is 13 years old.

He is wearing a blue short and striped shirt. His skin is smooth, dark complexion and good skin

turgor. His hair is black in color and evenly distributed with no infestations noted. He has long

and dirty fingernails. Presence of dental caries is noted. Upon interview, it is noted that he

is oriented to time, date, place and person and is coherent in answering the questions. His initial

vital signs were taken and recorded as follows:T=36.9 oC, PR= 88 bpm and RR= 18 cpm.


SKIN: Zidhaine skin is smooth, dark complexion, equally distributed with good skin turgor.

There are no lesions or discharges found.

NAILS:Upon inspecting the nails, fingernails are untrimmed and dirty. His nails were pink in

color and smooth in texture and with a capillary refill of less than 2 seconds.

HAIR:The hair is short, black, soft and evenly distributed with no presence of dandruff. There is

no presence of infestations.



facial movements.








objects in the periphery when looking straight ahead and able to read a print 14 inches apart.

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NOSE:The nose is symmetric, straight and no dischargesfound in nares. The color of the nose

is the same as the facial skin, no abnormalities of the shape can be seen. The air moves freely

when she breaths on both nares and the nasal septum is in between the nasal chambers. There

are no masses or swellings are palpated in maxillary and frontal sinuses.

MOUTH AND OROPHARYNX:The lips have symmetrical contour, no pallor noted, pink in color

and smooth and have the ability to purse lips. He has 4 tooth decays: 2 on his right mandible

and 2 on his right maxillary. His tongue is pink in color, at the central position, no lesions

observed and moves freely. The soft palate is light pink and smooth while the hard palate is

lighter pink. The uvula is positioned on the midline of soft palate. The oropharynx is smooth and

pink and the tonsils have no discharges.

NECK: Neck muscles are equal in size and head is centered. Client can move head smoothly

with no discomfort. Client can shrug shoulders against the resistance of student nurses hands.

Lymph nodes are not palpable and trachea is in the midline of neck.

THORAX AND LUNGS: Chest is symmetric in size and spine is vertically aligned. Both lung

fields are clear upon auscultation. Skin is intact with no palpable masses or nodules. Breathing

is regular and normal.

HEART:Zidhaines heart has no vibrations or pulsations are palpated on the aortic, pulmonic or

tricuspid area. There is no presence of swishing sound like murmurs. Has regular rate and

rhythm. And has identical pulse in radial and apical pulse.

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ABDOMEN:There is no blemished in the skin, no pulsation, masses and no tenderness. The

skin is intact and warm to touch.

UPPER EXTREMITIES: The arm has dark complexion, no lesions or wounds found and soft to

touch. Has smooth coordinated movement. No tenderness or swelling of muscles and bones


> Fine Sensory Test

The touch sensation is normal. He was able to discriminate sharp and dull

sensations. He can also determine hot and cold sensations.

> Fine Motor Test

Finger to Nose Test: Can repeatedly and rhythmically touchhis nose.


his hands at rapid pace.






> Gait and Balance

The client was able to maintain balance (Walking Gait). When he was asked to


Client was able to maintain upright posture and foot stance (Romberg Test). He

can also maintain heel-toe walking along a straight line.

> Fine Motor Test

He was able to maintain bilateral equal coordination. He can also move smoothly

with coordination.

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CranialNerve

Type andFunction

AssessmentProcedure

ExpectedResult

ActualResult


OlfactoryNerve




The clientidentified thesmell of theperfume andvinegar.


Optic

Nerve


The student nurseasked the client toread some printedwords from a paper14 inches apart and

identify some colors.

Client will beable to read whatwas written onthe paper 14inches apart and

able to seeobjects andidentify colors.

Client read whatwas written on thepaper 14 inchesapart and hasidentified colors.


Occulomo-tor Nerve


The client was askedto look at the straightdirection. Then withthe use of a penlight,light was focused onthe right eye and wasremoved to determineany changes on thepupil size. Sameassessment was doneto the left eye.


Pupils hadreacted to lightandaccommodation.He was also ableto close and openhis eyelids.


TrochlearNerve

Type:MotorFunction:Extra-ocularmovementof eyes indownwardand inwardmovement.

The client was askedto follow the directionof the penlight in anupward anddownward movementwithout moving hishead.

The client will beable to moveeyes on anupward anddownwarddirection withoutmoving the head.

The client movedhis eyes on anupward anddownwarddirection withoutmoving the head.


TrigeminalNerve


jawmovement.

Student nurse madeuse of a clean cottonwisp and gentlystroked client'seyelashes to elicitcorneal reflex. Also,the student nurseasked the client to

Client will beable to elicitcorneal reflexand identify thesensation of dullor sharp objects.The client mustbe able to close

The client elicitedcorneal reflex andhad identified thesensation of dullor sharp objects.The client wasable to close andopen, move side

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CranialNerve

Type andFunction

AssessmentProcedure

ExpectedResult

ActualResult

close his eyes todetermine if the objectis sharp or dull upon

introducing to face.The nurse also askedthe client to move his


and open, moveside to side his

jaw and make

somemastication.

to side his jaw andmade somemastication.


AbducensNerve




The clients eyesmoved in lateralmovement withoutmoving the head.


FacialNerve




The client wasable to raiseeyebrows, frown,smile, show teeth,puff out cheeks,and identifiedvarious taste onthe tip of tonguelike sweet andsalty.



Acoustics


Student nurse placeda second-hand watchnear the ears andasked the client if hecould hear the watchtick. Then, he wasalso asked to standon his own for severalseconds.


