Pamantasan ng Lungsod ng Marikina108

Rainbow St. Cor. Russet St., SSS Village Concepcion Dos, Marikina City
COLLEGE OF HEALTH SCIENCES

In Partial Fulfillment of the Requirement in

Community Health Nursing (CHN- 1)

A FAMILY CASE STUDY

Presented to the Faculty

of the Pamantasan ng Lungsod ng Marikina,

College of Health Sciences

Presented by:

Level II Bachelor of Science in Nursing, Batch 2027

Abarca, Jhonley G.
Abasolo, Gwyneth Heart M.
Asuncion, Shamel Rose R.
Banaticla, Neil Bryan C.
Cos, Samantha Eunice J.
Fernandez, Maxene A.
Katon, Jerroen C.
Ladines, Nathaniel L.
Rey, Shaira Mae B.
Salcedo, Rameia Jean O.
Sese, Althea Marie B.
Victorio, Janina Ira S.
Villamor, Jasmin Nicole
Viterbo, Trisha B.

COMMUNITY PRECEPTOR:

Mrs. Filipina, Peñaverde RN, MAN

SEPTEMBER 2024
 ACKNOWLEDGEMENT

The researcher would like to extend heartfelt gratitude to all persons who in one way or

another have contributed efforts and support to make this endeavor a reality. The completion of

this case study would not have been possible without the participation and assistance of the

people whose names are not mentioned due to confidentiality. Their contributions are sincerely

appreciated and acknowledged. The researcher would also like to express gratitude specifically to

the following:

Above all to Almighty God for the spiritual enlightenment, the wisdom and constant flow

of ideas which help a great deal for lighting up the lamp of hope, encouragement, courage, and

patience to the success of this undertaking to the finish for all these graces, our prayers of

thanks.

Mrs. Filipina Penaverde , the community preceptor, and our respective Clinical

Instructor Mrs. Evelyn Cailao, Mr. Ron Lopez, for their expertise, support, and guidance for this

case study, and sharing their knowledge to us.

To the “B’ family who lent their time to participate in this case study, without you this

research won’t be possible. To our parents, for their financial support, encouragement, and

understanding thank you very much.

1
 TABLE OF CONTENTS

I. Chapter I --------------------------------------------------------------------------------------- 4-5

INTRODUCTION

II. Chapter II -------------------------------------------------------------------------------------- 6

OBJECTIVES OF THIS STUDY
a) General Objectives
b) Specific Objectives

III. Chapter III ----------------------------------------------------------------------------------- 7-75

INITIAL FAMILY DATABASE
A. Family Structure, Characteristics, and Dynamics 7-8
B. Socio- Economic and cultural Characteristics 8-9
C. Home and Environment. 9-10
D. Health assessment of Each Family Member 11-75
1. Past and Present Illness
a) Husband-Mr. F.JB
b) Wife- Mrs. E.L.B
c) Child 1- M.F.B
d) Child 2- N.F.B
2. Gordon’s 11 Functional Health Pattern ---------------------------------- 65-75
a) Health Perception/ Health Management Pattern
b) Nutritional – Metabolic Pattern
c) Elimination Pattern
d) Activity – Exercise Pattern
e) Sleep /Rest Pattern
f) Cognitive- Perceptual Pattern
g) Self- Perception and Self- Concept Pattern
h) Role – Relationship Pattern
i) Sexuality- Reproductive Pattern
j) Coping- Stress Tolerance Pattern
k) Value – Belief Pattern
E. Values, Habits, practice of Health Promotion, Maintenance, and Disease
Prevention

2
IV. Chapter IV ------------------------------------------------------------------------------------- 76-78
FAMILY BACKGROUND
a) Family History 76
b) Data Base of the Respondent 76-77
c) Family Tree 77
d) General Household Data 78

V. Chapter V -------------------------------------------------------------------------------------- 79-83

FAMILY COPING INDEX

VI. Chapter VI -------------------------------------------------------------------------------------84-85

TYPOLOGY OF NURSING PROBLEM

VII. Chapter VII ---------------------------------------------------------------------------------- 86-96

PRIORITIZING PROBLEMS

VIII. Chapter VIII -------------------------------------------------------------------------------- 97-102

FAMILY NURSING CARE PLAN

IX. Chapter IX ------------------------------------------------------------------------------------ 103-104

SUMMARY, EVALUATION, RECOMMENDATION

X. REFERENCES ------------------------------------------------------------------------------ 105

XI. APPENDICES ------------------------------------------------------------------------------- 106

3
 Chapter I

INTRODUCTION

Access to necessary health care services continues to be a major obstacle in many

communities, especially for low-income families. Among these communities, the cities of

the Philippines are one of the places that has been suffering from this social barrier, poverty.

Consequently, despite the wider range of medical assistance and higher budget for providing

public health care, only a limited number of indigents benefit from these public services (El

Omari, 2021). In addition, the families belonging to this social group often face a daunting

reality: the choice between meeting basic necessities, such as food and housing, and seeking

medical attention, to which most tends to neglect their health condition and focus more on

their daily needs. The implications of this dilemma extend beyond immediate health

concerns, contributing to a cycle of poor health outcomes, increased emergency room visits,

and higher long-term medical costs.

In the locality of Marikina City, various public medical services are accessible to

those who are in need of medical attention. However, the number of people that require

treatments continues to increase, and the competition for medical assistance arises among the

less privileged citizens. For this reason, immediate response to those with critical conditions

often had to wait for longer waiting time which either leads to an increased urge of availing

private services or to not seek any form of medical treatment due to financial constraints.

To further analyze and understand this occurring situation in the field of public

medical availability, the researchers were tasked to conduct a case study which highlights the
lived experiences of one of the chosen families living in the municipality of Marikina,

specifically Brgy. Malanday . The “B” Family was chosen among the families residing on

Violet Street. The researchers performed a home visit to gather necessary information related

to their health and further assess their health condition. Moreover, the “B” Family was

considered as part of the indigent population based on their current social status who has

difficulty in accessing medical assistance for their family, which ensures that the data to be

gathered are highly relevant to this study. The “B” family consists of 7 members which

includes Mr. F.B., Mrs. E. B., Ms. P. A. B., Mr. FRL. B., Ms. FRN. B., Ms. M.F. B., and Ms.

N.F. B. Mrs. E. B., does not have a permanent job but works extra jobs. Mr. F.B., works as a

fruit vendor around the City. And their daughter Ms. P. A. B., works as a secondary teacher.

While the other children still go to school. This academic paper aims to evaluate and

understand the lived experiences of families living in low-income circumstances who

struggle to avail medical services for the purpose of providing insights regarding systemic

issues that contribute to health disparities and emphasize the urgent need for equitable health

care solutions.

5
 Chapter II

OBJECTIVES OF THIS STUDY

General Objectives

At the end of this study, the family’s well-being and health status will be assessed and

improved through the appropriate nursing intervention. Along with that, they will be

knowledgeable enough about their condition and will be able to maintain their health.

Specific Objectives

1. Establish rapport with the family and obtain information about overall state and health

status

2. Perform a family physical assessment and interview them utilizing the 11 functional

pattern of Gordon's.

3. Analyze the gathered data or information.

4. Identify the potential health problems of the family as well as the issue that may impair

the way of their life.

5. Consider student nurse strength, community resources, and family resources while

developing effective nursing interventions for the highlighted challenges.

6. Created and put into action the nursing care plan

7. Evaluate the effectiveness of the nursing interventions performed to the family

8. Make suggestions on how to assist the family in maintaining or improving their health.

6
 Chapter III

INITIAL FAMILY DATABASE

Name Age Sex Civil Status Occupation Educational

Background

Mr. F.J.B 50 Male Married Food Vendor Elementary

Graduate

Mrs. E.L.B 49 Female Married Vocational

On Graduate
call(massage
therapist,care
of
elderly,laundr
y worker)

Mr. F.B. 22 Male Single Hotel College

Receptionist Graduate

Ms. MF. B. 9 Female Single Student Elementary

Student

Ms. NF.B 5 Female Single Student Preschool

Student

A. Family Structure, Characteristics, and Dynamics

The The “B” family is a typical nuclear family residing in Barangay Malanday, Marikina

City. Consisting of Mr. FB, who works as a fruit vendor, and Mrs. EB, who helps with her husband

and works different sidelines, such as being a massage therapist to support their five children. The

eldest, currently a teacher, no longer resides with the family, as she is expecting and lives with her

fiancé. The second child works as a hotel receptionist and is a university student. The third child is a

full-time university student and also lives with her eldest sister. The two youngest daughters are in

primary and preschool.

7
 The mother gets to decide most of the family's affairs, such as budgeting their finances and

determining when family members are sick and need healthcare. The father asks and supports the

mother’s decision, disciplines their children, and provides for the family as his work is the main

source of income for the family. The third child, Mr. F, also works to help with the expenses and to

provide for himself.

The family’s relationship is tight-knit, as the mother shows enthusiasm for her first

grandchildren while her eldest daughter is pregnant. She has bought baby clothes, blankets, and a

bouncing bed. The mother and father exchange roles in watching their two youngest daughters

whenever one is at work; the second child also helps whenever he’s on a day off. Whenever the

mother is free of work, she mainly does household chores, such as cooking and preparing her

children for school. The family described their relationship as being open with one another; the

siblings are affectionate and sweet, and although they have some arguments, they apologize to each

other and resolve it right away.

B. Socio- Economic and Cultural Characteristics

The “B” Family’s primary source of income is from their mother and father. Both of the

parents work as a food vendor. The mother also finds other sources of income such as working as a

Housekeeper, Massager, launderer, and taking care of the elderly. The father earns between

₱2,000.00- ₱3,000.00 and the mother earns between ₱5,000.00- ₱8,000.00 a month. Their 1st child
8
works as a hotel receptionist and finances some of the household expenses and the educational

expenses of the siblings.. Both of the parents’ sources of income are estimated to be ten thousand

pesos (₱10,000.00), which can go up if the eldest child’s income is added to the estimated monthly

income. Their estimated range of their weekly expenses is about three thousand five hundred pesos

(₱3,500.00) that affects their daily needs since the family said that they are trying to make the

money fit to their expenses.

Table . Budget Allocation of Family “B” per month

Expenditure Allotment (per month) Priority ranking

Food ₱7,250.00 1st

Medicines ₱1,200.00 2nd

Utility bills ₱1,000.00 3rd

Educational expenses ₱4,200.00 4th

Other expenses ₱500.00 5th

Estimated total monthly ₱13,650.00

expenses

Monthly income ₱14,400.00

₱250.00 (savings)

C. Home and Environment.

The family doesn't have their own house; they live in their mother-in-law's house. The construction

materials that are being used are made up of cement and wood. The size of their house is only half

of the first floor, 14 sqm. The house space is not enough for five family members, and based upon

the inspection, the house is not well organized. It has one small window beside the door, which is

9
the only ventilation in the house. The house has one small bedroom, which is used for the third

child; it has a living room that is also used as a dining and kitchen area; and also a small bathroom.

The small bedroom has an electric fan, and also in the living room, the bedroom has foam, pillows,

and blankets for the third child, and the rest of the family members sleep in the living room with

foam, pillows, and blankets.

In their kitchen area, the mother cooks using a gas stove. They mostly consume vegetables and

fruits. For eating, the family uses both stainless plates and spoons. Upon inspection, the house

doesn't have a sink for the kitchen; they only wash their dishes in front of the house. They have a

plastic drawer for storing the kitchen utensils and glasses. They don't have a refrigerator for storing

meat and keeping their food.

The family's primary source of water is Nawasa or Manila water. Their drinking water is mineral

water bought from the mineral water station. They separate their garbage into biodegradable and

non-biodegradable. Every Monday and Thursday, the garbage collector comes to their house to

collect their trash. The drainage system in their house is man-made (kanal), which is cleaned once a

month by barangay workers. The family always maintains cleanliness in their house, but there is a

presence of cockroaches, mosquitoes, rats, and flies due to the weather. The family uses a washing

machine to wash their clothes and bed sheets.

