A Family Case Study of the A.

Family

IN PARTIAL FULFILLMENT OF THE COURSE

REQUIRMENT IN NCM 102 RLE IN
COMMUNITY HEALTH NURSING
BACHELOR OF SCIENCE IN NURSING

Presented to the Faculty

Of Manila Doctors College, College of Nursing

Buzon, Myra Katrina R.

Caberte, Iris D.
Jinno, Chieri D.

Group 31

March 2010
0

Acknowledgement
The students would like to extend their profound gratitude to the following
people who have generously shared their help in the completion of this study:
First and foremost, God Almighty for giving us unending intelligence and
strength to finish every task to facilitate and is dedicated for us to finish. Our
parents for providing us their never ending support in this study. And last but not
the least, to our clinical instructor, Mr. Nyl Rafols Patangan, RN, who is never weary
of providing us encouragement and guidance all throughout the making of this
study. He has always been accessible and approachable every time when we are in
need of help.

Dedication
This family nursing care plan is intended for the improvement and betterment
in terms of health of our host family, the Atienzas. We dedicate this presentation to
their family who gave us their cooperation and whole-heartedly accepted our favour
of giving us an ample amount of time for us to conduct our interviews and for
responding to us with complete honesty. We give our full efforts to make this care
plan the best and most appropriate one to improve their health. Lastly we ask God,
the Father Almighty to always guide the Atienzas in their future endeavours more
practically in the terms of their health.

Abstract
A family nursing care plan is the blue print of the care that the nurse designs
to systematically minimize or eliminate the identified health and family nursing
problems through explicitly formulated outcomes of care (goals and objectives) nd
deliberately

chosen

set

of

interventions,

resources

and

evaluation

criteria

standards, methods and tools.

Features of Family Nursing Care Plan:
1.

The nursing care plan focuses on actions which are designed to solve or
minimize existing problem. The plan is a blueprint for action. The core of
the plan are the approaches, strategies, activities, methods and materials
which the nurse hopes will improve the problem situation.

2.

The nursing care plan is a product of a deliberate systematic process. the

planning process is characterized by logical analyses of data that are put
together to arrive at rational decisions. The interventions the nurse
decides to implement are chosen from among alternatives after careful
analysis and weighing of available options.

3.

The nursing care plan, as with all plans, relates to the future. It utilizes
events in the past and what is happening in the present to determine
patterns. It also projects the future scenario if the current situation is not
corrected.

4.

The nursing care plan is based upon identified health and nursing
problems. The problems are the starting points for the plan, and the foci
of the objectives of care and intervention measures.

5.

The nursing care plan is a means to an end, not an end in itself. The goal
in planning is to deliver the most appropriate care to the client by
eliminating barriers to family health development.

6. Nursing care planning is a continuous process, not a one-shot-deal. The

results of the evaluation of the plans effectiveness trigger another cycle
of the planning process until the health and nursing problems are
eliminated.

Table of Contents
Acknowledgement

Dedication

Abstract

Table of Contents

I.
II.

Introduction

Background of Study
4-6
A. Study Locale
B. Spot Map

III.

Family Background
7

IV.

Socio-Economic Data
7

V.

Home and Environment 8

VI.

Family Functional Assessment by Gordons

9 - 15
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.

Health Perception-Health Management Pattern

Nutritional Metabolic Pattern
Elimination Pattern
Activity and Exercise
Cognitive Perception
Sleep and Rest
Self-Perception/Self Concept
Role-Relationship Pattern
Sexuality-Reproductive
Coping Stress Tolerance Pattern
Values Beliefs Pattern

VII.

Physical Examination
15 - 25

VIII.

Typology of Nursing Problems

26

A. 1st Level Assessment

B. 2nd Level Assessment
IX.

Problem Scoring

27 -28

X.

Priority Setting

29
3

XI.

Family Nursing Care Plan

32

30 -

XII.

Action Plans
35

33 -

XIII.

Evaluation

36

XIV.

Recommendation

37

Appendices
53
Appendix A
Appendix B
Appendix C
I.
Introduction

38 -

A family nursing care plan is the blue print of the care that the nurse
designs to systematically minimize or eliminate the identified the identified
health and family nursing problems through explicitly formulated outcomes of
care (goals and objectives) nd deliberately chosen set of interventions,
resources and evaluation criteria standards, methods and tools.
The use of the family nursing process will result in a care plan
describing the needs and care for each client. An organized sequence of
problem solving steps used to identify and to manage the health problems of
clients.
II.

Background of the Study

A. Study Locale
About Barangay Talon Dos
Barangay Talon Dos in the City of Las Pias was created on April
3, 1978 by virtue of Presidentiable Decree No. 1335 signed by then
President Ferdinand Marcos.
Predominantly Residential Components
The decree ordered that the subdivisions of BF resort, Sta.
Cecilia, Sarino, Mother Earth and Camella be detached from the
mother Barangay Talon to form Barangay Talon Dos. Today this
Barangay is composed of 26 residential villages and sectors.
Demography

Talon Dos is one of the twenty barangays of Las Pias City

with a population of 47, 479 (2007 PopGen) and land area of
391.61 hectares. It is situated on the southern side of the midsection of Las Pias. It is bounded on the north by ZapoteAlabang Road and Barangay Pamplona Dos; on the west by the
Zapote River, Bacoor, and Cavite; on the east by Barangay Talon
Cuatro and on the south by Barangay Talon Cinco.
Health and Sanitation
Barangay Talon Dos provides health and nutrition and social
welfare services such as the Barangay Health Centers and Days Care
Centers.

Barangay Health Centers

Two health centers are found in BF Resort Village and
Barangay Hall compound provide primary health care for minor
medical and dental problems, immunizations and pre-natal care.
Day Care Centers
A Day Care Center is a community work place facility
providing a full range of health, nutrition, early education,
psychosocial and other services to children below 6 years old.
Day care centers in Talon Dos are found in Carnival Park A and B,
Manggahan, Satima and Vatican Dulo River Side.
Feeding and Multivitamin Enhancement
A barangay nutrition scholar and barangay health workers
provide primary delivery of nutrition information and services in
the

community

together

with

the

regular

feeding

and

multivitamin supplementation programs of the committee on

health and sanitation.
Anti-Rabies Vaccination
To protect dogs and humans from the ill-effects of rabies,
the barangay, in the cooperation with the Department of
Agriculture conducts annual anti-rabies vaccination of dogs.
Waste Management

The proper management of solids and wastes protects public

health and the environment; thus; Barangay Talon Dos does its part by
composting and bio-digesting wet garbage.
Talon Dos Waste Management Facility
Wet wastes collected from homes by the barangay
biomen are processed into compost as soil conditioners into
biogas for cooking at the Waste Management Facility in BF
Resort Village. The facility is a project of Sen. Manny Villar and
Con. Cynthia Villar, in cooperation with Barangay Talon Dos and
BF Resort Village Homeowners Association.

B. Spot Map

BARANGAY

TALON DOS

LAS PIAS

CITY

Figure 1

Talon Dos is one of the twenty barangays of Las Pias City with a population
of 47, 479 (2007 PopGen) and land area of 391.61 hectares. It is situated on the
southern side of the mid-section of Las Pias. It is bounded on the north by ZapoteAlabang Road and Barangay Pamplona Dos; on the west by the Zapote River,
Bacoor, and Cavite; on the east by Barangay Talon Cuatro and on the south by
Barangay Talon Cinco.

III.

Family Background
The head of the family is Herminia D. Green. She was born on June 7,
1942 at Bulacan and is 67 years old. She is a Bachelor of Science in
Education and was a former Filipino teacher. She currently earns income
through a tricycle business. She owns three tricycles and earns money
7

through boundaries paid to her and usually owns P3, 000.00 a month. She
owns a bungalow type house at #24 Alice Crisostomo St., BR Resort Village,
Talon II, Las Pias City. They have been living there for 15 years already. The
primary dialect that they use is tagalong. They also use other dialects such
as, English, Ilonggo, Bicol, and Kapampangan.
Dante D. Atienza Jr. (Herminias son) is a 38 year old father of three
children. He was born on May 19, 1971 and is 38 years old. He worked as an
FX driver, but is currently not working. He is helping his wife managing the
food store where his wife is working. His wife, Lucila S. Atienza, 47 years old,
is a high school graduate who was born on October 30, 1963. She earns
about P1500.00 a day (5 days a week).
They have three children who are currently studying. Hannah Grace S.
Atienza is their eldest daughter. She was born on August 7, 1994 and is 15
years old. She is a third year high school student at Saint Francis of Assisi
College. Jay Marvin S. Atienza is the second among the siblings. He was born
on December 12, 1995 and is 14 years old. He is a freshmen student at St.
Marks Academy. The youngest of the sibling is John Oliver S. Atienza. He was
born on November 3, 1996 and is 13 years old. All of them are Roman
Catholics.
IV.

Socio Economic Data

According to the priorities for expenditure, the family prioritizes food
first. The next is health, followed by education, house bills and then clothing.
Their primary source of income is the food business that Lucila is currently in.
She earns about P13, 000.00 a month (minus the rental fee and other
expenditures in the food store). Other sources of income include the tricycle
business Herminia is in, where she earns P3, 000.00 monthly. When Dante
works as a FX driver he earns P20, 000.00 monthly, making their average
monthly income P36, 000.00. Now that Dante is currently jobless, the
average monthly income they earn as of now is P16, 000.00. The familys
monthly expenses reaches as much as P15, 000.00 P20,000.00 monthly;
making their earnings short for paying expenses.
The family recognizes the Barangay Captain as one of the first persons
they know to be leader of the community. Some of the projects that the
community has are Clean and Green Project, Proper Segregation Program and
Lighting System. The family is aware of these projects and are utilizing it.