The client heardthe ticking watchand was also ableto show balance.


Glossopha-ryngeal

Type: Motorand sensoryFunction:

Swallowingand Gagreflex,pharyngealmovementand senseof taste onthe posterior

Student nurse askedthe client to say AH;pressed the posterior

tongue with a tonguedepressor. Introducedthe vinegar to thetongue with eyesclosed. Lastly, thestudent nurse askedthe patient to swallow.

The client will beable to elicitupward

movement of softpalate whenmouth is opened,identify sourtaste, and able toswallow.

The client elicitedupward movementof soft palate

when mouth isopened, identifiedsour taste, andwas able toswallow.

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CranialNerve

Type andFunction

AssessmentProcedure

ExpectedResult

ActualResult

one-thirds ofthe tongue

Cranial

NerveNumber 10:

VagusNerve

Type: Motor

and SensoryFunction:Swallowingandspeaking

Student nurse asked

a question, andelicited gag reflex.

The client will be

able to speakwithouthoarseness, andwill elicit gagreflex.

The client spoke

withouthoarseness, andelicited gag reflex.


AccessoryNerve

Type:MotorFunction:Movementof shoulderblades

Student nurse askedthe client to move herhead from side to sideand asked to elevateher shoulders againstthe resistance

introduced by thestudent nurse.

The client will beable to shrugshoulders andmove head fromside to sideagainst applied

resistance.

The client wasable to shrugshoulders andmoved head fromside to sideagainst applied

resistance.


Hypoglossal Nerve




The client wasable to protrudetongue andmoved it from sideto side.


He is not able to assess during the home visits because he had his class at theafternoon.

Nutrition Status

Zidhaine, age 13 years old, has a height of 149cm (1.49 m), and weighs 36 kg.

BMI = weight in kg

height in m

= 36 kg

(1.49 m)

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= 16.22 kg/m


BMI Interpretation

< 18.5 Underweight


> 23.0 Overweight

23.0 24.9 At risk

25.0 29.9 Obese I

> 30.0 Obese II

Basing on the result of the computation on the above parameters, Zidhaine is classified

as underweight.


According to Mrs. Yuna, he experienced cough and colds, fever in the past. He already

experienced chickenpox. Ifhe has a fever, they managed it with tepid sponge bath and over the

counter medicines.


Zidhaine doesnt have any illness at present. Upon the student nurses assessment, hes

at good health.


Zidhaine wakes up at 8:00 in the morning and eats his breakfast. After that, he

will either play withhis friends or go to the internet shop. Usually, he will come back by 11:30

am to eat his lunch and prepare for school. Together withhis siblings, he will stay at school from

1:00 to 5:00 pm. At 5:30 pm, he goes home and after resting, starts to make his assignments

and watchTV afterwards. They will eat their supper at 7:00 pm and sleep at 9:00 pm.

CLOUD

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Cloud, who was the second eldest among four children of the family, is 10 years old. He

is a pure blooded Filipino born on October 14, 1990 in Balibago, Angeles City. He is wearing

white t-shirt and black pants. His skin was smooth, has dark complexion His hair was black in

color and evenly distributed. He has long and dirty fingernails. Presence of dental carries.

Upon interview, it is noted that he is oriented to time, date, place and person and is coherent in

answering the questions. His initial vital signs were taken and recorded as follows:T=36.5 oC,

PR= 92 bpm, RR= 24 cpm,


SKIN: Child Cloud was noted to have a dry skin and fair complexion. He has no edema on any

part of the body. He has a good skin turgor.

NAILS:Upon inspecting the nails, long and dirty fingernails were noted. His nails were pink in

color and smooth in texture. Normal capillary refill of 2 seconds was noted.

HAIR: He had a natural hair which is black in color. His hair was evenly distributed on his scalp.

No dandruff, infection or infestations noted upon inspecting the hair in several areas.


masses. Facial features are symmetrical and facial movements.






smooth with visible details of iris. Client blinks 16 times per minute and when the cornea is

touched with the use of cotton. Pupils are equally round and reactive to light and

accommodation. Client can see objects in the periphery when looking straight ahead and is able

to read a print 14 inches apart.

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EARS: Auricles are same as the color of facial skin, symmetric and aligned with outer canthus

of eye. It is mobile, firm, non tender and recoils after being folded.

NOSE: Nose is symmetrical to the face; patent nasal passage with septum on the midline, moist

and pink mucous membrane, no bleeding, whitish nasal discharges, and no masses palpated

on the sinuses, no nasal flaring and can breathe easily.

MOUTH AND OROPHARYNX: Lips are uniformly pink, soft and symmetrical. Client is able to

purse lips when asked to.

NECK: Neck muscles are equal in size and head is centered. Client can move head smoothly

with no discomfort. Client can shrug shoulders against the resistance of student nurses hands.

Lymph nodes are not palpable and trachea is in the midline of neck.

THORAX AND LUNGS: Chest is symmetric in size and spine is vertically aligned. Both lung

fields are clear upon auscultation. Skin is intact with no palpable masses or nodules. Breathing

is regular and normal. Has normal respiratory rate of 21 cycles per minute.

HEART: Heart rate is regular in rhythm upon auscultation without any murmurs. Peripheral

pulses are symmetrical with that of the apical pulse as well. Has a pulse rate of 82 beats per

minute.

ABDOMEN:Skin is uniform in color.

UPPER EXTREMITIES: Has

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