The family lives in a three-story house, but they only occupy the first floor because the other

relatives live on different floors. The family lives in a congested area. The community provides

both social and health services like schools, centers, and markets. The family owns a habal-habal,

which is a motorcycle with a sidecar, which they use to sell fruits and also for transportation.

10
D. Health assessment of Each Family Member

1. Past and Present Illness

a. Husband – Mr. FB
-He was hospitalized in February 2024 due to dehydration, high uric acid,
and acidity in his stomach. He has received all of his immunizations. He
had symptoms of COVID-19 and did self-medication.
b. Wife – Mrs. EB
-She occasionally suffers from asthma and takes salbutamol nebule to
treat her sudden attacks of asthma. She was also diagnosed with arthritis,
and she takes a vitamin B complex every night to treat her arthritis. In
June 2024, she went to the hospital to undergo a checkup on her breast.
She had a complication in the 4th month of her pregnancy with her first
child. She has received all of her immunizations.
c. Child 4 – Ms. MFB
-She has heart failure that she inherited on her mother's side. She had
received all of her immunizations. She went to the hospital last June 2024
to undergo a checkup for an ECG with her mother. She also takes Vitamin
C on a daily basis to boost her immune system.
d. Child 5 – Ms. NFB
-She went to the hospital to undergo a checkup with her mom in June
2024. She had taken all of her immunizations. Her recent ailment is on
August 15, 2024, she experienced fever, cough, and cold. She takes
Vitamin C on a daily basis to boost her immune system.

11
 2. Physical Assessment

Name Age Birth Date Height Weight

Mr. F.B 50 March 11,1974 5’4” 65kg (143.3 lbs)
Temperature Pulse rate Respiratory Blood pressure BMI
36.5 degrees 75 bpm rate 130/90 mmHg 23.9 Normal
19 cpm

AREAS TO BE METHOD NORMAL ACTUAL ANALYSIS

ASSESSED FINDINGS FINDINGS

SKIN INSPECTION Uniform skin color NORMAL

Skin color varies brown, No FINDINGS
from body part to presence of
body part. widespread color
change and lesions.
No presence of
widespread color
change; Erythema,
Cyanosis, Jaundice,
Pallor. No presence
of lesions.

PALPATION Skin Skin temperature is NORMAL

temperature warm to touch, and FINDINGS
For temperature, should be within temperature
moisture, texture, the normal reading is 36.5°C. but due to the
turgor. range (36.5°C to Skin moisture is weather the skin
37.5°C). sweaty. Skin turgor appears to be
is elastic and sweaty.
Skin moisture is mobile as it returns
normally to its position
smooth and dry. immediately.

Skin texture is
normally
smooth, soft,
and flexible.
Normally skin
returns
immediately to
12
 its position once
pinched.

HAIR INSPECTION Hair color and Hair is evenly NORMAL

distribution distributed, the FINDINGS
For color, should be color is black and
distribution, evenly no presence of
presence of distributed, infestation and
infestation, or there should be lesions.
lesions. no presence of
infestation or
lesions.

PALPATION Hair should The hair has no NORMAL

have no signs of signs of dryness FINDINGS
For moisture, thinning and it is smooth
thickness, presence brittleness, or and silky. There
of lesions. dryness. are some white
hairs but no lesions
No presence of or dandruff.
lesions such as
lumps or
masses.

SCALP INSPECTION Scalp is intact, White, clean, NORMAL

clean, smooth, smooth, and with FINDINGS
For color, and and free from no presence of
presence of lesions any lesions, lesions and
and infestation. infestation, or infestation.
scaling.

PALPATION Scalp should Scalp has regular NORMAL

have a regular contour and there FINDINGS
For contour, contour, no are no presence of
presence of lesions presence of lesions or
or tenderness lesions or tenderness.
tenderness.

13
NAILS INSPECTION Nail bed should Nail plate shape is ABNORMAL
be pink, no 160 degree convex, FINDINGS the nail
For nail bed color presence of the nails color pale. bed color should be
and nail plate widespread pink. The findings
shape. color change, may indicate pallor.
e.g., Pallor,
Jaundice, or
Cyanosis.

Nail plate shape

should be 160
degree convex.

PALPATION Nail condition The nail condition NORMAL

should be is rough and thick. FINDINGS due to
For nail condition, smooth, with The blanching of the work, cause
and capillary refill. uniform the nail bed is roughness of the
thickness. within 3 secs. nail condition.

Normal
blanching of
nail bed within 3
seconds.

HEAD INSPECTION Skull is The skull is NORMAL

symmetrical, symmetrical, FINDINGS
For skull contour, smooth, smooth and
and proportion to proportionate to proportionate to
body size. size, no size. There are no
deformities or deformities and
lumps. lumps.

PALPATION There should be No presence of NORMAL

no presence of tenderness, lesions, FINDINGS
For tenderness, tenderness, and masses.
presence of lesions lesions, or
or masses. masses.

14
FACE INSPECTION Symmetrical, Symmetrical with NORMAL
with round/oval, round appearance, FINDINGS
For shape, elongated, and no
symmetry and square abnormal/involunta
facial movement appearance. ry movements
observed.
No abnormal
movements
noted.

EYES INSPECTION Normally, light Straight; normal NORMAL

reflection on the and eyeballs are FINDINGS
For eye condition, eyes is equally symmetrical and
eyeballs, color of centered in both aligned in the
sclera, pupils and pupils. socket.
the lacrimal
apparatus

Eyeballs must be Symmetrical and

symmetrically aligned in the
aligned in the socket.
socket without
protruding or
sinking.
Reddish Sclera

Sclera is white and

Both pupils are
underlying
equal in size
structures are
(3mm).
visible.
Both eyes can
PERRLA – Pupils
accommodate light
are equal, round,
briskly. Able to
reactive to light
recognize objects
and
12-14 inches away.
accommodation.

PALPATION No swelling or Moist NORMAL

redness, no FINDINGS
drainage during
inspection and

15
 palpation the
nasolacrimal duct.
CONJUNCTIVA INSPECTION Bulbar conjunctiva Yellowish ABNORMAL
is clear, moist and FINDINGS
For color of smooth.
palpebral and Yellowish
bulbar conjunctiva conjunctiva could
be a sign of an
underlying health
conditions like liver
issues.
EYELASHES INSPECTION Eyelashes are No swelling and NORMAL
present, no lesions. FINDINGS
For distribution of swelling, no
hair, presence of lesions, or
lesions, or discharge
discharge. observed.

EYELIDS INSPECTION Eyelids are Effective closure, NORMAL

present, eyelids no swelling and no FINDINGS
For effective can close, and lesions.
closure and the direction of
presence of lesions, eyelids is
swelling, or aligned with the
discharge. eyeball. No
swelling, lesion,
or discharged
observed.

EARS INSPECTION Color of the ear The color of the NORMAL

matches the rest ear matches the FINDINGS
For color, of the client’s skin’s color. Both
symmetry, and size skin. Both ears ears are symmetric
proportion, should be and proportion to
presence of lesions symmetric and the head. There is
or discharge. proportion to the no presence of
head. No foreign deformities,
bodies, redness, lesions, redness
drainage, and drainage.

16
 deformities, and
lesions.

PALPATION Ear should be The ears are elastic NORMAL

elastic, there and have no FINDINGS
For texture and should be no presence of
elasticity. presence of tenderness and
tenderness, or lesions.
lesions.

WEBER’S TEST INSPECTION Sound should be NOT ASSESSED NOT ASSESSED

heard on the DUE TO DUE TO
center of the CLIENT’S CLIENT’S
head, or equally REFUSAL REFUSAL
on both sides of
ears.

RINNES TEST INSPECTION Normally, air NOT ASSESSED NOT ASSESSED

conduction DUE TO DUE TO
should be better CLIENT’S CLIENT’S
than bone REFUSAL REFUSAL
conduction.

NOSE INSPECTION Color is the The nose color NORMAL

same as the rest matches the skin's FINDINGS
For color of of the face, color and the nasal
external nose, nasal structure is septum is in the
mucosa, and nasal smooth and midline. The nasal
cavity condition. symmetric. mucosa is dark
Structure of nose, Nasal septum is pink, moist, and
presence of lesions in the midline, free of exudate.
or discharge. intact, and free
of ulcers. Nasal
mucosa is dark
pink, moist, and
free of exudate.
Nasal Cavity is
clear, moist, no
swelling,

17
 discharge, or
lesions.

PALPATION Normally, client Both nostrils are NORMAL

should be able clear and both FINDINGS
For patency and to breathe from patent. No
presence of lesions both nostrils, presence of lesions
or obstruction. there should be and obstructions.
no presence of
lesions or
obstructions.

SINUSES PALPATION Sinuses should The sinuses are NORMAL

be non-tender, non-tender and no FINDINGS
and no crepitus crepitus evident.
evident.

LIPS INSPECTION Lips are smooth, The lips is ABNORMAL

symmetrical, Symmetrical and FINDINGS
For color, texture, and moist dark.
symmetry Dark lips can be
without lesions
caused by
or swelling.
hyperpigmentation,
sun exposure,
dehydration or
unhealthy lifestyle
like smoking.

GUMS INSPECTION Gums are pink Pallor Pale gums may

in color with no indicate oral health
swelling, issues.
bleeding, or
pain.

TEETH INSPECTION 32 pearly white Incomplete set of Incomplete set of

teeth with teeth teeth can be caused
For color, and smooth surfaces by tooth extraction,
presence of lesions. and edges. tooth decay, and
Upper molars untreated cavities.
align with lower
molars, and

18
 upper incisors
slightly overlap
lower incisors.
No decay or
repairs.

TONGUE INSPECTION Tongue is pink, Midline and NORMAL

shiny, moist smooth FINDINGS
For alignment, moderate in size
texture, and color. with papillae
(little
perturbances)
present; with
visible veins and
no lesions,
ulcers, or
nodules.

NECK INSPECTION Neck should be The muscles of the NORMAL

equal in size, neck are FINDINGS
For size, range of with no symmetrical with
motion (ROM), presence of the head at a
and alignment of swelling, and no central position.
the trachea. limited neck The patient is able
movements, and to move head
the trachea’s through a full
alignment range of motion
should be without complaint
midline. of discomfort or
noticeable
limitation.

PALPATION No presence of No presence of NORMAL

masses and masses and FINDINGS
For lymph nodes, tenderness. tenderness on the
and thyroid glands. neck muscles,
lymph nodes,

19
 trachea, and
thyroid gland

POSTERIOR INSPECTION Anteroposterior NOT ASSESSED NOT ASSESSED

to transverse DUE TO DUE TO
THORAX diameter in ratio CLIENT’S CLIENT’S
of 1.2; chest REFUSAL REFUSAL
symmetric;
spine column
vertically
aligned. No
patches, no
abnormal
inspiratory
retraction of
interspaces.

PALPATION The skin should NOT ASSESSED NOT ASSESSED

be intact; DUE TO DUE TO
uniform CLIENT’S CLIENT’S
temperature. REFUSAL REFUSAL
The chest wall is
intact; uniform
temperature.
Full and
symmetric chest
expansion.

PERCUSSION Bilateral NOT ASSESSED NOT ASSESSED

symmetry of DUE TO DUE TO
vocal fremitus. CLIENT’S CLIENT’S
Fremitus is REFUSAL REFUSAL
heard most
clearly at the
apex of the
lungs.
Low-pitched
voices of males
are more readily
palpated than
higher pitched
20
 voices of
females.