V.

Home and Environment

8

Herminia owns the land and house they are living at. The house is
made of light materials and concrete. The house is well-ventilated and use
electricity as a source of light. The familys source of drinking water is
commercially prepared. They have their drinking water delivered from a
nearby water station. They store their drinking water in clean bottles and
pitchers which are usually covered. Their water supply is supplied by Nawasa,
and if water is not available, they have it delivered.
The type of toilet the family owns is a flush type toilet. The sewerage
system is a blind drainage and its condition is free flowing. The family
practices waste segregation. They used a covered trashcan as a container
used for garbage collection. Garbage is collected once a week, during
Thursdays.
Herminia owns three love birds. She keeps them in a cage and feed
them every day. Roaches an flies are present in their household. They control
these pests by using pesticide to kill them. The health programs that are
present in the community are free consultation and weighing , EPI, Ligtas
Tigdas, Well-baby clinic , pre-natal checkups, Anti-rabies vaccine. The family
is aware of the health programs present in the community but does not utilize
it at once. The first person that the family consults in times of illness is the
neighbourhood albularyo and they only consult the doctor whenever the
illness becomes severe.

Formula for Ventilation:

Total window area (cm.sq)
X 100
Total floor area (cm.sq)
Total window area (TWA) = window length x window width
Total floor area (TFA) = floor length x floor width
Results:
Well ventilated: >20%
Fair: 18 19%
Poor: <17%

VI.

Family Functional Assessment by Gordons

A. Health Perception-Health Management Pattern
1. History
The familys general heath has been good in the last few years.
The children in the family experience cough and colds, but not very
often. Hannah Grace and John Oliver have also had fever 2 months
ago, once at the same time during the Christmas break. Luckily these
illnesses didnt affect the childrens school attendance. In cases like
these, Herminia and Lucila call their neighbourhood albularyo for help.
They only consult the doctor in cases where in sickness becomes
severe. Lucila, started having hypertension, September last year. She
was given prescription by her physician and has been taking her
Diovan (Valsartan) medications for hypertension 80mg once a day,
every day, since then as maintenance. The family takes vitamins to
keep themselves healthy.
Herminia and Lucila also tidy the house daily to keep the house
clean and keep themselves away from an environment that may cause
sickness to them. None of the family members drink alcohol, take
prohibit drugs or smoke. The children have complete immunizations
since they were 8 years old. The client states that it has been easy to
find ways to follow suggestions of doctors, nurses, social workers.
2. Examination
The general appearance of the familys home environment is
conducive to their health. It is clean and tidy, has well-ventilation and
lighting, and the family can control the presence of pests and vectors
such as flies and cockroaches. Lucila stores the available medications
at home in a safe place which is unreachable by her children. She and
Herminia make sure that hazards are eliminated such as knives on the
counters, are put back to their appropriate places so that they are out
of reach to the children.

10

B. Nutritional Metabolic Pattern

1. History
Breakfast
Bread, fried egg

Lunch
Rice and pork

Merienda
Bread, Pancit

Dinner
Rice and beef

with tomatoes,

with water or

canton with soft

with water

fried rice, with

juice

drinks, juice,

water or coffee
Bread, beef

+ fruits
Rice and fish

coffee or water
BananaQue with

Rice and

noodles/mami

with water or

soft drinks,

chicken with

with added rice,

juice

coffee or water

water or juice

with water or

+ fruits

coffee
Bread,

Rice and

Lugaw added

Rice and beef

Champorado

chicken with

with

with water or

with added milk

water or juice

tofu/Macaroni

juice

and dried fish,

+ fruits

soup added with

with water or

milk, with coffee

coffee
Bread, left over

Rice and beef

or water
Pancakes with

Rice and fish

foods from last

with water or

milk, coffee or

with water or

night (may be

juice

water

juice

beef, pork or

+ fruits

chicken), with
water or coffee
(May have any of these meal patterns. Meal patterns change every
day.)
The family makes it sure that each member drinks 6 8 glasses
of water daily. The client says that usually, the elders never fail to have
a cup of coffee daily. The children are given juice and milk. They also
drink soft drinks. The family usually eats meaty foods such as beef,
pork and chicken. They do not cook vegetables that much because the
children dislike eating it. All the family members have a good appetite,
except for Herminia who eats only small quantities of food per meal.

11

The children have regular dental check-ups, twice a year. The

family doesnt have any problems with regards to the skin, and wound
healing.

2. Examination
The refrigerator mostly contains food stocks of beef, pork, and
chicken. Bottles of drinking water and dairy products are also present.
Fruits such as apples, bananas, oranges and avocado are placed on top
of the refrigerator. Vegetables such as tomatoes, string beans,
cauliflower, carrots, cabbages, and eggplants are also found. The
family usually eats adobo, nilaga, champorado, pancit, chicken curry,
kare-kare, pork/beef sinigang, afritada, fried pork/chicken, beef steak.
C. Elimination Pattern
1. History
All members of the family sighted no abnormalities observed in
their stool. The family members regularly have normal defecation
patterns:
Herminia: Every other day at around 5 in the morning
Dante: Every day at night time
Lucila: Every other day in the afternoon
Hannah: Every other day in the afternoon
Jay: Every other day in the afternoon
Oliver: Everyday in the morning
The family practices waste segregation. They used a covered
trashcan as a container used for garbage collection. Garbage is
collected once a week, during Thursdays. Herminia owns three love
birds. Their wastes are disposed every other day, outdoors. Roaches
and flies are present but are controlled through the use of pesticides
(baygon).
2. Examination
12

The family has 3 functional toilets at home. The toilet bowls are
all flush type and kept clean. Garbage disposal doesnt seem to be a
problem and the pet cages are also kept clean. Flies and roaches are
not considered as a problem.
D. Activity and Exercise
1. History
Lucila and Herminia consider doing everyday household chores
as their form of exercise. Oliver and Jay are members of their school
basketball

team,

and

have

drills

and

training

every

Monday,

Wednesday, Friday and Saturday. Hannah Grace on the other hand is a

member of her schools volleyball team and is a team A player. Her
drills and training schedule take place during Monday, Wednesday and
Friday afternoon and Tuesday, Thursday and Saturday in the morning.
Dante does no form of exercise at all.
The family doesnt experience problems in housekeeping,
budgeting for food education and clothes.
2. Examination
The home is well organized and clean. Personal belongings of
each member are appropriately arranged and maintained by Lucila and
Herminia.
E. Sleep and Rest
1. History
Generally, each family member is well-rested and ready for
school or work at the start of the day. Herminia has her own room
where she sleeps in. She sleeps using a banig topped by a comforter.
Lucila and Dante share their room with Oliver and Jay, with Lucila and
Dante using a floor mattress topped by a comforter for sleep and
Oliver and Jay sharing the King sized bed. Hannah sleeps on a separate
room. She sleeps on a wooden bed topped by a soft mattress.
Usually the children wake up at around 5:00 AM to get ready for
school. Lucila also wakes up at 5:00 AM to assist the needs of her
children such as preparing breakfast for the whole family, boiling water
for a warm bath, and checking if her childrens school needs are all
prepared. Dante wakes up at around 6:00 AM. He gets himself
13

prepared to give his children a ride to school. Herminia also wakes up

at 6:00 AM and starts doing the household chores. The family usually
sleeps at around 9:00 PM.
2. Examination
The sleeping space is adequate for each family member and is
also appropriately arranged.
F. Cognitive Perception
1. History
No family member has hearing problems however; Lucila and
Herminia

have

visual

problems.

Herminia

has

vision

of

275(Left)/250(Right), while Lucila has 120(Left)/120(Left). They both

have personal reading glasses.

2. Examination
The primary dialect that they use is tagalong. They also use
other dialects such as, English, Ilonggo, Bicol, and Kapampangan.
G. Self Perception-Self Concept
1. History
Herminia states that the family feels good most of the time.
They normally have their own family problems like every other family
and tend to help each other at times of family crisis. The show the
children that they feel happy most of the time, to lessen the stress that
the children have in studying for school. Herminia, Dante and Lucila
feel anxious sometimes because of Dante being jobless at the
moment. With Dante jobless, they are worrying about the monthly
expenses that they have to pay for. Examples of things that may affect
their mood are quarrels or misunderstandings between their members,
when the children become stubborn at times and problems regarding
finances.
2. Examination
General mood state: rate is 3 because Herminia presents herself
to be fine at the moment of interview when their family is under a
state of crisis. She is cooperative but gets serious at times. Her mood
14

changes whenever she talks about the current financial problems in

the family.
Members are generally assertive. Rate given is 5 because during
interview,

interviewee

is

cooperative

and

honest

in

answering

questions.
H. Role-Relationship Pattern
1. History
Name

Relationship to
the head of the
family

Age

Sex

Educational
Attainment

Herminia D. Green

Head of the
Family

68

College BSE
Graduate

Dante D. Atienza Jr.