AUSCULTATION Percussion notes NOT ASSESSED NOT ASSESSED

resonate except DUE TO DUE TO
over scapula. CLIENT’S CLIENT’S
REFUSAL REFUSAL

ANTERIOR INSPECTION Quiet, rhythmic, NOT ASSESSED NOT ASSESSED

and effortless DUE TO DUE TO
For the breathing respirations. CLIENT’S CLIENT’S
patterns, rate, Breathing REFUSAL REFUSAL
depth, the coastal pattern should
angle, shape of be smooth.
patient’s chest, and Costal angle is
color. less than 90°,
and the ribs
insert into the
spine at
approximately a
45° angle.

Normal rate of
breathing in
adults it is 46/16
per min. red
patches present,
ribs sloping
downward with
symmetric
interspaces.
Colors should
be even and
consistent with
the color of the
patient's face.
Shoulder should
be at the same
height. shape of
thorax –
elliptical shape.

21
 PALPATION It should be full NOT ASSESSED NOT ASSESSED
symmetric DUE TO DUE TO
For respiratory excursion; CLIENT’S CLIENT’S
excursion thumbs REFUSAL REFUSAL
tenderness, masses normally
and temperature. separate to 3-5
cm (1 ½ to 2 in).
Equal
expansion, no
tenderness, no
masses, skin
should be warm
and dry, no
pulsation should
be present.
Fremitus is
normally
decreased over
heart and breast
tissue.

PERCUSSION Normal lung NOT ASSESSED NOT ASSESSED

tissue resonant DUE TO DUE TO
For it’s different sound, rib flat CLIENT’S CLIENT’S
sound. sound. REFUSAL REFUSAL

AUSCULTATION Air brushing NOT ASSESSED NOT ASSESSED

through the DUE TO DUE TO
For full two respiratory tract CLIENT’S CLIENT’S
breaths and sounds during REFUSAL REFUSAL
inspiration
expiration
generates
different breath
sounds.

HEART PALPATION No strong NOT ASSESSED NOT ASSESSED

pulsation should DUE TO DUE TO
be palpable over CLIENT’S CLIENT’S
REFUSAL REFUSAL

22
 aortic and
pulmonic areas.

AUSCULTATION Apical has the NOT ASSESSED NOT ASSESSED

loudest sound; it DUE TO DUE TO
For heart sounds, should be 60-80 CLIENT’S CLIENT’S
rate, and rhythm, beats/min. No REFUSAL REFUSAL
and presence of murmurs should
heart murmurs be heard.

ABDOMEN INSPECTION Abdomen NOT ASSESSED NOT ASSESSED

should have a DUE TO DUE TO
For skin integrity, normal racial CLIENT’S CLIENT’S
contour, and tone, with no REFUSAL REFUSAL
symmetry, presence of
movement. lesions. Its
contour should
be flat and
should be
symmetrical,
with no visible
peristaltic
movement.

AUSCULTATION Normal bowel NOT ASSESSED NOT ASSESSED

sounds are up to DUE TO DUE TO
For bowel sounds 5 to 30 BS per CLIENT’S CLIENT’S
minute/ REFUSAL REFUSAL
quadrant.

PERCUSSION Normally, NOT ASSESSED NOT ASSESSED

tympany sounds DUE TO DUE TO
should be heard CLIENT’S CLIENT’S
generally across REFUSAL REFUSAL
the abdomen;
dull sounds are
only heard in
areas where the
kidney, spleen,

23
 and liver are
located.

PALPATION As palpation, NOT ASSESSED NOT ASSESSED

the client should DUE TO DUE TO
not feel any CLIENT’S CLIENT’S
tenderness, and REFUSAL REFUSAL
For tenderness,
there should be
masses
no masses
palpated.

Name Age Birth Date Height Weight

Mrs. E.B. 49 December 24,1974 149.86 cm 69 kg ( lbs)

Temperature Pulse rate Respiratory Blood pressure BMI

36.5°C 89 bpm rate 110/ 70 mmHg 30.7

Overweight
16 cpm

AREAS TO BE METHOD NORMAL ACTUAL ANALYSIS

ASSESSED FINDINGS FINDINGS

SKIN INSPECTION Uniform skin color NORMAL

Skin color varies brown, No presence FINDINGS
from body part to of widespread color
body part. change and lesions.
No presence of
widespread color
change; Erythema,
Cyanosis,
Jaundice, Pallor.
No presence of
lesions.

24
 PALPATION Skin Skin temperature is NORMAL
temperature warm to touch, and FINDINGS
For temperature, should be temperature reading
moisture, texture, within the is 36.5°C. Skin
turgor. normal range moisture is sweaty.
(36.5°C to Skin turgor is elastic
37.5°C). and mobile as it
returns to its position
Skin moisture is immediately.
normally
smooth and dry.

Skin texture is
normally
smooth, soft,
and flexible.
Normally skin
returns
immediately to
its position once
pinched.

HAIR INSPECTION Hair color and Hair is evenly NORMAL

distribution distributed and no FINDINGS
For color, should be presence of lesions/
distribution, evenly infestations.
presence of distributed,
infestation, or there should be
lesions. no presence of
infestation or
lesions.

PALPATION Hair should Hair is thick NORMAL

have no signs of FINDINGS
For moisture, thinning
thickness, presence brittleness, or
of lesions. dryness.

No presence of
lesions such as

25
 lumps or
masses.

SCALP INSPECTION Scalp is intact, Clean and smooth NORMAL

clean, smooth, FINDINGS
For color, and and free from
presence of lesions any lesions,
and infestation. infestation, or
scaling.

PALPATION Scalp should No lesions detected NORMAL

have a regular FINDINGS
For contour, contour, no
presence of lesions presence of
or tenderness lesions or
tenderness.

NAILS INSPECTION Nail bed should Nail bed color is ABNORMAL

be pink, no pale. FINDINGS, the
For nail bed color presence of nail bed color
and nail plate widespread should be pink.
shape. color change, The findings
e.g., Pallor, may indicate
Jaundice, or pallor.
Cyanosis.

Nail plate shape

should be 160
degree convex.

PALPATION Nail condition Rough and within 3 ABNORMAL

should be seconds of capillary FINDINGS
For nail condition, smooth, with refill. Factors such as
and capillary refill. uniform repeated
thickness. wetting and
drying and
Normal chemical
blanching of exposure like
nail bed within nail polish can
3 seconds. cause rough nail
bed.
26
HEAD INSPECTION Skull is The skull is NORMAL
symmetrical, symmetrical, smooth FINDINGS
For skull contour, smooth, and proportionate to
and proportion to proportionate to size. There are no
body size. size, no deformities and
deformities or lumps.
lumps.

PALPATION There should be No presence of NORMAL

no presence of tenderness, lesions, FINDINGS
For tenderness, tenderness, and masses.
presence of lesions lesions, or
or masses. masses.

FACE INSPECTION Symmetrical, Symmetrical face, NORMAL

with round , and FINDINGS
For shape, round/oval, symmetrical facial
symmetry and elongated, movement.
facial movement square
appearance.

No abnormal
movements
noted.

27
EYES INSPECTION Normally, light Straight; normal and NORMAL
reflection on the eyeballs are FINDINGS
For eye condition, eyes is equally symmetrical and
eyeballs, color of centered in both aligned in the socket.
sclera, pupils and pupils.
the lacrimal
apparatus
Symmetrical and
Eyeballs must be aligned in the socket.
symmetrically
aligned in the
socket without
Reddish Sclera
protruding or
sinking.

Both pupils are equal

in size (3mm).
Sclera is white and
underlying
Both eyes can
structures are
accommodate light
visible.
briskly. Able to
recognize objects
PERRLA – Pupils
12-14 inches away.
are equal, round,
reactive to light
and
accommodation.

PALPATION No swelling or No drainage during NORMAL

redness, no palpation FINDINGS
drainage during
inspection and
palpation the
nasolacrimal duct.
CONJUNCTIVA INSPECTION Bulbar conjunctiva Yellowish ABNORMAL
is clear, moist and FINDINGS
For color of smooth. Yellowish of
palpebral and conjunctiva
bulbar conjunctiva may suggest
liver disease
and other

28
 underlying
conditions.
EYELASHES INSPECTION Eyelashes are No swelling and NORMAL
present, no lesions. FINDINGS
For distribution of swelling, no
hair, presence of lesions, or
lesions, or discharge
discharge. observed.

EYELIDS INSPECTION Eyelids are Effective closure, no NORMAL

present, eyelids swelling and no FINDINGS
For effective can close, and lesions.
closure and the direction of
presence of lesions, eyelids is
swelling, or aligned with the
discharge. eyeball. No
swelling, lesion,
or discharged
observed.

EARS INSPECTION Color of the ear The color of the ear NORMAL
matches the rest matches the skin’s FINDINGS
For color, of the client’s color. Both ears are
symmetry, and size skin. Both ears symmetric and
proportion, should be proportion to the
presence of lesions symmetric and head. There is no
or discharge. proportion to presence of
the head. No deformities, lesions,
foreign bodies, redness and drainage.
redness,
drainage,
deformities, and
lesions.

PALPATION Ear should be The ears are elastic NORMAL

elastic, there and have no presence FINDINGS
For texture and should be no of tenderness and
elasticity. presence of lesions.

29
 tenderness, or
lesions.

WEBER’S TEST INSPECTION Sound should NOT ASSESSED NOT

be heard on the DUE TO CLIENT’S ASSESSED
center of the REFUSAL DUE TO
head, or equally CLIENT’S
on both sides of REFUSAL
ears.

RINNES TEST INSPECTION Normally, air NOT ASSESSED NOT

conduction DUE TO CLIENT’S ASSESSED
should be better REFUSAL DUE TO
than bone CLIENT’S
conduction. REFUSAL

NOSE INSPECTION Color is the The nose color NORMAL

same as the rest matches the skin's FINDINGS
For color of of the face, color and the nasal
external nose, nasal structure septum is in the
mucosa, and nasal is smooth and midline. The nasal
cavity condition. symmetric. mucosa is dark pink,
Structure of nose, Nasal septum is moist, and free of
presence of lesions in the midline, exudate.
or discharge. intact, and free
of ulcers. Nasal
mucosa is dark
pink, moist, and
free of exudate.
Nasal Cavity is
clear, moist, no
swelling,
discharge, or
lesions.

PALPATION Normally, client Both nostrils are NORMAL

should be able clear and both patent. FINDINGS
For patency and to breathe from No presence of
presence of lesions both nostrils, lesions and
or obstruction. there should be obstructions.
no presence of
30
 lesions or
obstructions.

SINUSES PALPATION Sinuses should The sinuses are NORMAL

be non-tender, non-tender and no FINDINGS
and no crepitus crepitus evident.
evident.

LIPS INSPECTION Lips are Symmetrical and NORMAL

smooth, pink lips. FINDINGS
For color, texture, symmetrical,
symmetry and moist
without lesions
or swelling.

GUMS INSPECTION Gums are pink Pink with no NORMAL

in color with no swelling or bleeding. FINDINGS
swelling,
bleeding, or
pain.

TEETH INSPECTION 32 pearly white Incomplete set of Incomplete set

teeth with teeth of teeth can be
For color, and smooth surfaces caused by tooth
presence of lesions. and edges. extraction, tooth
Upper molars decay, and
align with lower untreated
molars, and cavities.
upper incisors
slightly overlap
lower incisors.
No decay or
repairs.

TONGUE INSPECTION Tongue is pink, Midline and smooth NORMAL

shiny, moist FINDINGS
For alignment, moderate in size
texture, and color. with papillae
(little
perturbances)
present; with
31
 visible veins
and no lesions,
ulcers, or
nodules.

NECK INSPECTION Neck should be The muscles of the NORMAL

equal in size, neck are symmetrical FINDINGS
For size, range of with no with the head at a
motion (ROM), presence of central position. The
and alignment of swelling, and patient is able to
the trachea. no limited neck move head through a
movements, and full range of motion
the trachea’s without complaint of
alignment discomfort or
should be noticeable limitation.
midline.

PALPATION No presence of No presence of NORMAL

masses and masses and FINDINGS
For lymph nodes, tenderness. tenderness on the
and thyroid glands. neck muscles, lymph
nodes, trachea, and
thyroid gland

POSTERIOR INSPECTION Anteroposterior No patches, no NORMAL

to transverse abnormal inspiratory FINDINGS
THORAX diameter in retraction of
ratio of 1.2; interspaces.
chest
symmetric;
spine column
vertically
aligned. No
patches, no
abnormal
inspiratory
32
 retraction of
interspaces.

PALPATION The skin should NOT ASSESSED NOT

be intact; DUE TO CLIENT’S ASSESSED
uniform REFUSAL DUE TO
temperature. CLIENT’S
The chest wall REFUSAL
is intact;
uniform
temperature.
Full and
symmetric chest
expansion.

PERCUSSION Bilateral NOT ASSESSED NOT

symmetry of DUE TO CLIENT’S ASSESSED
vocal fremitus. REFUSAL DUE TO
Fremitus is CLIENT’S
heard most REFUSAL
clearly at the
apex of the
lungs.
Low-pitched
voices of males
are more readily
palpated than
higher pitched
voices of
females.

AUSCULTATION Percussion NOT ASSESSED NOT

notes resonate DUE TO CLIENT’S ASSESSED
except over REFUSAL DUE TO
scapula. CLIENT’S
REFUSAL

33
ANTERIOR INSPECTION Quiet, Regular breathing NORMAL
rhythmic, and pattern.. Colors FINDINGS
For the breathing effortless should be even and
patterns, rate, respirations. consistent with the
depth, the coastal Breathing color of the patient's
angle, shape of pattern should face. Shoulder
patient’s chest, and be smooth. should be at the same
color. Costal angle is height. shape of
less than 90°, thorax – elliptical
and the ribs shape.
insert into the
spine at
approximately a
45° angle.
Normal rate of
breathing in
adults it is
46/16 per min.
red patches
present, ribs
sloping
downward with
symmetric
interspaces.
Colors should
be even and
consistent with
the color of the
patient's face.
Shoulder should
be at the same
height. shape of
thorax –
elliptical shape.

34
PALPATION It should be full Symmetrical with NORMAL
symmetric equal expansion. No FINDINGS
For respiratory excursion; tenderness palpated.
excursion thumbs
tenderness, masses normally
and temperature. separate to 3-5
cm (1 ½ to 2
in). Equal
expansion, no
tenderness, no
masses, skin
should be warm
and dry, no
pulsation
should be
present.
Fremitus is
normally
decreased over
heart and breast
tissue.

PERSUSSION Normal lung NOT ASSESSED NOT

tissue resonant DUE TO CLIENT’S ASSESSED
For it’s different sound, rib flat REFUSAL DUE TO
sound. sound. CLIENT’S
REFUSAL

AUSCULTATION Air brushing Rales (fine crackles) ABNORMAL

through the heard in bronchial FINDINGS
For full two respiratory tract base of lungs.
breaths and sounds during Crackles or
rales sound may
inspiration
suggest asthma,
expiration
infection, and
generates
other
different breath
complications.
sounds.

35
HEART PALPATION No strong NOT ASSESSED NOT
pulsation DUE TO CLIENT’S ASSESSED
should be REFUSAL DUE TO
palpable over CLIENT’S
aortic and REFUSAL
pulmonic areas.

AUSCULTATION Apical has the Heart rate: 89 bpm; Abnormal

loudest sound; Regular rhythm. findings—pulm
For heart sounds, it should be Aortic heart sound onic and
rate, and rhythm, 60-80 clearly heard. tricuspid heart
and presence of beats/min. No Pulmonic and sounds should
heart murmurs murmurs should Tricuspid not heard be heard—may
be heard. clearly. be caused by a
tumor in the left
breast.

ABDOMEN INSPECTION Abdomen Normal racial tone, NORMAL

should have a scar is present, FINDINGS
For skin integrity, normal racial symmetrical and no
contour, and tone, with no visible peristaltic
symmetry, presence of waves
movement. lesions. Its
contour should
be flat and
should be
symmetrical,
with no visible
peristaltic
movement.

AUSCULTATION Normal bowel Gurgling sound NORMAL

sounds are up to heard in all four FINDINGS
For bowel sounds 5 to 30 BS per quadrants.
minute/
quadrant.

36
PERCUSSION Normally, NOT ASSESSED NOT
tympany sounds DUE TO CLIENT’S ASSESSED
should be heard REFUSAL DUE TO
generally across CLIENT’S
the abdomen; REFUSAL
dull sounds are
only heard in
areas where the
kidney, spleen,
and liver are
located.

PALPATION As palpation, NOT ASSESSED NOT

the client DUE TO CLIENT’S ASSESSED
should not feel REFUSAL DUE TO
any tenderness, CLIENT’S
For tenderness,
and there REFUSAL
masses
should be no
masses
palpated.

37
Name Age Birth Date Height Weight

Mrs. M.F.B. 9 June 11, 2015 129 cm 25.4 kg ( lbs)

Temperature Pulse rate Respiratory Blood pressure BMI

36.3°C 102 bpm rate N/A 15.3 Underweight

13 cpm

AREAS TO BE METHOD NORMAL ACTUAL ANALYSIS

ASSESSED FINDINGS FINDINGS

SKIN INSPECTION Normal skin color, NORMAL

Skin color varies witho no presence FINDINGS
from body part to of widespread color
body part. change and lesions.
No presence of
widespread color
change; Erythema,
Cyanosis,
Jaundice, Pallor.
No presence of
lesions.

38
 PALPATION Skin Skin temperature NORMAL
temperature warm within the FINDINGS
For temperature, should be within normal reading
moisture, texture, the normal range, 36.3°C. Skin
turgor. range (36.5°C to moisture is dry and
37.5°C). texture is rough.
After pinching, skin
Skin moisture is immediately return
normally to its position.
smooth and dry.

Skin texture is
normally
smooth, soft,
and flexible.
Normally skin
returns
immediately to
its position once
pinched.

HAIR INSPECTION Hair color and Hair color is black NORMAL

distribution and evenly FINDINGS
For color, should be distributed, with no
distribution, evenly presence of any
presence of distributed, infestation and
infestation, or there should be lesions.
lesions. no presence of
infestation or
lesions.

PALPATION Hair should Hair is thick, shiny NORMAL

have no signs of , and there is no FINDINGS
For moisture, thinning presence of lesions.
thickness, presence brittleness, or
of lesions. dryness.

No presence of
lesions such as
lumps or
masses.

39
SCALP INSPECTION Scalp is intact, Scalp is white and NORMAL
clean, smooth, clean with no FINDINGS
For color, and and free from presence of
presence of lesions any lesions, infestation, lesions,
and infestation. infestation, or or scaling.
scaling.

PALPATION Scalp should Scalp has a regular NORMAL

have a regular contour, there is no FINDINGS
For contour, contour, no presence of lesions
presence of lesions presence of found or any
or tenderness lesions or tenderness as
tenderness. palpated.

NAILS INSPECTION Nail bed should Nail bed is pink, NORMAL

be pink, no and nail plate is in FINDINGS
For nail bed color presence of 160 degree convex.
and nail plate widespread
shape. color change,
e.g., Pallor,
Jaundice, or
Cyanosis.

Nail plate shape

should be 160
degree convex.

PALPATION Nail condition Nail is rough, with ABNORMAL

should be uniform thickness. FINDINGS
For nail condition, smooth, with After pinching each
and capillary refill. uniform nail bed, the color Rough fingernails
thickness. returns with, and in on kids may
3 seconds. indicate underlying
Normal problems or issues
blanching of such as nutritional
nail bed within deficiencies, such as
3 seconds. lack of the
necessary vitamins
and minerals.

40
HEAD INSPECTION Skull is Skull is NORMAL
symmetrical, symmetrical and FINDINGS
For skull contour, smooth, proportionate to
and proportion to proportionate to body size, smooth
body size. size, no contour, with no
deformities or presence of
lumps. deformities or
lumps.

PALPATION There should be No presence of NORMAL

no presence of lesions or masses FINDINGS
For tenderness, tenderness, and tenderness as
presence of lesions lesions, or palpated.
or masses. masses.

FACE INSPECTION Symmetrical, Face is symmetrical NORMAL

with round/oval, and round. Facial FINDINGS
For shape, elongated, movement is
symmetry and square symmetrical with
facial movement appearance. ease.

No abnormal
movements
noted.

41
EYES INSPECTION Normally, light Eyes are straight NORMAL
reflection on the and normal, with no FINDINGS
For eye condition, eyes is equally signs of strabismus.
eyeballs, color of centered in both
sclera, pupils and pupils. Eyeballs not
the lacrimal symmetrical with
apparatus left eyeball
protruding.
Eyeballs must be
symmetrically
Left sclera is white
aligned in the
and moist, right
socket without
sclera show signs
protruding or
of redness.
sinking.
Pupils are equal in
size, approximately
Sclera is white and 3mm in size, round
underlying and is reactive to
structures are light as both pupil
visible. constricts briskly.

PERRLA – Pupils
are equal, round,
reactive to light
and
accommodation.

PALPATION No swelling or Lacrimal apparatus NORMAL

redness, no non-tender, no FINDINGS
drainage during swelling or
inspection and discharge noted
palpation the upon palpation.
nasolacrimal duct.
CONJUNCTIVA INSPECTION Bulbar conjunctiva Bulbar and NORMAL
is clear, moist and palpebral FINDINGS
For color of smooth. conjuctiva is white
palpebral and and clear with no
bulbar conjunctiva signs of redness.

42
EYELASHES INSPECTION Eyelashes are Eyelashes present NORMAL
present, no with no presence of FINDINGS
For distribution of swelling, no swelling lesions
hair, presence of lesions, or and discharge noted
lesions, or discharge upon observation.
discharge. observed.

EYELIDS INSPECTION Eyelids are Eyelids present, NORMAL

present, eyelids able to close, and is FINDINGS
For effective can close, and aligned with
closure and the direction of eyeball. No
presence of lesions, eyelids is swelling, lesions or
swelling, or aligned with the discharge noted
discharge. eyeball. No upon observation.
swelling, lesion,
or discharged
observed.

EARS INSPECTION Color of the ear Ear has normal NORMAL

matches the rest racial tone, FINDINGS
For color, of the client’s symmetrical and
symmetry, and size skin. Both ears proportionate to
proportion, should be head. No presence
presence of lesions symmetric and of foreign bodies,
or discharge. proportion to lesions, and
the head. No discharge noted
foreign bodies, upon observation.
redness,
drainage,
deformities, and
lesions.

PALPATION Ear should be Ear is elastic, and NORMAL

elastic, there non-tender, pinna FINDINGS
For texture and should be no recoils when
elasticity. presence of folded, with no
tenderness, or presence of lesions
lesions. noted upon
palpation.

43
WEBER’S TEST INSPECTION Sound should be Sound is heard on NORMAL
heard on the the center of the FINDINGS
center of the head, and equally
head, or equally on both sides of ear.
on both sides of
ears.

RINNES TEST INSPECTION Normally, air Both ears have NORMAL

conduction greater air FINDINGS
should be better conduction than
than bone bone conduction.
conduction.

NOSE INSPECTION Color is the Nose has normal NORMAL

same as the rest racial tone, FINDINGS
For color of of the face, structure is
external nose, nasal structure symmetrcal. Nasal
mucosa, and nasal is smooth and septum in midline
cavity condition. symmetric. with no signs of
Structure of nose, Nasal septum is deviation or
presence of lesions in the midline, perforation. Nasal
or discharge. intact, and free mucosa pink, free
of ulcers. Nasal from any discharge,
mucosa is dark and nasal cavity
pink, moist, and clear and moist
free of exudate. with no presence of
Nasal Cavity is lesions or
clear, moist, no discharge.
swelling,
discharge, or
lesions.

PALPATION Normally, client Upon palpation, NORMAL

should be able client was able to FINDINGS
For patency and to breathe from breathe from both
presence of lesions both nostrils, nostrils, with no
or obstruction. there should be presence of
no presence of tenderness and
lesions or lesions palpated.
obstructions.