Son

38

College Undergrad

Lucila S. Atienza

Daughter-in-law

47

High School
Graduate

Hannah Grace S.
Atienza

Granddaughter

15

Still Studying

Jay Marvin S. Atienza

Grandson

14

Still Studying

John Oliver S. Atienza

Grandson

13

Still Studying

The Atienzas are an extended type of family. Regarding the

familys role-relationship pattern, Herminia states that they sometimes
get rough with the kids and sometimes experience a hard time in
disciplining them; most usually with Hannah and Oliver. They may
sometimes answer back at any of their elders. They also find it hard to
make Hannah and Oliver cooperate with helping in the household
during their free time. Herminia states that all they do sometimes is
laze around all day after doing their school activities. Jay is however a
responsible child, sharing his part in doing the household chores at
home. However like Oliver, they may stay in computer shop late up
until midnight.

Herminia also states that even though they have a

hard time in disciplining the kids, their relationship as brother and

sister remain equal.
The family also considers themselves as a part of their
community and keep contact/socialize with their neighbours.

15

2. Examination
The family communicates during meals. The elders and Jay help
each other out in doing household chores. The siblings help each other
out in times of need, such a help in school assignments. The family is
an extended type and it
I.

Sexuality-Reproductive

1. History
Lucila and Dante are still sexually active. They say that their
sexual relationship is satisfying. The parents are using the BBT method
for family planning since Lucila is still not menopausal. They still dont
educate their children about topics regarding sex and reproduction.
They feel that it is inappropriate for them to discuss that topic to their
children.
J.

Coping Stress Tolerance Pattern

1. History
The family is adjusting to the financial problem that they are
currently facing. The family tries to help each other as possible. When
family problems arise, the elders first discuss regarding what steps
they will have to take in solving the problems, and then they will
discuss these to the family members. They take things slowly and
think of resolutions they may do to solve the problem. Lucila
experiences hypertension once tension in situations rises. She resolves
this by taking her Diovan medications, deep breathing and drinking
plenty of water. The other family members only cool off for a moment
and just try to relax to decrease the tension. When all members have
cooled down, the family then goes back to discussion of how to solve
the conflict. Herminia states that her methods are successful most of
the time.
K. Values-Beliefs Pattern
1. History
The family members do not get everything they want because of
current financial problems. One of the parents goals is to let their
children be able to get a college degree, stay healthy and live a
harmonious life. Only Herminia participates in religious activities of the
community, such as attending afternoon sessions of praying the rosary
at the community grotto. She and Lucila try their best to get Dante and
the kids attached to religion. They usually go to Church every Sunday
afternoon.

Religion is very important to them once problems arise

16

since they call God and ask for guidance to help them during crisis in
the family arises.
VII.

Physical Examination
Herminia D. Green
Age: 68 y/o

Weight: 125 lbs

Height: 52

1. Skin
I: The clients skin is fair in color evenly, decrease elasticity, wrinkled
and moles scattered on facial skin and on upper and lower extremities
and only small healed scars are present. Skin is intact, and no
reddened areas.
P: There are no masses palpated. Skin temperature is warm and
clammy and skin is dry.
2. Nails
I: Nails are clean, thick, and slightly pink in color, convex curvature,
nails are evenly cut; tissue surrounding the nails is intact with beaus
line.
P: Nails are hard and immobile. Capillary refill is present at 2 sec,
smooth texture.
3. Head, Face and Neck
I: Head and neck is symmetrically aligned, head is normocephalic, held
still and upright. Neck has slight cervical curvature, decrease flexes
without bulging mass. Symmetric facial movements, Hair is short and a
mixture of brown, gray and white in color, thin but evenly distributed,
no presence of flakes.
Facial wrinkles are prominent, mouth is drawn inward.
P: No lumps or masses, no inflammation of lymph node in the face,
there is presence of pulsations on temporal artery.
4. Eyes
I: Eyebrows are brown in color and symmetrically aligned, no
discharges, pupils are equally round and reactive to light and
accommodation. There is no discoloration of the eye, sclera appears
white, and eyes are at the level of the ears, can follow the six ocular
movements. Yellowish nodules on bulbar conjunctiva on medial side of
iris are present. The vision of client is 275/270 she is near sighted.
P: Absence of masses and tenderness and discharges on inner and
outer cantus upon palpation

5. Ears
I: Color same as facial skin, both are symmetric and evenly aligned to
the head and auricle of the ear aligns with aligned to the corner of the
eye. Can react to sounds or noises, normal voice tone audible, able to
hear snapping fingers on both ears.
P: No tenderness, no lesions and masses
6. Nose and Sinuses

17

I: upon assessment the nose is symmetrical and able to sniff through

each nostril, no discharges or nasal flaring, same color of the face, no
lesions and deformities
P: No tenderness and masses felt over bony prominence above each
eye and maxillary sinuses.
7. Mouth and Pharynx
I: Lips are pinkish in color, all are false teeth slightly yellow stained.
Gums are pink and tight. No bulging masses. Tongue is pinkish in
appearance and is in midline, moves freely up, down and sideward.
Uvula hangs freely in the midline. Hard palate is pale with transverse
rugae.
P: The client elicits gag reflex. And tongue offers strong resistance on
up, down, and side to side tongue pressure.
8. Spine
I: The patient has a slight curvature of the thoracic spine. The spine is
vertically aligned right and left clavicles and hips are at the same
height and moves symmetrically.
P: No masses or tenderness noted.
9. Thorax/Chest
I: the posterior and anterior thorax is uniform in color. No lesions or
bulging mass noted. No respiratory distress noted. Ratio of AP
diameter is 1:2.
Pa: No masses or tenderness are present. Has uniform body
temperature. Has symmetric chest expansion.
Pe: normal resonance sounds is elicited upon percussion of the
thorax/chest.
A: Lung sounds are clear to auscultation bilaterally. No abnormal breath
sounds was heard.
10.Cardiovascular and Peripheral Vascular/Heart
I: There are no heaves noted on the chest of the patient. No pulsations
noted.
A: No bruit was noted. No extra heart sounds noted.
P: No masses or tenderness palpated.
11.Breast and Axilla - refused
12.Abdomen
I: Presence of striae and small healed on the skin of the abdominal
area. Inverted umbilicus, color is symmetric to the upper extremities
and face.
A: Bowel sounds heard
Pe:
Pa: abdomen is soft and with doughy texture, warm to touch, no
masses present. No pain is elicited.
13.Extremities
I: Varicosities are present in both legs and feet and back of the hands;
scars are present on arms and legs.
P: Has equal pulsations in both sides of lower and upper extremities
14.Genitals refused
15.Rectum and Anus - refused
.
16.Neurologic Exam
18

Patient was conscious, oriented, and coherent. She was aware on what
is happening around her. She was actively voluntarily cooperative. She
was able to identify objects with open and closed eyes. She can also
answer questions appropriately and she was oriented.

Dante D. Atienza Jr.

Age: 38 y/o

Weight: 170lbs

Height:56

1. Skin
I: Skin is dark in color evenly, skin is elastic, and moles scattered on
skin on upper and lower extremities and only small healed scars are
present. Skin is intact, and no reddened areas.
P: There are no masses palpated. Skin temperature is warm and
clammy and skin is moist.
2. Nails
I: Nails are clean, slightly pink in color, convex curvature, nails are
evenly cut; tissue surrounding the nails is intact. Some nails on feet
have darkened in color (light brown) and with beaus line.
P: Nails are hard and immobile. Capillary refill at 2 sec, smooth texture.
3. Head, Face and Neck
I: Head and neck is symmetrically aligned, head is normocephalic, held
still and upright. Neck is without bulging mass. Symmetric facial
movements, Hair is short and black in color some strands of hair are
white, thick and evenly distributed, no presence of flakes.
P: No lumps or masses, no inflammation of lymph node in the face,
there is presence of pulsations on temporal artery.
4. Eyes
I: Eyebrows are black in color and symmetrically aligned, no
discharges, pupils are equally round and reactive to light and
accommodation. There is no discoloration of the eye, sclera appears
white, and eyes are at the level of the ears, can follow the six ocular
movements
P: Absence of masses and tenderness and discharges on inner and
outer cantus upon palpation
5. Ears
I: Color same as facial skin, both are symmetric and evenly aligned to
the head and auricle of the ear aligns with aligned to the corner of the
eye. Can react to sounds or noises, normal voice tone audible, able to
hear snapping fingers on both ears.
P: No tenderness, no lesions and masses
6. Nose and Sinuses
I: upon assessment the nose is symmetrical and able to sniff through
each nostril, no discharges or nasal flaring, same color of the face, no
lesions and deformities
P: No tenderness and masses felt over bony prominence above each
eye and maxillary sinuses.
7. Mouth and Pharynx
I: Lips are pinkish brown in color, teeth are intact and 2 false teeth on
the upper front have 32 slight yellow stained teeth. Gums are pink and
tight margins to the tooth. No bulging masses. Tongue is pinkish in
19

appearance and is in midline, moves freely up, down and sideward.

Uvula hangs freely in the midline.
P: The client elicits gag reflex. And tongue offers strong resistance on
up, down, and side to side pressure.
8. Spine
I: The patient has no bone deformities. The spine is vertically aligned
Right and left clavicles and hips are at the same height.
P: No masses or tenderness noted.
9. Thorax/Chest
I: the posterior and anterior thorax is uniform in color. No lesions or
bulging mass noted. No respiratory distress noted. Ratio of AP
diameter is 1:2
Pa: No masses or tenderness are present. Has uniform body
temperature. Has symmetric chest expansion.
Pe: normal resonance sounds is elicited upon percussion of the
thorax/chest.
A: Lung sounds are clear to auscultation bilaterally. No abnormal breath
sounds was heard.
10.Cardiovascular and Peripheral Vascular/Heart
I: There are no heaves noted on the chest of the patient. No pulsations
noted.
A: No bruit was noted. No extra heart sounds noted.
P: No masses or tenderness palpated.
11.Breast and Axilla refused
12.Abdomen
I: Presence of striae and small healed on the skin of the abdominal
area. Inverted umbilicus, color is symmetric to the upper extremitites
and face.
A: Bowel sounds heard
13.Extremities
I: Varicosities are present in both legs, scars are present on arms and
legs.
P: Has equal pulsations in both sides of lower and upper extremities
14.Genitals refused
15.Rectum and Anus - refused
.
16.Neurologic Exam
Patient was conscious, oriented, coherent and cooperative. He was
able to identify objects with open and closed eyes. He can also answer
questions appropriately and he was oriented.

Lucila S. Atienza
20

Age: 47 y/o

Weight: 141 lbs

Height: 54

1. Skin
I: The client has an evenly fair skin tone, wrinkles around the eyes and
moles scattered on facial skin and on upper and lower extremities and
only small scars are present on extremities. Skin is intact, and no
reddened areas. Calluses are present on the sole. Has 3 large scars
from 3 cesarean delivery.
P: There are no masses palpated. Skin is smooth, temperature is warm
and clammy and skin is dry but has good mobility and turgor.
2. Nails
I: Nails are clean, thick, and slightly pink in color, convex curvature,
nails are filed; tissue surrounding the nails is intact with beaus line.
P: Nails are hard and immobile. Capillary refill is present at 2 sec,
smooth texture.
3. Head, Face and Neck
I: Head and neck is symmetrically aligned, head is normocephalic, held
still and upright. Neck has slight cervical curvature, good flexion
without bulging mass. Symmetric facial movements, Hair is short and
black in color, thick and evenly distributed, no presence of flakes.
Facial wrinkles are prominent.
P: No lumps or masses, no inflammation of lymph node in the face,
there is presence of pulsations on temporal artery.
4. Eyes
I: Eyebrows are black in color and symmetrically aligned, no
discharges, pupils are equally round and reactive to light and
accommodation. There is no discoloration of the eye, sclera appears
white, and eyes are at the level of the ears, can follow the six ocular
movements. The vision of client is 120/120 she.
P: Absence of masses and tenderness and discharges on inner and
outer cantus upon palpation
5. Ears
I: Color same as facial skin, both are symmetric and evenly aligned to
the head and auricle of the ear aligns with aligned to the corner of the
eye. Can react to sounds or noises, normal voice tone audible, able to
hear snapping fingers on both ears.
P: No tenderness, no lesions and masses
6. Nose and Sinuses
I: upon assessment the nose is symmetrical and able to sniff through
each nostril, no discharges or nasal flaring, same color of the face, no
lesions and deformities
P: No tenderness and masses felt over bony prominence above each
eye and maxillary sinuses.
7. Mouth and Pharynx
I: Lips are pinkish brown in color, all teeth are intact slightly yellow
stained with pasta at left lower molar. Gums are pink and tight. No
bulging masses. Tongue is pinkish in appearance and is in midline,
moves freely up, down and sideward. Uvula hangs freely in the midline.
Hard palate is pale with transverse rugae.
P: The client elicits gag reflex. And tongue offers strong resistance on
up, down, and side to side tongue pressure.
21

8. Spine
I: The patient has a straight spinal cord, without any deformities. The
spine is vertically aligned right and left clavicles and hips are at the
same height and moves symmetrically.
P: No masses or tenderness noted.
9. Thorax/Chest
I: the posterior and anterior thorax is uniform in color. No lesions or
bulging mass noted. No respiratory distress noted. Ratio of AP
diameter is 1:2.
Pa: No masses or tenderness are present. Has uniform body
temperature. Has symmetric chest expansion.
Pe: normal resonance sounds is elicited upon percussion of the
thorax/chest.
A: Lung sounds are clear to auscultation bilaterally. No abnormal breath
sounds was heard.
10.Cardiovascular and Peripheral Vascular/Heart
I: There are no heaves noted on the chest of the patient. No pulsations
noted.
A: No bruit was noted. No extra heart sounds noted.
P: No masses or tenderness palpated.
11.Breast and Axilla -refused
12.Abdomen
I: Presence of striae and large scars due to past CS deliveries on the
skin of the abdominal area. Inverted umbilicus, color is symmetric to
the upper extremities and face.
A: present bowel sounds
Pe:
Pa: abdomen is soft and with doughy texture, warm to touch, no
masses present. Fundus is firm, at the midline and tenderness is
present when palpated. No pain is elicited.
13.Extremities
I: Varicosities are present in both legs and feet and back of the hands;
scars are present on arms and legs.
P: Has equal pulsations in both sides of lower and upper extremities
14.Genitals refused
15.Rectum and Anus refused
16.Neurologic Exam
Patient was conscious, oriented, and coherent. She was aware on what
is happening around her. She was actively voluntarily cooperative. She
was able to identify objects with open and closed eyes. She can also
answer questions appropriately and she was oriented.

22

Hannah Grace S. Atienza

Age: 15y/o

Weight: 110 lbs

Height: 56

1. Skin
I: Colors is light brown and uniform.
P: The texture is smooth, even and smooth. Normal skin turgor. Warm
to touch.
2. Nails
I: Nailbeds are pink in color.Convex and curvature
P: Normal capillary refill.
3. Head, Face and Neck
I: The patients head is symmetrical to the body. The size, shape and
symmetry of skull is normal. The color of the skin is the same with the
rest of the body. Theres no distention of jugular vein.
P: The carotid artery is easily palpable and theres no enlarged lymph
nodes and
any tenderness. Theres no bruit sounds heard
while auscultation .
4. Eyes
I: Pupils are equally round, reactive to light and accommodation.It has
full ocular visions and peripheral visions. The eyebrows have equal hair
distribution and eyelashes are cured outward. The eyelids are color
light brown.
P: No abnormal findings
5. Ears
I: The ears are symmetric and proportional to the head, even in color
and consisitent with the rest of the skin. It is aligned with the
eyebrows.
P: Normal pinna recoil and no abnormal findings
6. Nose and Sinuses
I: Color is consistent with the rest of the skin. The client can tell the
smell od=f an object being presented.
P: No abnormal findings
7. Mouth and Pharynx
I: She has dry and pinkish brown colored lips. The tongue is moist.
Gums are pink and smooth. Tonsils are small, pink and symmetric in
shape
P: No abnormal findings
8. Spine
I: The spine is centrally placed no curvature.
P: No masses or tenderness noted.
9. Thorax/Chest

23

I: Chest is symmetric and color is consistent with the rest of the skin.It
has equal anterior and posterior excursion Pa: It has equal anterior and
posterior excursion
Pe:.
A: No abnormal breath sounds
10.Cardiovascular and Peripheral Vascular/Heart
I:
A: No bruit was noted. No extra heart sounds noted.
P: The pulmonic and aortic pulsations is easily palpable.. Peripheral
pulses are equal (radial, brachia, carotid, popliteal).
11.Breast and Axilla -refused
12.Abdomen
I: The patients abdomen has the same skin color with the rest of the
body.
Pe:
Pa: No masses and tenderness.
13.Extremities
I: The patients muscles, bones and joints are bilaterally symmetrical to
left and right side of body, scar present on left index finger
P: Theres no presence of edema, swelling, pain and tenderness
14.Genitals refused
15.Rectum and Anus - refused
.
16.Neurologic Exam
Patients is awake and alert. She is able to express self through
speaking and gestures. Muscles and bones are bilaterally symmetrical
to left and right side of the body. Movement of arms and legs are both
in normal power and coordinated with all senses

Jay Marvin S. Atienza

Age: 14y/o

Weight: 115lbs

Height: 57

1. Skin
I: Colors is fair and uniform.
P: The texture is smooth, it is also even and soft. Skin turgor and
mobility goes back after 2-3 seconds. The skin is also warm and dry.
2. Nails
I: Nailbeds are pink in color.Convex and curvature
P: Normal capillary refill.
3. Head, Face and Neck
I: The patients head is symmetrical to the body. The size, shape and
symmetry of skull is normal. The color of the skin is the same with the
rest of the body. Theres no distention of jugular vein.
P: The carotid artery is easily palpable and theres no enlarged lymph
nodes and
any tenderness. Theres no bruit sounds heard
while auscultation .
4. Eyes

24

I: The clients eye lashes is curled outward while the eyebrows have
equal hair
distribution. His conjunctiva is pink in color and the
sclera is white and clear. Pupils are equally round, reactive to light and
accommodation. The pupil response properly.
P: Absence of masses and tenderness and discharges on inner and
outer cantus upon palpation
5. Ears
I: The patients ears are symmetric to each other just above the level
of the eye. The
color of the skin is the same as the color of the face
P: Normal pinna recoil and no abnormal findings
6. Nose and Sinuses
I: The patients nose has the same color with the rest of the face. No
discharges seen, and has no pain and edema in maxillary and frontal
sinuses Color is consistent with the rest of the skin. The client can tell
the smell of an object being presented.
P: No tenderness and masses felt over bony prominence above each
eye and maxillary sinuses.
7. Mouth and Pharynx
I: Lips are pinkish in color. Gums are pink and tight. No bulging masses.
Tongue is moist, moves freely up, down and sideward. Tonsils are
small, pink and symmetric in shape
P: No abnormal findings
8. Spine
I: The spine is centrally placed no curvature.
P: No masses or tenderness noted.
9. Thorax/Chest
I: Chest is symmetric and color is consistent with the rest of the skin.It
has equal anterior and posterior excursion
Pa: It has equal anterior and posterior excursion
Pe:.
A: No abnormal breath sounds
10.Cardiovascular and Peripheral Vascular/Heart
I:
A: No bruit was noted. No extra heart sounds noted.
P: The pulmonic and aortic pulsations is easily palpable.. Peripheral
pulses are equal (radial, brachia, carotid, popliteal).
11.Breast and Axilla
12.Abdomen
I: The patients abdomen has the same skin color with the rest of the
body.
Pe:
Pa: No masses and tenderness.
13.Extremities
I: The patients muscles, bones and joints are bilaterally symmetrical to
left and right side of body
P: Theres no presence of edema, swelling, pain and tenderness
14.Genitals refused
15.Rectum and Anus - refused
25

.
16.Neurologic Exam
The patient is conscious and able to answer questions immediately.
Movements are well coordinated with the rest of the body parts.