44
SINUSES PALPATION Sinuses should Sinuses are NORMAL
be non-tender, non-tender noted FINDINGS
and no crepitus upon palpation.
evident.

LIPS INSPECTION Lips are Lips smooth and NORMAL

smooth, symmetrical, with FINDINGS
For color, texture, symmetrical, no presence of
symmetry and moist lesions noted upon
without lesions observation.
or swelling.

GUMS INSPECTION Gums are pink Gums are pink, NORMAL

in color with no with no presence of FINDINGS
swelling, lesions observed.
bleeding, or
pain.

TEETH INSPECTION 32 pearly white Number of teeth is Incomplete number

teeth with incomplete, only 19 of teeth due to age
For color, and smooth surfaces teeth, there are as child is in
presence of lesions. and edges. discoloration replacement phase
Upper molars observed on some where primary teeth
align with lower teeth. are replaced by
molars, and permanent teeth.
upper incisors Dental discoloration
slightly overlap may have been due
lower incisors. to factors such as
No decay or poor oral hygiene,
repairs. and consumption of
staining foods.

45
TONGUE INSPECTION Tongue is pink, Tongue is pink, NORMAL
shiny, moist smooth, and in the FINDINGS
For alignment, moderate in size midline. No lesions
texture, and color. with papillae observed.
(little
perturbances)
present; with
visible veins
and no lesions,
ulcers, or
nodules.

NECK INSPECTION Neck should be Neck muscle is NORMAL

equal in size, equal in size, was FINDINGS
For size, range of with no able to do ROM
motion (ROM), and presence of with no limited
alignment of the swelling, and no movements, and
trachea. limited neck trachea in the
movements, and midline.
the trachea’s
alignment
should be
midline.

PALPATION No presence of Lymph node NORMAL

masses and non-tender and FINDINGS
For lymph nodes, tenderness. non-palpable.
and thyroid glands. Thyroid glands are
non-palpable.

POSTERIOR INSPECTION Anteroposterior AP to lateral ratio NORMAL

to transverse 1:2. Lung FINDINGS
THORAX diameter in ratio expansion
of 1.2; chest symmetrical, with
symmetric; no use of accessory
spine column muscle.
vertically
aligned. No
patches, no
abnormal
inspiratory
46
 retraction of
interspaces.

PALPATION The skin should Skin is intact with NORMAL

be intact; uniform FINDINGS
uniform temperature, full
temperature. and symmetric
The chest wall chest expansion not
is intact; exceeding 3-5 cm.
uniform (4cm)
temperature.
Full and
symmetric chest
expansion.

PERCUSSION Bilateral NOT ASSESSED NOT ASSESSED

symmetry of DUE TO DUE TO
vocal fremitus. CLIENT’S CLIENT’S
Fremitus is REFUSAL REFUSAL
heard most
clearly at the
apex of the
lungs.
Low-pitched
voices of males
are more readily
palpated than
higher pitched
voices of
females.

AUSCULTATION Percussion NOT ASSESSED NOT ASSESSED

notes resonate DUE TO DUE TO
except over CLIENT’S CLIENT’S
scapula. REFUSAL REFUSAL

47
ANTERIOR INSPECTION Quiet, rhythmic, Client has quiet, NORMAL
and effortless effortless breathing FINDINGS
For the breathing respirations. at 14 breaths per
patterns, rate, Breathing minute. The thorax
depth, the coastal pattern should is elliptical with a
angle, shape of be smooth. costal angle under
patient’s chest, and Costal angle is 90°, and ribs slope
color. less than 90°, symmetrically. Skin
and the ribs color is even,
insert into the matching the face,
spine at and shoulders are
approximately a aligned.
45° angle.
Normal rate of
breathing in
adults it is 46/16
per min. red
patches present,
ribs sloping
downward with
symmetric
interspaces.
Colors should
be even and
consistent with
the color of the
patient's face.
Shoulder should
be at the same
height. shape of
thorax –
elliptical shape.

48
 PALPATION It should be full NOT ASSESSED NOT ASSESSED
symmetric DUE TO DUE TO
For respiratory excursion; CLIENT’S CLIENT’S
excursion thumbs REFUSAL REFUSAL
tenderness, masses normally
and temperature. separate to 3-5
cm (1 ½ to 2
in). Equal
expansion, no
tenderness, no
masses, skin
should be warm
and dry, no
pulsation should
be present.
Fremitus is
normally
decreased over
heart and breast
tissue.

PERSUSSION Normal lung NOT ASSESSED NOT ASSESSED

tissue resonant DUE TO DUE TO
For it’s different sound, rib flat CLIENT’S CLIENT’S
sound. sound. REFUSAL REFUSAL

AUSCULTATION Air brushing NOT ASSESSED NOT ASSESSED

through the DUE TO DUE TO
For full two breaths respiratory tract CLIENT’S CLIENT’S
and sounds during REFUSAL REFUSAL
inspiration
expiration
generates
different breath
sounds.

HEART PALPATION No strong NOT ASSESSED NOT ASSESSED

pulsation should DUE TO DUE TO
be palpable over CLIENT’S CLIENT’S
REFUSAL REFUSAL

49
 aortic and
pulmonic areas.

AUSCULTATION Apical has the NOT ASSESSED NOT ASSESSED

loudest sound; it DUE TO DUE TO
For heart sounds, should be 60-80 CLIENT’S CLIENT’S
rate, and rhythm, beats/min. No REFUSAL REFUSAL
and presence of murmurs should
heart murmurs be heard.

ABDOMEN INSPECTION Abdomen Abdomen has NORMAL

should have a normal racial tone, FINDINGS
For skin integrity, normal racial no presence of
contour, and tone, with no lesions observed.
symmetry, presence of Abdomen contour
movement. lesions. Its is flat, movement is
contour should symmetrical with
be flat and no visible
should be peristaltic
symmetrical, movement
with no visible observed.
peristaltic
movement.

AUSCULTATION Normal bowel NOT ASSESSED NOT ASSESSED

sounds are up to DUE TO DUE TO
For bowel sounds 5 to 30 BS per CLIENT’S CLIENT’S
minute/ REFUSAL REFUSAL
quadrant.

PERCUSSION Normally, NOT ASSESSED NOT ASSESSED

tympany sounds DUE TO DUE TO
should be heard CLIENT’S CLIENT’S
generally across REFUSAL REFUSAL
the abdomen;
dull sounds are
only heard in
areas where the
kidney, spleen,

50
 and liver are
located.

PALPATION As palpation, NOT ASSESSED NOT ASSESSED

the client should DUE TO DUE TO
not feel any CLIENT’S CLIENT’S
tenderness, and REFUSAL REFUSAL
For tenderness,
there should be
masses
no masses
palpated.

Name Age Birth Date Height Weight

Mrs. N.F.B. 5 January 22, 2019 129 cm 35.4 kg ( lbs)

Temperature Pulse rate Respiratory Blood pressure BMI

36.1°C 90 bpm rate N/A 24.4 Normal

18 cpm

AREAS TO BE METHOD NORMAL ACTUAL ANALYSIS

ASSESSED FINDINGS FINDINGS

SKIN INSPECTION The skin color NORMAL

Skin color varies doesn't have any FINDINGS
from body part to discoloration on the
body part. body. No presence insect bites on the
of erythema, right leg indicates
No presence of
cyanosis, Jaundice, presence of insects
widespread color
and Pallor. There is in their home and
change; Erythema,
insect bites on the environment.
Cyanosis,
right leg.
Jaundice, Pallor.

51
 No presence of
lesions.

PALPATION Skin The skin NORMAL

temperature temperature is FINDINGS
For temperature, should be 36.1°C and it is
moisture, texture, within the warm. The skin
turgor. normal range moisture is smooth
(36.5°C to and dry. The skin is
37.5°C). soft and flexible,
skin returns
Skin moisture is immediately to it's
normally position when it
smooth and dry. pinched.

Skin texture is
normally
smooth, soft,
and flexible.
Normally skin
returns
immediately to
its position once
pinched.

HAIR INSPECTION Hair color and The hair is evenly NORMAL

distribution distributed and FINDINGS
For color, should be there's no sign of
distribution, evenly infestation and
presence of distributed, lesions.
infestation, or there should be
lesions. no presence of
infestation or
lesions.

PALPATION Hair should The hair is smooth NORMAL

have no signs of and silky, it is also FINDINGS
For moisture, thinning thin and no
thickness, presence brittleness, or presence of lesions
of lesions. dryness. and dandruffs.

52
 No presence of
lesions such as
lumps or
masses.

SCALP INSPECTION Scalp is intact, The scalp is white, NORMAL

clean, smooth, clean, and smooth. FINDINGS
For color, and and free from No presence of
presence of lesions any lesions, lesions, infestation,
and infestation. infestation, or and scaling.
scaling.

PALPATION Scalp should The scalp is regular NORMAL

have a regular contour, no FINDINGS
For contour, contour, no presence of lesions
presence of lesions presence of and no tenderness.
or tenderness lesions or
tenderness.

NAILS INSPECTION Nail bed should The nail plate NORMAL

be pink, no shape is 160 degree FINDINGS
For nail bed color presence of convex and the
and nail plate widespread color is pink.
shape. color change,
e.g., Pallor,
Jaundice, or
Cyanosis.

Nail plate shape

should be 160
degree convex.

PALPATION Nail condition The nail texture is NORMAL

should be smooth with FINDINGS
For nail condition, smooth, with uniform thickness.
and capillary refill. uniform The blanching of
thickness. nail bed is within 3
seconds.
Normal
blanching of

53
 nail bed within
3 seconds.

HEAD INSPECTION Skull is The skull is NORMAL

symmetrical, symmetrical, FINDINGS
For skull contour, smooth, smooth,
and proportion to proportionate to proportionate to
body size. size, no size, no deformities
deformities or and lumps.
lumps.

PALPATION There should be No presence of NORMAL

no presence of tenderness, lesions, FINDINGS
For tenderness, tenderness, and masses.
presence of lesions lesions, or
or masses. masses.

FACE INSPECTION Symmetrical, The face is NORMAL

with symmetrical and FINDINGS
For shape, round/oval, round with no
symmetry and elongated, abnormal
facial movement square movements.
appearance.

No abnormal
movements
noted.

54
EYES INSPECTION Normally, light The reflection of NORMAL
reflection on the eyes is both equally FINDINGS
For eye condition, eyes is equally in centered pupils.
eyeballs, color of centered in both Eyeballs are
sclera, pupils and pupils. symmetrically
the lacrimal aligned in the
apparatus socket, not
protruding or
Eyeballs must be
sinking. The sclera
symmetrically
is white and clear.
aligned in the
The pupils are
socket without
equal, round,
protruding or
reactive to light and
sinking.
accomodation.

Sclera is white and

underlying
structures are
visible.

PERRLA – Pupils
are equal, round,
reactive to light
and
accommodation.

PALPATION No swelling or No swelling and NORMAL

redness, no redness, no FINDINGS
drainage during drainage during
inspection and inspection and
palpation the palpation.
nasolacrimal duct.
CONJUNCTIVA INSPECTION Bulbar conjunctiva The bulbar and NORMAL
is clear, moist and palpebral FINDINGS
For color of smooth. conjunctiva are
palpebral and both clear, moist
bulbar conjunctiva and smooth.

55
EYELASHES INSPECTION Eyelashes are The eyelashes are NORMAL
present, no present in both FINDINGS
For distribution of swelling, no eyes, no fallen
hair, presence of lesions, or lashes and swelling
lesions, or discharge are observed.
discharge. observed.

EYELIDS INSPECTION Eyelids are The eyelids are NORMAL

present, eyelids present and can FINDINGS
For effective can close, and close. The direction
closure and the direction of of eyelid is aligned
presence of lesions, eyelids is with the eyeball
swelling, or aligned with the with no swelling,
discharge. eyeball. No lesion, or
swelling, lesion, discharge.
or discharged
observed.