John Oliver S. Atienza

Age: 13 y/o

Weight: 103 lbs

Height: 54

1. Skin
I : Color is light brown. Its texture is even, smooth, and intact.
P : Skin temperature is warm. Good skin turgor.
2. Nails
I :The nails are colored pink in nail beds & convex. Upon assessment, it
is 160 between the nail and base.
P : It has a smooth texture and capillary refill is 1-2 seconds.

3. Head, Face and Neck

I :Head is normocephalic while the color is consistent with rest of the
skin. It is symmetrical to the body. Eyes, nose, ears and mouth are
symmetrical to each other.
P : No other abnormal observations
4. Eyes
I : The eyes are parallel to each other.Pupils are equally round, reactive
to light and accommodation. It has good ocular visions and peripheral
visions while the eyebrows have equal hair distribution and eyelashes
are curled outward. The eyelashes are color black. The conjunctiva is
pinkish in color.
P : No other abnormal observations
5. Ears
I: The ears are symmetric and proportional to the head, smooth, even
in color and consistent with the rest of the skin. Auricles are normally
level to each other and smooth in texture. Good hearing acuity.
P : Has good pinna recoil and it can hear whispered voice from 1-2 feet
away from the patient.
6. Nose and Sinuses
I - Nose is symmetrical to the face and has neither underlying
deviations nor nasal discharge or flaring. Color is consistent with the
rest of the skin; the client can also identify the smell of an object
being presented such as perfume and alcohol.
P No other abnormal observations
7. Mouth and Pharynx

26

I- Lips are soft, moist, and pink. The tongue is located in the midline
and it moves freely from side to side and up and down. Gums are pink
and smooth. The tonsils are bilateral, small, pink and symmetric in
shape. Uvula is at the center.
P No other abnormal observations
8. Spine
I: The spine is centrally placed no curvature.
P: No masses or tenderness noted.
9. Thorax/Chest
I :Chest is symmetric and color is consistent with the rest of the skin.
Pa : It has equal anterior and posterior thorax excursion.
A :Normal Breath Sounds
10.Cardiovascular and Peripheral Vascular/Heart
I : No visible palpitations
A :No S3 or S4 sounds.
Pa : There is palpable pulsation on aortic and pulmonic and at Point of
Maximal impulse. Peripheral pulses are bilaterally equal (radial,
brachia, carotid, popliteal).
11.Breast and Axilla
12.Abdomen
I : Abdomen color is consistent with the rest of the skin Umbilicus is
centrally located.
A :No abnormal sounds
Pe :
Pa : No masses and tenderness
13.Extremities
I :Muscles and bones are bilaterally symmetrical to left and right side
of body. The patient can perform active range of motion.
P : No other abnormal observations
14.Genitals refused
15.Rectum and Anus - refused
.
16.Neurologic Exam
Patient is awake and able to cooperate with us during the interview.
Coordinated body movements.

27

VIII.

Typology of Nursing Problems

Second Level Assessment

Cues/Data

Family Nursing Plan

Hindi kami kumakain ng gulay. Ayaw

kasi ng mga bata. as stated
Herminia.

Mrs. Green verbalized Hindi kami

nag-papatingin agad sa doctor. Sa
albularyo kami nagpapatingin.
When Hannah Grace and John Oliver
had fever 2 months ago, they call
their neighborhood albularyo for help.
They only consult the doctor in cases
where in sickness becomes severe.

28

A. Faulty eating habits Health

Threat
1. Inability to recognize the presence
of the condition due to attitude in
life which hinders acceptance of a
problem
2. Inability to make decisions with
respect to taking appropriate
action due to:
a. Conflicting
opinions
among
family
members
regarding
action to take
b. Negative attitude towards the
health condition.
3. Inability to provide
adequate
nursing care to the sick, disabled,
dependent or at-risk member of
the family due to inadequate
knowledge
about
child
development and care.
B. Inappropriate Health Care
Health Deficit
1. Inability to recognize the presence
of the condition or problem due to
philosophy in life which hinders
acceptance of a problem.
2. Inability to make decisions with
respect to taking appropriate
action due to:
a. Failure to comprehend the
nature of the problem.
b. Negative attitude towards the
health condition.
c. Misconceptions about proposed
course of action.
3. Inability to provide
adequate

nursing care to the sick, disabled,

dependent or at-risk member of
the family due to philosophy in life
which hinders caring for the sick,
disabled,
dependent,
at-risk
member.
4. Failure
to
utilize
community
resources for health care due to
negative philosophy in life which
hinders effective or maximum
utilization of community resources
for health care.

Lucila, started having hypertension,

September last year.
She was given prescription by her
physician and has been taking her
Diovan (Valsartan) medications for
hypertension 80mg once a day, every
day for lifetime, since then as
maintenance.
Nakakadagdag sa gastos yung
gamot ni Lucila. As stated by the
client.

IX.

C. Hypertension Health Deficit

1. Inability to recognize the presence
of the problem due to denial about
its existence as a result of fear of
consequences of diagnosis of
problem,
specifically
cost
implications.
2. Inability to make decisions with
respect to taking appropriate
health actions due to:
a.
Failure to comprehend
the nature of the problem.
b.
Inaccessibility
of
appropriate resources for care,
specifically cost constraints.
3. Inability to provide
adequate
nursing care to the sick, disabled,
dependent or vulnerable/at-risk
family member due to:
a.
Inadequate
knowledge
and skill in carrying out the
necessary care.
b.
Inadequate
family
resources for care, specifically
absence of responsible member
and financial constraints.

Problem Scoring

A. Faulty eating habits

Criteria
Computation
1.
Nature of
the problem

2/3 x 1

29

Actual Score

Justification

0.67

The problem is a
health threat since
it may affect the

familys health.
2.
Modifiabil
ity of the Problem

2/2 x 2

The
problem
is
easily
modifiable
and the resources
are available.

3.
Preventiv
e Potential

3/3 x 1

The problem can

be
prevented
temporarily but it
affects the whole
community.

4.
Salience
of the Problem

2/2 x 1

The
family
recognizes as a
problem but does
need
immediate
action.

Total Score

4.67

B. Inappropriate Health Care

Criteria

Computation

Actual Score

Justification

1. Nature of the
problem

3/3 x 1

The problem is a health

deficit because they
call
the
albularyo
instead of seeing the
doctor.

1. Modifiability of
the problem

2/2 x 2

The problem is easily

modifiable
and
the
resources
are
available.

2. Preventive
Potential

3/3 x 1

The problem is high

prevention because the
health
center
is
available
and
accessible to them.

3. Salience
of
the Problem

1/2 x 1

0.5

It is perceived as a
condition
needing
change since it makes
them
well
without
doctors diagnosis.

TOTAL SCORE:

4.5

C. Hypertension
30

Criteria

Computation

Actual Score

Justification

1.
Nature of
the problem

3/3 x 1

The problem is a
health deficit since
it is a lifetime
illness and can be
hereditary or due
to lifestyle.

2.
Modifiabil
ity of the Problem

2/2 x 2

The
problem
is
easily
modifiable
and the resources
are available in the
health center.

3.
Preventiv
e Potential

3/3 X 1

The problem is high

prevention because
the health center is
available
and
accessible to them.

4.
Salience
of the Problem

2/2 x 1

The
family
recognized as a
problem.
It
consulted to the
health
personnel
and
needs
immediate action.

Total Score
X.

Priority Setting
RANK 1

Hypertension

RANK 2

Faulty Eating Habits

4.67

RANK 3

Inappropriate Health Care

31

4.5

32

XI.

Family Nursing Care Plan

Intervention Plan

Health
Problem

Family Nursing Problems

4.
Hypertension

5.

6.

Inability to recognize the

presence of the problem
due to denial about its
existence as a result of fear
of
consequences
of
diagnosis
of
problem,
specifically
cost
implications.
Inability to make decisions
with
respect
to
taking
appropriate health actions
due to:
a. Failure to comprehend the
nature of the problem.
b. Inaccessibility
of
appropriate resources for
care,
specifically
cost
constraints.

Goal of Care

Objectives of care

Nursing
Interventions

Method of
Nurse-family
contact

After
nursing
intervention,
the
family will be able to
have
adequate
knowledge
in
hypertension
treatments, nature,
causes, effects, and
management.

After
nursing
intervention, the family
will be able to:

1. Discuss:
a.
Nature
and
causes
of
hypertension.
b.
Signs
and
symptoms
of
hypertension.
c.
Possible effects
of hypertension.
d.
Benefits of the
treatment.
e.
Side
and
Adverse effect of
the medications.
f.
It will take 3-6
weeks for the full
therapeutic
effect
of the drug.