EARS INSPECTION Color of the ear The color of the ear NORMAL
matches the rest matches the skin’s FINDINGS
For color, of the client’s color. Both ears are
symmetry, and size skin. Both ears symmetric and
proportion, should be proportion to the
presence of lesions symmetric and head. No redness,
or discharge. proportion to drainage,
the head. No deformities, and
foreign bodies, lesions are present.
redness,
drainage,
deformities, and
lesions.

PALPATION Ear should be The ears are both NORMAL

elastic, there elastic and there is FINDINGS
For texture and should be no no tenderness and
elasticity. presence of lesions.
tenderness, or
lesions.

56
WEBER’S TEST INSPECTION Sound should NOT ASSESSED NOT ASSESSED
be heard on the DUE TO DUE TO
center of the CLIENT’S CLIENT’S
head, or equally REFUSAL REFUSAL
on both sides of
ears.

RINNES TEST INSPECTION Normally, air NOT ASSESSED NOT ASSESSED

conduction DUE TO DUE TO
should be better CLIENT’S CLIENT’S
than bone REFUSAL REFUSAL
conduction.

NOSE INSPECTION Color is the The color of the NORMAL

same as the rest nose matches the FINDINGS
For color of of the face, skin's color. The
external nose, nasal structure nasal septum is in
mucosa, and nasal is smooth and the midline and
cavity condition. symmetric. intact. Nasal
Structure of nose, Nasal septum is mucosa is dark
presence of lesions in the midline, pink, moist and free
or discharge. intact, and free of exudate. Nasal
of ulcers. Nasal Cavity is clear,
mucosa is dark moist, and no
pink, moist, and swelling and
free of exudate. discharge.
Nasal Cavity is
clear, moist, no
swelling,
discharge, or
lesions.

PALPATION Normally, client Both nostrils are NORMAL

should be able clear and both FINDINGS
For patency and to breathe from patent. No presence
presence of lesions both nostrils, of lesions and
or obstruction. there should be obstructions.
no presence of
lesions or
obstructions.

57
SINUSES PALPATION Sinuses should The sinuses are NORMAL
be non-tender, non-tender and no FINDINGS
and no crepitus crepitus evident.
evident.

LIPS INSPECTION Lips are Lips are smooth NORMAL

smooth, and symmetrical, FINDINGS
For color, texture, symmetrical, the color is pink
symmetry and moist and moist. No
without lesions lesions and
or swelling. swelling.

GUMS INSPECTION Gums are pink Gums are pink with NORMAL
in color with no no bleeding, FINDINGS
swelling, swelling or pain.
bleeding, or
pain.

TEETH INSPECTION 32 pearly white Incomplete set of ABNORMAL

teeth with teeth FINDINGS
For color, and smooth surfaces Incomplete set of
presence of lesions. and edges. teeth can be caused
Upper molars by tooth extraction,
align with lower tooth decay.
molars, and
upper incisors
slightly overlap
lower incisors.
No decay or
repairs.

TONGUE INSPECTION Tongue is pink, The tongue is pink, NORMAL

shiny, moist moist, and is in the FINDINGS
For alignment, moderate in size midline. No
texture, and color. with papillae lesions, ulcers and
(little nodules are visible.
perturbances)
present; with
visible veins
and no lesions,

58
 ulcers, or
nodules.

NECK INSPECTION Neck should be The neck is equal NORMAL

equal in size, in size and has no FINDINGS
For size, range of with no presence of
motion (ROM), presence of swelling. The neck
and alignment of swelling, and movement is
the trachea. no limited neck smooth with no
movements, and difficulties. The
the trachea’s trachea is in the
alignment midline.
should be
midline.

PALPATION No presence of There is no NORMAL

masses and presence of lumps FINDINGS
For lymph nodes, tenderness. and masses. The
and thyroid glands. lymph nodes and
thyroid gland are
not palpable.

POSTERIOR INSPECTION Anteroposterior The anteroposterior NORMAL

to transverse to transverse FINDINGS
THORAX diameter in diameter in ratio is
ratio of 1.2; 1:2, the chest is
chest symmetric and the
symmetric; spine columns are
spine column vertically aligned.
vertically No patches, no
aligned. No abnormal
patches, no inspiratory
abnormal retraction of
inspiratory interspaces are
present.

59
 retraction of
interspaces.

PALPATION The skin should NOT ASSESSED NOT ASSESSED

be intact; DUE TO DUE TO
uniform CLIENT’S CLIENT’S
temperature. REFUSAL REFUSAL
The chest wall
is intact;
uniform
temperature.
Full and
symmetric chest
expansion.

PERCUSSION Bilateral NOT ASSESSED NOT ASSESSED

symmetry of DUE TO DUE TO
vocal fremitus. CLIENT’S CLIENT’S
Fremitus is REFUSAL REFUSAL
heard most
clearly at the
apex of the
lungs.
Low-pitched
voices of males
are more readily
palpated than
higher pitched
voices of
females.

AUSCULTATION Percussion NOT ASSESSED NOT ASSESSED

notes resonate DUE TO DUE TO
except over CLIENT’S CLIENT’S
scapula. REFUSAL REFUSAL

60
ANTERIOR INSPECTION Quiet, NOT ASSESSED NOT ASSESSED
rhythmic, and DUE TO DUE TO
For the breathing effortless CLIENT’S CLIENT’S
patterns, rate, respirations. REFUSAL REFUSAL
depth, the coastal Breathing
angle, shape of pattern should
patient’s chest, and be smooth.
color. Costal angle is
less than 90°,
and the ribs
insert into the
spine at
approximately a
45° angle.
Normal rate of
breathing in
adults it is
46/16 per min.
red patches
present, ribs
sloping
downward with
symmetric
interspaces.
Colors should
be even and
consistent with
the color of the
patient's face.
Shoulder should
be at the same
height. shape of
thorax –
elliptical shape.

61
 PALPATION It should be full NOT ASSESSED NOT ASSESSED
symmetric DUE TO DUE TO
For respiratory excursion; CLIENT’S CLIENT’S
excursion thumbs REFUSAL REFUSAL
tenderness, masses normally
and temperature. separate to 3-5
cm (1 ½ to 2
in). Equal
expansion, no
tenderness, no
masses, skin
should be warm
and dry, no
pulsation
should be
present.
Fremitus is
normally
decreased over
heart and breast
tissue.

PERSUSSION Normal lung NOT ASSESSED NOT ASSESSED

tissue resonant DUE TO DUE TO
For it’s different sound, rib flat CLIENT’S CLIENT’S
sound. sound. REFUSAL REFUSAL

AUSCULTATION Air brushing NOT ASSESSED NOT ASSESSED

through the DUE TO DUE TO
For full two breaths respiratory tract CLIENT’S CLIENT’S
and sounds during REFUSAL REFUSAL
inspiration
expiration
generates
different breath
sounds.

HEART PALPATION No strong NOT ASSESSED NOT ASSESSED

pulsation DUE TO DUE TO
should be
palpable over
62
 aortic and CLIENT’S CLIENT’S
pulmonic areas. REFUSAL REFUSAL

AUSCULTATION Apical has the NOT ASSESSED NOT ASSESSED

loudest sound; DUE TO DUE TO
For heart sounds, it should be CLIENT’S CLIENT’S
rate, and rhythm, 60-80 REFUSAL REFUSAL
and presence of beats/min. No
heart murmurs murmurs should
be heard.

ABDOMEN INSPECTION Abdomen The abdomen color NORMAL

should have a matches the skin's FINDINGS
For skin integrity, normal racial color. No presence
contour, and tone, with no of lesions and the
symmetry, presence of contour is flat and
movement. lesions. Its symmetrical.
contour should
be flat and
should be
symmetrical,
with no visible
peristaltic
movement.

AUSCULTATION Normal bowel NOT ASSESSED NOT ASSESSED

sounds are up to DUE TO DUE TO
For bowel sounds 5 to 30 BS per CLIENT’S CLIENT’S
minute/ REFUSAL REFUSAL
quadrant.

PERCUSSION Normally, NOT ASSESSED NOT ASSESSED

tympany sounds DUE TO DUE TO
should be heard CLIENT’S CLIENT’S
generally across REFUSAL REFUSAL
the abdomen;
dull sounds are
only heard in
areas where the
kidney, spleen,

63
 and liver are
located.

PALPATION As palpation, NOT ASSESSED NOT ASSESSED

the client DUE TO DUE TO
should not feel CLIENT’S CLIENT’S
any tenderness, REFUSAL REFUSAL
For tenderness,
and there
masses
should be no
masses
palpated.

64
 FAMILY ASSESSMENT BASED ON FUNCTIONAL HEALTH PATTERN

GORDON’S 11 FUNCTIONAL HEALTH PATTERN

Mr. F.B.

Gordons Patterns Analysis

Health Perception-Health CANNOT BE ASSESSED CANNOT BE ASSESSED

Management Pattern DUE TO WORK DUE TO WORK

Nutritional–Metabolic Pattern CANNOT BE ASSESSED CANNOT BE ASSESSED

DUE TO WORK DUE TO WORK

Elimination Pattern CANNOT BE ASSESSED CANNOT BE ASSESSED

DUE TO WORK DUE TO WORK

Activity–Exercise Pattern CANNOT BE ASSESSED CANNOT BE ASSESSED

DUE TO WORK DUE TO WORK

Sleep–Rest Pattern CANNOT BE ASSESSED CANNOT BE ASSESSED

DUE TO WORK DUE TO WORK

Cognitive–Perceptual Pattern CANNOT BE ASSESSED CANNOT BE ASSESSED

DUE TO WORK DUE TO WORK

Self-Perception-Self-Concept CANNOT BE ASSESSED CANNOT BE ASSESSED

Pattern DUE TO WORK DUE TO WORK

Roles–Relationship Pattern CANNOT BE ASSESSED CANNOT BE ASSESSED

DUE TO WORK DUE TO WORK

Sexual–Reproductive Pattern CANNOT BE ASSESSED CANNOT BE ASSESSED

DUE TO WORK DUE TO WORK

Coping-Stress Tolerance CANNOT BE ASSESSED CANNOT BE ASSESSED

Pattern DUE TO WORK DUE TO WORK

Values–Beliefs Pattern CANNOT BE ASSESSED CANNOT BE ASSESSED

DUE TO WORK DUE TO WORK

65
Mrs. E.B

Gordon’s 11 Functional Pattern Analysis

Health Pattern

She described her health She only takes her vitamins

Health Perception-Health status as "alanganin," still and her medication for her
uncertain as she waits for asthma. The doctor
Management Pattern additional check-ups, such suggested she do a biopsy
as a biopsy for the lump in for her left breast lump and
her left breast. She she didn't do that due to
discovered a lump on her financial problems.
breast through a self-breast
examination while bathing
every day. As she waits for
a biopsy, she only takes
vitamins and medications
for her asthma. She also
had an injury recently as
she slipped while at work.
Has a complete
immunization.

66
 She prefers losing weight as She was prescribed by her
also prescribed by her doctor; doctor to watch what she
she has been losing weight eats and to lose weight.
for the past six months. She
eats 4 times a day, including
Nutritional-Metabolic Pattern
snacks (merienda), and limits
her intake of fats and chicken.
She loves to include
vegetables, fruits, and rice in
her meals and drinks 4–8
(1-2L) glasses of water daily.

She states that she has bowel No difficulty in urinating

movements every morning. and defecating since the
Her stool is solid and brown. mother drinks a lot of water
Elimination Pattern Does not have any history of every day. This confirms
constipation or diarrhea. that she is not experiencing
Urination occurs every 2 dehydration.
glasses of water for around 30
minutes. Do not have any
problems with urinating, such
as bleeding and pain.