Home Visit and

a.
b.

Relieve symptoms
Comply
with
the
medications
prescribed by the
doctor.

Inability to provide adequate

nursing care to the sick,
disabled,
dependent
or
vulnerable/at-risk
family
member due to:
a. Inadequate knowledge and
skill in carrying out the
necessary care.
b. Inadequate
family
resources
for
care,
specifically
absence
of
responsible member and
financial constraints.

2.

33

Ask the client to:

a.
Check
blood
pressure
and
cardiac
rate
regularly.
b.
Decrease
potassium intake.
c.
Continue
medication even if
feeling well.
d.
Take
the
medication
same
time each day.

Clinic Visit

Resources
Required

Material Resources:
Visual Aids on teaching
principles
of
afterdeath call.

Human Resources:
Time and effort of the
nurse and the family.

Financial Resources:
Expenses for teaching
aids,
food,
and
transportation of the
nurse.

Intervention Plan
Health
Problem

Family Nursing Problems

1.

Inability

to

recognize

the

Goal of Care

Objectives of care

After

nursing

34

Nursing
Interventions

Method of
Nurse-family
contact

Resources
Required

Faulty Eating
Habits

presence of the condition due to

attitude in life which hinders
acceptance of a problem.

2. Inability to make decisions with

respect to taking appropriate
action due to:
a.
b.

3.

After
nursing
intervention,
the
family will be able to
understand
the
importance
of
balanced diet.

intervention, the family

will be able to:
a.

b.

Understand
the
importance
of
vegetables in the
body.
Eat
vegetables
regularly.

1. Discuss:
a.
b.

Food pyramid
Importance
balance diet

Home Visit and

Clinic Visit
of

Human Resources:
Time and effort of
the nurse and the
family.

b. Exercise regularly

3. Devise a food plan

that specifies total daily
calories (1600 kcal/day)
and includes all food
groups, with three meals
plus a light evening
snack.

Inability to provide adequate

nursing care to the sick,
disabled, dependent or at-risk
member of the family due to
inadequate knowledge about
child development and care.

Visual
Aids
on
teaching principles of
after-death call.

2. Ask the family to:

a.
Increase
vegetables intake

Conflicting
opinions
among family members
regarding action to take
Negative
attitude
towards
the
health
condition.

Material Resources:

Financial Resources:
Expenses
for
teaching aids, food,
and transportation of
the nurse.

Intervention Plan
Health
Problem

Family Nursing Problems

Goal of Care

Objectives of care

35

Nursing
Interventions

Method of
Nurse-family
contact

Resources
Required

Inappropriate

1.

Health Care

2.

Inability to recognize the

presence of the condition or
problem due to philosophy in
life which hinders acceptance
of a problem.

Inability to make decisions

with
respect
to
taking
appropriate action due to:
a. Failure to comprehend
the
nature
of
the
problem.
b.
Negative
towards
the
condition.

After
nursing
intervention,
the
family will be able to
acknowledge
the
importance
of
regular check up
with
health
care
providers.

After
nursing
intervention, the family
will be able to:
a.
b.

Visit the health care

providers for regular
check up.
Appreciate
the
health center within
their community.

Discuss:
a.
b.

Importance
of
regular check up.
Benefits
and
programs offered
by
the
health
facilities
within
the community.

Home Visit and

Clinic Visit

Material Resources:
Visual
Aids
on
teaching principles of
after-death call.

Human Resources:
Time and effort of
the nurse and the
family.

attitude
health
Financial Resources:

c. Misconceptions about
proposed
course
of
action.

3.

Inability to provide adequate

nursing care to the sick,
disabled, dependent or at-risk
member of the family due to
philosophy in life which
hinders caring for the sick,
disabled, dependent, at-risk
member.

4.

Failure to utilize community

resources for health care due
to negative philosophy in life
which hinders effective or
maximum
utilization
of
community
resources
for
health care.

Expenses
for
teaching aids, food,
and transportation of
the nurse.

36

XII.

Action Plans

HYPERTENSION
Time frame

2 weeks

Problem

Goals/Objective
s

Implementation

Risk to develop severe To

maintain Conduct
health
hypertension
normal
blood teaching
about
pressure
hypertension
treatments, nature,
causes,
effects,
To
monitor and management.
blood pressure
and cardiac rate
regularly

To
educate
family members
about
hypertension

37

Focus of
Responsibility

Affected family
member

Resources

Evaluation

BP
Apparatus After two weeks
and stethoscope of
health
education
and
implementation,
the client will be
able
to
be
compliant to the
medications

FAULTY EATING HABITS

Time frame

Problem

Goals/Objective
s

Implementation

Focus of
Responsibility

Resources

Evaluation

2 weeks

Readiness for enhanced

nutrition

To
follow
appropriate
standard
for
intake
according to the
food pyramid

Conduct
health
teaching
about
importance
of
balance diet, and
food pyramid.

Children

Visual aids or
pictures of food
pyramid,
malnutrition,
and obesity.

After two weeks

of
health
education
and
implementation,
the family eats
balance
diet
meals.

Conduct
cooking
To be free from sessions with the
malnutrition or mother
to
obesity
implement
the
intake
of
vegetables within
the
dishes
that
children will like.

38

Real vegetables

INAPPROPRIATE HEALTH CARE

Time frame

Problem

Goals/Objective
s

Implementation

Focus of
Responsibility

2 weeks

Health seeking behavior

To
express
desire
to
change specific
lifestyle
patterns
to
maintain
optimal health

Conduct
health
teaching
about
importance
of
regular check up
and benefits given
by
the
health
center.

The whole family

To
seek
community
resources with
desired change

Have the family to

tour to the health
facilities within the
community.

39

Resources

Evaluation

Time and money After two weeks

for
of
health
transportation
education
and
implementation,
the family visits
the
health
center
for
regular
check
ups.

XIII.

Evaluation
Criteria

Mark if observed
YES

1. The family was

able
to
be
compliant with
their
medications.
2. The family was
able
to
take
balance
diet
meals.
3. The family was
able
to
recognize
the
health
center
and its offered
programs.
4. The
family
practices regular
check-ups.

Remarks
NO

40

XIV.

Recommendation
Our group came up with the following recommendations to help the
family cope up with the existing health problems, promoting proper nutrition,
and maximizing the benefits of health facilities within the community:
1. Assess their preparedness and capabilities to learn additional knowledge
about health promotion and health lifestyle of the family.
2. Educate the family about the benefits and programs offered by the health
facilities within the community.
3. Regular consultation and monitoring of the family members health status
promotes wellness.
4. Compliance with the medications and proper treatment helps the family
maintain healthy lifestyle.

41

List of Appendices
Appendix A
I.

Family Functional Health Patterns Assessment

A. Health Perception-Health Management Pattern
1. History
a. How has familys general health been (in the last few years)?
___________________________________________________________________
___________________________________________________________________
________________________________________________
b. Colds in the past year? Absence from work/school due to health
reasons?
___________________________________________________________________
___________________________________________________________________
________________________________________________
c. Most important thing you do to keep healthy? Do you think these
make a difference to health?
___________________________________________________________________
___________________________________________________________________
________________________________________________
Members use of cigarettes, alcohol, drugs?
___________________________________________________________________
___________________________________________________________________
________________________________________________
d. Immunizations? Health care provider? Frequency of checkups?
Accidents (home, work, school, driving)?
___________________________________________________________________
___________________________________________________________________
________________________________________________
e. In the past, has it been easy to fins ways to follow suggestions of
doctors, nurses, social workers?
___________________________________________________________________
___________________________________________________________________
________________________________________________
f. Are there things important in the familys health that I could help
with?
___________________________________________________________________
___________________________________________________________________
________________________________________________
2. Examination
a. General appearance of family members and home.
___________________________________________________________________
___________________________________________________________________
________________________________________________
b. If appropriate: Storage of medicines, location of cribs, playpens,
stove, scattered rugs, presence of hazards etc.
___________________________________________________________________
___________________________________________________________________
________________________________________________

42

B. Nutritional-Metabolic Health Pattern

1. History
a. Typical family meal pattern/food intake? Make a 24 hours meal
pattern table.
b. Typical family fluid intake. (Describe). Supplements: types available
(fruit juices, carbonated beverages, coffee, etc.)?
___________________________________________________________________
___________________________________________________________________
________________________________________________
c. Does family have good appetite?
___________________________________________________________________
___________________________________________________________________
________________________________________________
d. Anyone on the family with dental problems? How often does the
family visit the dentist?
___________________________________________________________________
___________________________________________________________________
________________________________________________
e. Any skin problems/ healing problems in the family?
___________________________________________________________________
___________________________________________________________________
________________________________________________
2. Examination
If opportunity available: Describe refrigerator contents, meal
contents and preparation, etc.
_________________________________________________________________
_________________________________________________________________
______________________________________________
C. Elimination Pattern
1. History
a. Family members use of laxatives or any other aids in elimination?
___________________________________________________________________
___________________________________________________________________
______________________________________________
b. Problems in waste / garbage disposal?
___________________________________________________________________
___________________________________________________________________
______________________________________________
c. Any pet animals at home? How are wastes disposed? (indoor/
outdoor)
___________________________________________________________________
___________________________________________________________________
______________________________________________
d. If indicated: Any problems with flies, roaches, rodents in your
house?
___________________________________________________________________
___________________________________________________________________
______________________________________________
2. Examination
If opportunity available: examine toilet facilities, garbage and pet
waste disposal;
Indicators of risk for flies, roaches, rodents
D. Activity-Exercise Pattern
43

1. History
a. In general, do family get a lot/ little exercise? Type? Frequency?
__________________________________________________________________
__________________________________________________________________
________________________________________________
b. Are there any family leisure activities? Active/ Passive?
__________________________________________________________________
__________________________________________________________________
________________________________________________
c. Are there problems in shopping (transportation), cooking, keeping
up the house, budgeting for food. Clothes, housekeeping, house
cross?
__________________________________________________________________
__________________________________________________________________
________________________________________________
2. Examination
Describe pattern of general home maintenance, Personal
maintenance.
_________________________________________________________________
_________________________________________________________________
______________________________________________
E. Sleep-Rest Pattern
1. History
a. Generally family members seem to be well rested and ready for
school /work?
___________________________________________________________________
___________________________________________________________________
______________________________________________
b. Is there sufficient space? Is it quiet or noisy?
___________________________________________________________________
___________________________________________________________________
______________________________________________
c. Does the family find time to relax?
___________________________________________________________________
___________________________________________________________________
______________________________________________
2. Examination
If appropriate: Observe sleeping space and arrangements.
_________________________________________________________________
_________________________________________________________________
______________________________________________
F. Cognitive-Perception Pattern
1. History
a. Is there any member of the family with visual or hearing problem?
How was it managed?
___________________________________________________________________
___________________________________________________________________
______________________________________________
b. Any big decisions family has to make? How was it made?
___________________________________________________________________
___________________________________________________________________
______________________________________________
2. Examination

44

a. If indicated: Language/ Dialect spoken at home?

__________________________________________________________________
__________________________________________________________________
________________________________________________
b. Grasp of ideas and questions (abstract/concrete)?
__________________________________________________________________
__________________________________________________________________
________________________________________________
c. Vocabulary Level
__________________________________________________________________
__________________________________________________________________
________________________________________________
G. Self Perception-Self Concept Pattern
1. History
a. Most of the time , do the family members feel food/ not so good
about themselves as a family
__________________________________________________________________
__________________________________________________________________
________________________________________________
b. General mood of family? Happy? Anxious? Depressed?
What affects family mood?
__________________________________________________________________
__________________________________________________________________
________________________________________________
H. Roles-Relationship Pattern
1. History
a. Name of family (or household) members? Indicate age and family
structure (nuclear/extended). Draw a family tree or diagram
Name

Relationship to the
head of the family

Age

Sex

Educational
Attainment

b. Any family problems that is difficult to handle? Child rearing? If

appropriate: Spouse/Parents (should be included if children are
interviewed) or children ever get rough with you?
___________________________________________________________________
___________________________________________________________________
______________________________________________
Family Assessment
c. Relationship good/not so good among family members? Sibling?
Support each other?
___________________________________________________________________
___________________________________________________________________
______________________________________________
d. If appropriate: Is family income sufficient for needs?
___________________________________________________________________
___________________________________________________________________
______________________________________________
e. Does the family feel apart of (or isolated from) neighbors or
community?
___________________________________________________________________
45

___________________________________________________________________
______________________________________________
2. Examination
a. Describe interaction among family members (if present).
___________________________________________________________________
___________________________________________________________________
______________________________________________
b. Observe family leadership roles.
___________________________________________________________________
___________________________________________________________________
______________________________________________
I.

Sexuality-Reproductive Pattern
1. History
a. If appropriate (sexual partner within household or situation):
Sexual relationships satisfying? Any problem or changes?
__________________________________________________________________
__________________________________________________________________
________________________________________________
b. Use of family planning methods? Problems?
__________________________________________________________________
__________________________________________________________________
________________________________________________
2. Examination: None

J.

Coping-Stress Tolerance Pattern

1. History
a. Any big changes within the family in the last few years?
___________________________________________________________________
___________________________________________________________________
______________________________________________
b. Family tensed or relaxed most of the time? When tense, what
helps? Use of medicines, drugs, alcohol to decrease tension?
___________________________________________________________________
___________________________________________________________________
______________________________________________
c. When family problems arise, how is it being handled?
___________________________________________________________________
___________________________________________________________________
______________________________________________
d. Most of the time, is this way successful?
___________________________________________________________________
___________________________________________________________________
______________________________________________
2. Examination: None

K. Values-Beliefs Pattern
1. History
a. Generally, does the family get what it wants from life?
___________________________________________________________________
___________________________________________________________________
______________________________________________
b. Important goals for the future?
___________________________________________________________________
___________________________________________________________________
______________________________________________
46

c. Any rules in the family that everyone believes important?

___________________________________________________________________
___________________________________________________________________
______________________________________________
d. Is religion important in the family? Does this help when difficulties
aries?
___________________________________________________________________
___________________________________________________________________
______________________________________________
2. Examination: None
II.

FAMILY STRENGTH AND WEAKNESSES

A. Identify two family strengths and why do you say so? How can this
be mobilized to solve other family concerns/problems?
___________________________________________________________________
___________________________________________________________________
______________________________________________
B. Identify two family weaknesses and why do you say so How can
this be strengthened to help develop the family?
___________________________________________________________________
___________________________________________________________________
______________________________________________

III.

PERCEPTION ON MY FAMILYS LEVEL OF FUNCTIONING:

Instruction: For each statement listed below, indicate your answer
by placing a check ( / ) on the corresponding columns marked Almost
always, Some of the Time or Hardly ever. Then total your score for each
of the five statements.
ALMOS
T
ALWAY
S 2PTS

STATEMENTS

1. I am satisfied with the help that I receive

from my family when something is
troubling me
2. I am satisfied with the way my family
discusses topics of common interest and
shares problems solving with me.
3. I find that my family accepts my wishes to
take on new activities or make changes in
my lifestyle.
4. I am satisfied with the way my family
expresses affection and responds to my
feelings of anger, sorrow and love.
5. I am satisfied with the amount of time my
family and I spend together.
TOTAL SCORE: 10 points
Appendix B

47

SOME
OF THE
TIME
1PT

HARDL
Y EVER
0PT

Scale for Ranking Health Conditions and

Problems According to Priorities
Criteria

Weight

Scale

1. Nature of the condition or problem presented

Wellness State
Health Deficit
Health Threat
Foreseeable Crisis

3
3
2
1

2
1
0

3
2
1

Scale

2. Modifiability of the condition of problem

Easily Modifiable
Partially Modifiable
Not Modifiable

Scale

3. Preventive Potential

High
Low
Moderate

4. Salience

Scale

A condition or problem needing immediate

attention
A condition or problem not needing immediate
attention
Not perceived as a problem or condition needing
change

48

1
0

Appendix C
Manila Doctors College
College of Nursing
COMMUNITY HEALTH SURVEY TOOL
Control No:
Head of the Family (HF) (Kinikilalang puno ng pamilya):

Date:

I.

DEMOGRAPHIC INDICES
A. Family Information
Complete Address (tirahan):
Extended
Length of Residency (tagal ng paninirahan sa lugar):
sa nasabing bahay):
Ethnic Background (etnikong grupo na kinabibilangan):
( ) Matriarchal
Primary Dialect Spoken (pangunahing salitang ginagamit):
Egalitarian
Place of Origin (rehiyong pinanggalingan):
No
.

Name of Family
Members
(pangalan ng
miyembro ng pamilya)

Sex
(kasaria
n)

Age
(Edad
)

Type of Family (uri ng pamilya): ( ) Nuclear ( )

No. of Families in the House (bilang ng pamilya
Type of Family according to authority: ( ) Patriarchal
( )

Birth Date
(araw ng
kapanganakan)
Month/Day/Year

49

Birth Place
(lugar ng
kapanganakan
)

Civil
Status
(Estadon
g Sibil)

Religion
(relihiyon)

Relationship
to HF
(relasyon sa
puno ng
pamilya)

Ethnic Background: Igorot, Negrito, Kalinga, Mangyan, Maranaw, Manobo, Badjao, Matigsalug, Tasaday, Tausug, etc.
Civil Status: S (single) M (married)
W (widowed)
Sep (separated) CL (common law)
Relationship to HF: Wife (W) Husband (H)
Son (S)
Daughter (D)
Mother (M)
Father (F)
Grandfather (GF) Grandmother (GM)
Sister (Sis)
Brother (Bro)
Uncle (Un)
Auntie (Au)
Others (specify)
B. OCCUPATION (15y/o and above but may include working individual below 15)
Name of Family
Members (pangalan
ng miyembro ng
pamilya)

Age
(eda
d)

Occupation
Unemploy
ed

Employed
Privat
e

Governme
nt

SelfEmploy
ed

Nature of
Occupation

Place of Work

Estimated
Monthly
Income

C. EDUCATION (7 y/o and above)

Name

Ag
e

No
Formal
Educatio
n

Elementary Level
Out
of
Scho
ol

Still
Studyin
g

Undergradua
te

Graduat
e

High School Level

Out of
School

Still
Studyin
g

50

Undergradua
te

Graduat
e

College Level
Out
of
Scho
ol

Still
Studyin
g

Undergradua
te

Graduat
e

Others
(Please
Specify)