She does household chores, Since the mother loves to

Zumba to sweat, walking, and walk to attend her extra
stretching as an exercise. In jobs, it is a great advantage
Activity- her free time, she enjoys to improve her health. She is
sewing clothes for her also creative and has a lot of
Exercise Pattern
children and blankets for the ideas in mind. This helps her
family; she also creates a pen to focus on the goal she
holder using a magazine. really wants to accomplish.

67
 She regularly sleeps at 11 After doing several house
p.m. and has 4–7 hours of chores and attending extra
sleep a day. Has no difficulty jobs, she makes sure that she
Sleep Rest Pattern sleeping only when she's has enough hours of sleep to
working at night wake up early and help her
consecutively. She uses two husband. Sometimes, due to
pillows to sleep on. Feel well overworking, she
rested enough after sleeping. experiences difficulty
sleeping that affects the
hours of sleep she should
get. She feels relaxed after
sleeping.

She considers a lot of things All her senses are

when deciding and also feels functioning well and she is
satisfied with her very prudent when making a
Cognitive self-knowledge, especially decision. She reads and
concerning her health. She searches for information
-Perceptual Pattern
can still remember things when she wants to gain
from the past and current knowledge which can help
times. Her senses function her to understand her
normally. condition.

She perceived herself as Her condition affected her

simple; she changed her self-perception. Still, she
perception after discovering sees herself as a simple
Self-Perception and Self- her condition. She rates her person with a simple life.
Concept Pattern control over her situation as 3 She believes that she has
on a scale of 0-5. She doesn't partial control over her
think much about her condition. So, to divert her
situation and distracts herself attention from ideas that
by eating. could cause stress, she visits
parks, eats snacks outside,
reads a book, and listens to
the words of God online.

68
 She decides most of the She has a good relationship
family's internal affairs. She's with her family especially to
also supportive as a mom and her children but when in
Role-Relationship Pattern wants her children to be terms of her neighbors she
successful in life. She limits limits socializing to them.
socializing but is comfortable
with it.

She has experienced irregular According to her doctor

menstruation. She has taken she's currently experiencting
oral pills for 10 years but symptomatic menopausal
Sexual-Reproductive Pattern stopped after her 2nd child. state which explains her
She has a problem with her irregular menstruation.
reproductive system; lumps
on her left breast.

When stressed, Mrs. EB takes Praying is her main way of

a walk around their coping with her problems
neighborhood. Her main way and when she’s stressed, she
Coping-Stress Tolerance of coping with problems is by takes a walk around their
Pattern praying. She also quoted neighborhood to help her
"Baha" as their main think and reflect.
traumatic and stressful event.

She values her children the She has faith in God and she
most, as she gains hope and believes that whenever she
strength through them. She has a problem she knows
Values/Belief Pattern states that having a that God will help and guide
relationship with God is her.
important; as she faces
problems, she finds strength
in Him as per her "Ikaw na
ang bahala sa akin."

69
Ms. M.F.B

Gordon’s 11 Functional Pattern Analysis

Health Pattern

She was diagnosed with She stops taking her

Congenital Heart Disease medication for her heart
Health Perception-Health
when she was 3 months old. disease due to change in her
Management Pattern Last 2024 she was bitten by a behavior according to her
stray cat and she completed Mother.
the anti-rabies vaccine last .
She already completed her
immunization but didn't
receive COVID-19 vaccine.

She eats 5 meals per day, She's picky with her food
including the afternoon and but she takes her vitamins
midnight snacks. She takes and eats fruits everyday to
her daily vitamins but she gain vitamins for her body.
stops taking her medication
Nutritional-Metabolic Pattern
for her heart disease
(Furosemide) due to her
behavioral issues, according
to her mother. She is picky
with her food but she eats
fruits every day.

She defecates every other day She doesn't have any

Elimination Pattern and the color is brown in problem with defecation and
small sizes. urination.

70
 Due to her age, her form of She exercises everyday by
Activity- exercise is playing outside playing outside but it is
with their neighbors but it is limited because sometimes
Exercise Pattern limited due to her condition. she can't breathe properly
due to her heart condition.

She sleeps at 8:00 pm and She has an adequate sleep

wakes up early to prepare to which can help her to have
go to school. Around 8-10 sufficient energy when
Sleep Rest Pattern hours of sleep every day and going to school.
she uses 2 pillows when
sleeping. She doesn't
experience any difficulty in
sleeping.

She doesn't have any problem Her senses are functioning

Cognitive with her senses. well.

-Perceptual Pattern

CANNOT BE ASSESSED CANNOT BE ASSESSED

Self-Perception and Self- DUE TO THE CLIENT’S DUE TO THE CLIENT’S
Concept Pattern AGE AGE

According to her mother, she According to her mother,

Role-Relationship Pattern concentrates on her studies she concentrates on her
and goes straight home after studies and goes straight
school. home after school.

CANNOT BE ASSESSED CANNOT BE ASSESSED

Sexual-Reproductive Pattern DUE TO THE CLIENT’S DUE TO THE CLIENT’S
AGE AGE
71
 CANNOT BE ASSESSED CANNOT BE ASSESSED
Coping-Stress Tolerance DUE TO THE CLIENT’S DUE TO THE CLIENT’S
Pattern AGE AGE

CANNOT BE ASSESSED CANNOT BE ASSESSED

Values/Belief Pattern DUE TO THE CLIENT’S DUE TO THE CLIENT’S
AGE AGE

Ms. N.F.B

Gordon’s 11 Functional Pattern Analysis

Health Pattern

CANNOT BE ASSESSED
DUE TO THE CLIENT’S CANNOT BE ASSESSED
Health Perception-Health DUE TO THE CLIENT’S
AGE
AGE
Management Pattern

According to her mother, She's not picky with her

Mrs. EB, she loves to eat rice food and she likes salty food
with soy sauce and salt, such as soy sauce and salt
Nutritional-Metabolic Pattern “She’s not picky with food.” which may cause future
said Mrs. EB. She regularly problems for her.
takes vitamins and eats fruits
daily.

She defecates every other day She doesn't have any

Elimination Pattern and it is a yellow-like-yolk problem with urination and
colored stool. defecating.

72
 Due to her age, playing She's actively exercising by
Activity- outside with her neighbors is playing outside which is
her form of exercise every good for her health and also
Exercise Pattern day. for socializing.

She sleeps 8-10 hours per She doesn't experience any

Sleep Rest Pattern day, sleeps at around 8 pm, difficulty in sleeping and
and wakes up early to prepare she gets adequate sleep.
for her school at 9 am. She
drinks milk before sleeping.

CANNOT BE ASSESSED CANNOT BE ASSESSED

Cognitive DUE TO THE CLIENT’S DUE TO THE CLIENT’S
AGE AGE
-Perceptual Pattern

CANNOT BE ASSESSED CANNOT BE ASSESSED

Self-Perception and Self- DUE TO THE CLIENT’S DUE TO THE CLIENT’S
Concept Pattern AGE AGE

CANNOT BE ASSESSED CANNOT BE ASSESSED

Role-Relationship Pattern DUE TO THE CLIENT’S DUE TO THE CLIENT’S
AGE AGE

CANNOT BE ASSESSED CANNOT BE ASSESSED

Sexual-Reproductive Pattern DUE TO THE CLIENT’S DUE TO THE CLIENT’S
AGE AGE

73
 CANNOT BE ASSESSED CANNOT BE ASSESSED
Coping-Stress Tolerance DUE TO THE CLIENT’S DUE TO THE CLIENT’S
Pattern AGE AGE

CANNOT BE ASSESSED CANNOT BE ASSESSED

Values/Belief Pattern DUE TO THE CLIENT’S DUE TO THE CLIENT’S
AGE AGE

E. Values, Habits, Practice of Health Promotion, Maintenance, and Disease Prevention

One of the family's religious beliefs, especially the mother, is that God will take care of

everything. They believe that what will happen to them is based on God's plan. The mother of the

family always prays that "ikaw na ang bahala sa akin at sa mga anak ko". They pray often and

watch videos about the words of God because they believe that having a relationship to God is

important. The mother believed that the most important thing she values in their current state are

her children. She hopes that before she dies, she wants her children to see them all finished school

and have a good job.

Based on the mother, the members of the family do not experience difficulty sleeping. Their

children sleep at 8 pm and wake up early to be ready and go to school. Sometimes, the parents sleep

at 11 pm and wake up around 3-4 am to prepare the fruits the father has to sell in the morning. The

family can finish 3 or more liters of water everyday. The mother also has a habit of eating food,

reading books, walking, and visiting parks to relieve stress.

74
 The family's practices when it comes to managing their health includes having a good

pattern of eating, drinking, and exercise patterns. The mother is also taking medications for her

asthma and arthritis, and both of the mother and child are taking vitamins everyday. When a family

member becomes ill, they use herbal medicines and over-the-counter (OTC) drugs.

75
 Chapter IV

FAMILY BACKGROUND

This Chapter shows the family background that includes the Family History, Data Base of

the Respondent, Family Tree, and General Household Data which is analytical for the present

well-being status of the family and to inform and influence such members.

A. Family History

The B family's mother, Mrs. E, was questioned by the nursing students in order to gather

information about the family history. During the interview, the nursing students found out that 2 of

the family members were sick. The mother was diagnosed with breast cancer 1 month ago and there

is no any other medication or treatment yet. Also, Mrs. E, has asthma and the third child has heart

disease, which is inborn.

B. Data Base of the Respondent

Mother

Name Mrs. E.L.B.

Age 49
Gender Female
Address 2 Violet St. Malanday, Marikina
City
Birthplace Iloilo City
Religion Roman catholic
Occupation On call job (e.g laundry worker, massage
therapist, care of elderly)
Civil status Married

76
 Nationality Filipino
Educational attainment Vocational
Estimated Monthly Income 10,000
Name of Husband/ Partner Mr. F.J.B.
Number of Children 5
Total number of family 5
members

C. Family Tree

77
D. General Household Data
1. Total number of Children: 4
2. List of Household Members: 6

78
 Chapter V

FAMILY COPING INDEX

Scaling Cues

1 - No competence

3 - Moderate competence
5 - Complete competence

Family Coping Areas Point Scale Assessed Problems Justificatio

n
statement
All family

Physical 1 3 5 None members

Independence
demonstrate a

keen awareness

of their

surroundings

and are capable

of performing

daily tasks with

ease. Each

individual is

receiving the

necessary care,

and there are no

discrepancies in

their levels of

79
 physical

independence.

The family is
Therapeutic 1 3 5 Family members are partially
aware of the
competence aware of their health status. prescribed

medications

but they do not

regularly intake

the medicine.

The family

Knowledge of None possesses a

Health
comprehensive
Condition
1 3 5
awareness of their

health conditions

and symptoms,

demonstrating

self-awareness

regarding their

health issues.

Their dining table is not properly They have a small

Application of the 1 3 5
Principle of General organized. Some family members are space household
Hygiene and one of the
not partially aware on their eating
family member
habits.
usually eat salty

foods.

80
 The family does not follow the One of the family
Health Attitudes 1 3 5
Doctor’s prescription regarding their members skipped

medication. her prescription

because she was

worried about a

serious drug side

effect.

The family experience stress Concerning their

Emotional 1 3 5
financial situation

and the illnesses

Competence
of the two family

members.

None The family

Family Living 1 3 5
relationships are

characterized by

openness and

closeness, with

children feeling

comfortable and

fostering positive

interactions within

the family.

Although the

81
 father consumes

alcohol regularly,

the mother has not

reported any

issues arising from

this behavior that

may negatively

impact the family

dynamic.

Presence of pest infestations, Is close to The neighborhood

the river and the community is prone for is vulnerable to

Physical Environment 1 3 5
flooding.
flooding due to its
And overcrowding is observed.
proximity to a

river and the

presence of pest

infestations in

their household.

Due to small

spaces but there

are no enough

spaces for other

objects.