Out of school: if a person whose age is proper for an educational level, but nit currently enrolled in the same level.
Undergraduate: a person who did not finish an educational level and his/her age is no longer appropriate to the same level.
Age Brackets Per Level Elementary 7-12 y/o, High School 13-17 y/o, College 18-23y/o.
1.) Source of income
Primary Source:
Other sources of income or livelihood
(iba pang pinagkukuhaan ng kabuhayan)
You can check more than one.
( ) Sari-sari store
( ) Livestock
( ) Craft making
( )Public utility
( ) Others, pls. specify:

4.) First 5 priorities for expenditure. Rank 1 to 5, 1 as the

highest and 5 as the least priority.
Food (pagkain)
Health (kalusugan)
( ) Farming
( )Fishing
Clothing (damit)
tubig, etc)

2.) Average family income (buwanang kita ng pamilya)

Income
P 1,000 and below
P 1,001 5,000
P 5,001 10,000
P 10,001 15,000
P 15,001 20,000
P 20,001 25,000
P 25,001 30,000
P 30,001 35,000
P 35,001 and Above
3.) Monthly family expenditure (buwanang gastusin ng pamilya)
Expenditure
P 1,000 and below

House rental (upa sa bahay)

Education (edukasyon)
Housebills (bayad sa kuryente,

Others, pls. specify:

5.) Land and House ownership
a.) Land ownership (pagmamay-ari ng lupang tinitirahan)
( ) Owned ( ) Rented ( ) Rent to own
( ) Rent
Free
( ) Others, pls. specify:
b.) House ownership (pagmamay-ari ng bahay na tinitirahan)
( ) Owned ( ) Rented ( ) Rent to own
( ) Rent
Free
( ) Others, pls. specify:
6.) Type of materials used for building the house (yari ng
bahay)
( ) Light
( ) Concrete
( ) Mixed
7.) House Ventilation
( ) Well ventilated ( ) Fair
51
8.) Source of Light
( ) Electricity
( ) Others, pls. specify:

( ) Poorly ventilated

( ) Kerosene

( ) Candle

P 1,001 5,000
P 5,001 10,000
P 10,001 15,000
P 15,001 20,000
P 20,001 25,000
P 25,001 30,000
P 30,001 35,000
P 35,001 and Above
ENVIRONMENTAL INDICES

3. Garbage
a. Waste Segregation ( ) Yes
( ) No
( ) Sometimes
b. Container used for garbage collection (pinaglalagyan ng iniipong
basura)
( ) none
( ) Garbage bag ( ) Sack
( ) Trash can/pail)
II.
( ) others, pls. specify:
c. Condition of garbage container? (kalagayan ng lalagyan ng basura)
A. WATER SUPPLY
( ) Covered ( ) Uncovered
1. Source of drinking water (pinagmumulan ng inuming tubig) d. Types of disposal ( ) collected
( ) open dumping ( ) burning
( ) Level I- Point source (without distribution system- protected
( ) composting
( ) throw in river/canals
well, developed spring)
( ) others, pls. specify:
( ) Level II- Faucet system (piped and communal faucet)
( ) Level III- Individual household connection
C. ANIMALS AND PESTS
( ) Commercially prepared
a. Domestic animals
( ) Others, pls. specify:
Kind (uri ng
Numb
Vaccination
Status
alagang
er
With
W/o
Chained Astray
Either
2. Storage of drinking water (paraan ng pag-iimbak)
hayop)
(bilang
(meron
(wala) / Caged/
( ) Covered
( ) Uncovered
)
)
Penned
Dogs
3. Method used in water treatment (paraang ginagamit upang
mapanatiling malinis ang inuming tubig)
Cats
( ) None ( ) Boiling ( ) Sedimentation ( ) Chlorination
Others, pls.
( ) Filtration
( ) Processed (multi- stages)
Specify:
( ) others, pls. specify:
b. Presence of vectors, rodents and other pests
B. WASTE DIPOSAL
( ) mosquitoes
( ) roaches ( ) termites ( ) flies
( )
1.) Excreta
rodents
a. Type of toilet (uri ng palikuran)
( ) others, pls. specify:
( ) No toilet
( ) Open pit privy ( ) Closed/
c. Ways to control
Covered pit privy
Breeding place of:
Ways to control
Effective
( ) Water-sealed
( ) Flush
( ) others, pls. specify:
Yes
No
Mosquitoes
b. Ownership of toilet (pagmamay-ari ng palikuran)
Roaches
Termites
52
Flies
Rodents
Others (specify):

( ) Private (sariling palikuran)

( ) Public (gamit pambayan
( ) Shared (may ibang pamilyang gumagamit) ( ) N/A(no toilet)
2.) Sewerage
a. Sewerage system
( ) Blind drainage
( ) Open drainage ( ) none
b. Condition of sewerage (kalagayan ng tubig)
( ) Free-flowing( ) Stagnant
( ) N/A (blind drainage)
III.
HEALTH INDICES
A. Morbidity (past 6mos.)
Illness
Acute lower RTI
andPneumonia
Acute Diarrhea
Influenza
Hypertension
TB Respiratory
Parasitism
Chickenpox
Diseases of the Heart
Malaria
Dengue Fever
UTI
Scabies
DM
Others, pls. specify:
B. Mortality (past 5 years)
1.)Infant Mortality (0-1 year)
Illness
Neonatal sepsis

Age

Sex

Treatment
With Without

2.) Maternal Mortality

(Related to pregnancy, labor, delivery Puerperium)
Cause of Death

Age

Intervention
With
Without

Complications
Hypertension
Hemorrhage
Pregnancy with
abortive outcome
Others, pls. specify:
3.) Other Mortality
Cause of Death

Age in
month
s

Treatment
With

Withou

Heart Disease
Vascular System
Diseases
Malignant
Neoplasm(Ca)
Pneumonia
Tuberculosis, all forms
Chronic lower
respiratory diseases
Diabetes Mellitus
Acute Peptic Ulcer
Others, pls. Specify:
53

Age

Sex

Interventions
With
Without

t
Pneumonia
Congenital malformations of the
heart
Disorders related to short
gestation and low birth weight
Intrauterine hypoxia and birth
asphyxia
Diarrhea
Others, pls. specify:
C. For women of reproductive age (15-45 y/o)
1.)Previous pregnancy (Last 3 pregnancies, if applicable)
No.

With iron
supplemen
t
Yes
No

If no, why?

TT
immunizatio
n
Yes
No

If, no why?

Prenatal check
up of at least
3x
Yes
No

If no, why?

1st
2nd
3rd
2.)Previous deliveries (Last 3 deliveries, if applicable)
No
.

Docto
r
P G

1st
2nd
3r
d
Legend:

Nurse
P

Midwif
e
P
G

P-Private

Traditional Birth
Attendant

Others, specify

Reason for choosing

the person to handle
delivery

G-Government

54

Post Partum visits

Yes

No

Why?

3.)Present Pregnancy
Name

Obstetric
Score
G

LMP

AOG

EDD/
EDC

Prenatal Checkup
1st

2n
d

3rd

Tetanus Toxoid

Reason for
absence or
Incomplete TT
immunization
5

With
iron
supplem
ent
Yes No

If no, why?

A
L
Legend: G-Gravida

P-Parity

(T-full term delivery; P-preterm delivery; A-abortion/miscarriage; L-living)

D. For Children
1) Immunizatio (0-8years)
Nam
e

Birth
date

BCG
1

2.)
Nam
e

ag
e

OPV
2

DPT
2

HEPA B
1
2

MEASLE
S
3

STATUS
(0-1)
NOT
FIC
FIC

STATUS
1 YEAR
Complet
e
Incomplete

Feeding(0-2 years)
Exclusiv
es
BF until

Complementa
ry
BF until 6 mos
&

Reasons for not BF until

6 mos.

Age of
weanin
g
55

Bottle Feeding
Formula
othe
Milk
rs

Other food given aside from

milk

Yes

6 mos.
No

1 day-2yrs
Yes
No

3.)Nutritional Status (0-72 mos.)

Name

Birthday

Nutritional Status:
E.

Age in months

N: Normal

Date of weighing

A: Above Normal

weight in kilogram

Nutritional Status( N,A, B)

B:Below Normal

For Married Couples Of Reproductive Age

1) Practice Family Planning (FP) ( ) Yes ( ) No ( ) Sometimes
2) If yes, for how long?
3) If no, why?
4) If sometimes, reason for not consistently using FP
5) Family Planning Methods
Natural

Basal
Body

Awar
e

Not
aware

Utilize
d

Artificial

Aware

Not
aware

Utilize
d

Permanent

Vasectom
y

Condom
56

aware

Not
aware

Utilize
d

Willingness
to learn more
about
FP methods
Yes

No

What
topic

Temp

Tubal
Ligation

IUD
Injectible
hormonal
contraceptives
Pills

Calendar
Cervical
mucous
Lactationa
l
Amenorrh
ea
Others,

Others,

Others,

F. Other Practices Related to Health

1) Food
a) Food Frequently eaten ( Pagkaing madalas kinakain)
( )Fish ( )Vegetable ( )Pork ( )Beef ( )junk food
( )canned or processed food Others, pls. specify:
b) Usual food preparation (pinakamadals na paraan ng pagluto)
( )Boiled ( )Fried ( )Broiled ( )Steamed
( )Raw
( )Others, pls. specify:
2) Smoker/s Alcoholic drinker/Prohibited drug user
a) Prohibited drug user (Kapamilya na gumagamit ng pinagbabawal na gamot)
( )Yes ( )No
b) Smoker/s(kapamilya na naninigarilyo) ( )Yes ( )No
57

c) Alcoholic Drinker (kapamilya na umiinum ng alak) ( )Yes ( )No

58