82
 None The family
1 3 5
actively
Use of
Community
Facilities participates in

various

organizations and

program. They

also receive care

from public health

centers provided

by the government

and are

well-informed

about where to

seek assistance

from public

facilities.

83
 Chapter VI

TYPOLOGY OF NURSING PROBLEM

FIRST LEVEL OF SECOND LEVEL OF ASSESSMENT

ASSESSMENT

Inadequate family resources, specifically financial

Poor home due to: constraints.

Failure to see benefits of investment in home environment

improvement.
A. inadequate living space;

B. poor lighting and ventilation,

and; .

C. presence of breeding sites of

vectors of diseases, specifically
mosquitoes and rodents

Inability to provide adequate nursing care to the sick/at risk

Asthma member of the family due to financial constraints.
- Family member's health
condition disrupts the Unavailability of required care/service
body's normal function.
Inaccessibility of required care/service due to cost
Congenital Heart Disease constraints.
-Unable to perform
labor-intensive tasks that people
typically complete.

(Highly Suggestive of Malignancy)

84
Underweight
Inability to have proper nutritional intake due to lack of
Unhealthful nutritional Habits due knowledge of its possible effects.
to inadequate food intake in both
quality and quantity

85
 Chapter VII

PRIORITIZING PROBLEMS

Scale for Ranking

A. Criteria

CRITERIA SCORE WEIGHT

1. Nature of the problem 1

3
Health Deficit 2
Health Threat 1
Foreseeable Crisis

2. Modifiability of the Problem 2

2
Easily 1
Moderate 0
Not Modifiable

3. Preventive Potential 1
3
High 2
Moderate 1

Low

86
4. Salience of the problem 1
Problem needing urgent attention 2
1
Problem not needing urgent
attention 0
Not perceived as a problem

87
B. Scoring

1. Decide on a score for each of the criteria

2. Divide the score by the highest possible score and multiply by the
weight
Score
x Weight
Highest Score

3. Sum up all the scores for all of the criteria. The highest score is 5,

equivalent to the total weight.

4. The higher score (near 5 and above) of a given problem, the more likely

it is taken as a PRIORITY.

5. With the available scores, the NURSE then ranks health problems

accordingly.

88
 SCALE FOR RANKING HEALTH CONDITION AND PROBLEMS ACCORDING TO THE

PRIORITIES OF THE “B” FAMILY

Poor home due to inadequate living space/poor lighting and ventilation/presence of breeding sites of
vectors of disease as a health threat

Criteria Computation Actual Score Justification

1. Nature of the Problem

The problem is a health
2
threat, because without
x1 0.67 proper air circulation and
Health Threats poor lighting can lead to
3 respiratory issues and
headaches to more serious
conditions like asthma. It
can also become a
breeding ground for
vectors like cockroaches,
flies, rats, and mosquitoes
that can transmit and
cause disease due to
inadequate space.

2. Modifiability of the Problem

The problem is
1
moderately modifiable,
Moderate x2 1 since they can minimize
2 the available living space
by rearranging and
removing furniture that
they do not use, they can
maintain proper
ventilation and lighting
by opening their window
in daylight.

89
3. Preventive Potential
The preventive potential
1
is low because the
x1 0.33 family’s income is only
Moderate
3 sufficient for their daily
necessities.

4. Salience of the Problem

The family perceives it as
3
a condition or problem,
x1 1.5 needing immediate
2 attention since the family
Problem not needing urgent had aspirations of owning
a house that is capacious
attention and comfortable.

Total Score 3.5

90
Congenital heart disease as a health deficit

Criteria Computation Actual Score Justification

1. Nature of the Problem
The problem is a health
3
deficit because it affects
Health Deficit x1 1 their ability to live
healthy lives—a
3 fundamentally biological
condition needing
medical intervention from
infancy onwards.

2. Modifiability of the Problem

The problem is not
0
modifiable since the
Not modifiable x2 0 disease itself cannot
2 change or cure easily.

3. Preventive Potential
The preventive potential
1 0.33
of the problem is low
x1 because they cannot adapt
low 3 to regular physical
activity and there are no
regular check ups.

4. Salience of the Problem

The family perceives it as
2 1
Not perceived as a problem a problem needing
x1 attention because the
2 problem is all about the
heart that needs
operation.

91
 Total Score 2.33

Asthma as a Health Deficit

Criteria Computation Actual Score Justification

1. Nature of the Problem
The problem is a health
3
deficit because it disrupts
Health deficit x1 1 the body's normal
function, which can affect
3 the person's quality of
life. Since the trigger is
everywhere, a normal
lifestyle can be affected.

2. Modifiability of the Problem

The problem is not
0
modifiable as the family
Not modifiable x2 0 is having difficulty
2 providing proper nursing
care to the sick/risk
members due to financial
constraints.

3. Preventive Potential
The problem is
1 0.33
moderately preventable
x1 because there are no
Low 3 recent symptoms
occurred.

92
 4. Salience of the Problem
The family perceives it as
2 1
Problem needing attention a problem that needs
x1 immediate attention to
2 prevent complications and
a life-threatening
situation.

Total Score 2.33

Highly Suggestive of Malignancy as Health Deficit

Criteria Computation Actual Score Justification

1. Nature of the Problem
The problem is a health
3
deficit because one of the
Health deficit x1 1 family members highly
suggests malignancy on
3 the left breast.

2. Modifiability of the Problem

The problem is not
0
modifiable as the family
Not modifiable x2 0 is having difficulty with
2 expensive procedures and
procedures or treatment
due to a lack of financial
constraints.

93
 3. Preventive Potential
The problem is not easily
1 0.33
preventable as the family
x1 lacks resources to proceed
low 3 with the procedure for
cancer treatment.

4. Salience of the Problem

The family perceives it as
2 1
Problem needing attention a serious problem that
x1 needs immediate attention
2 because the breast cancer
tumor can continuously
grow and spread, causing
potentially
life-threatening
consequences.

Total Score 2.33

Underweight as Foreseeable Crisis

Criteria Computation Actual Score Justification

1. Nature of the Problem
The problem is a Health
3
deficit because it may
Health deficit x1 1 lead to malnutrition,
weakened function.
3

94
 2. Modifiability of the Problem
The problem is not
1
moderately modifiable
Moderate x2 1 because they have lack of
2 knowledge in proper
nutritional intake.

3. Preventive Potential
The preventive potential
1 0.33
is moderate because as
x1 student nurses we can
Moderate 3 promote proper
nutritional food for their
Lifestyle.

4. Salience of the Problem

The family perceives it as
2 1
Problem needing urgent attention a problem because the
x1 amount of money that
2 they earn is insufficient
for needed medical
expenses especially the
disease that needs to be
treated immediately.

Total Score 2.66

95
 RANKING AND SCORING OF EACH HEALTH PROBLEM

List of Health Problem According to Priorities of “B” Family

HEALTH PROBLEMS SCORE

3.5
Poor home due to inadequate living
space/poor lighting and
ventilation/presence of breeding sites of
vectors of disease as a health threat

2.66

Underweight as foreseeable crisis

2.33

Asthma as a health deficits

2.33

Congenital heart disease as a health

deficit

2.33

Highly suggestive of malignancy as

health deficit

96
 Chapter VIII

FAMILY NURSING CARE PLAN

HEALTH FAMILY GOAL OF OBJECTIVES INTERVENTION PLAN EVALUATION

PROBLEM NURSING CARE OF CARE
INTERVENTI NURSING METHOD OF RESOURCES
ON INTERVENTI NURSE-FAMI REQUIRED
ON LY CONTACT

Poor home due Risk of After the 1.Be able to Instructing the Home Visit Time and effort Goal met if the
to: Infection nursing learn why it is family of student family was able
Related to: The intervention, the important to regarding: nurses and to:
a.inadequate existence of family will find have more family
a.Was able to
living space; rodents and ways on how to space. a.Education on members.
breeding sites properly proper hygiene: show
b.poor lighting for mosquitoes. minimize their 2.Be able to Cleaning understanding
and ventilation, space by conduct a safety routine, Proper on proper
and; Impaired home rearranging assessment for waste disposal, hygiene in the
maintenance their furniture their living and self-care house.
c.presence of evidenced by: and cleaning space. hygiene. b.Was able to
breeding sites of Crowded living their house
get rid of some
vectors of conditions, poor properly. 3.Be able to get b.Adopt safety
disease, ventilation, and rid of some of precaution: breeding sites in
specifically poor lighting. the breeding Removing or their house.
mosquitoes and sites in their replacing things c.Was able to
rodents house. that are a hazard understand and
especially for adopt safety
4.Be able to children. precautions by
clean their
removing and
house properly.
replacing things
that are a hazard
especially for

97
 children.

HEALTH FAMILY GOAL OF OBJECTIVES INTERVENTION PLAN EVALUATION

PROBLEM NURSING CARE OF CARE
INTERVENTI NURSING METHOD OF RESOURCES
ON INTERVENTI NURSE-FAMI REQUIRED
ON LY CONTACT

Underweight as Inability of the After the After the Provide health Home Visit Time and effort Goal met if the
foreseeable family to nursing nursing teachings of student family was able
crisis provide proper intervention, the intervention the regarding: nurses and to;
balanced food
parent will be family will: family
nutrition due to
able provide a. be able to a. on basic members. a. Understand
the:
proper nutrition understand the nutrition, the importance
a. Knowledge
importance of balanced meals,
deficit for their of
balance and and portion
regarding children. well-balanced
proper meal control.
importance of nutritious food
nutrition. b. on meal
proper/balanced intake.
b. be able to planning,
food nutrition.
show budgeting, and b.Choose
b. Financial
improvement in how to make nutritious food
strain due to
nutritional nutritious meals within the
economic
status as with available
difficulties. financial budget
evidenced by resources.
using a meal
improved
weight and plan.
overall health,
especially to a
family that is
underweight.

98
 HEALTH FAMILY GOAL OF OBJECTIVES INTERVENTION PLAN EVALUATION
PROBLEM NURSING CARE OF CARE
INTERVENTI NURSING METHOD OF RESOURCES
ON INTERVENTI NURSE-FAMI REQUIRED
ON LY CONTACT

Asthma as a Environmental After the After the Educate the Home Visit Time and effort Goal met if the
health deficit factors exposure nursing nursing family on the of student family was able
to asthma intervention the intervention: asthma basics nurses and to demonstrate:
triggers client will be a. Family will such as: family
a.An
able to identify demonstrate an a. The triggers members.
the triggers, understanding (pollens, dust, understanding
signs and of asthma mold, smoke) the triggers by
symptoms of management, and how to avoidance of
asthma. including avoid them. irritants.
trigger b. proper use of b.An correctly
avoidance and inhalers and administration
medication use. rescue
of asthma
b.The family medication.
member with c.Educate the medications
asthma will family on early
experience signs of an
fewer asthma asthma
exacerbations, attack(coughing
as evidenced by at night,
fewer shortness of
emergency breath after
visits and mild exertion)
improved and what
breathing actions to take.
patterns.

99
 HEALTH FAMILY GOAL OF OBJECTIVES INTERVENTION PLAN EVALUATION
PROBLEM NURSING CARE OF CARE
INTERVENTIO NURSING METHOD RESOURCE
N INTERVENTIO OF S
N NURSE-FA REQUIRED
MILY
CONTACT

Congenital Risk for delayed After the After the nursing Educate the Home Visit Time and The goal met if
heart disease as growth and nursing intervention: family on the effort of the family was
a health deficit development intervention, a. The child will nature of the student nurses able to:
related to chronic the family will achieve disease the: and family
a.understand and
illness and demonstrate age-appropriate a.cause members.
decreased energy understanding growth and b.signs and recognize the
from reduced of the care developing symptoms nature of CHD.
cardiac output. required for milestones, such as c.complication b. consistently
Knowledge managing physical, cognitive, d.medication comply with
deficit about the CHD, and social e. nutrition medical
underlying including development. needed appointments,
disease and medication, b. The family will
treatments, and
methods of nutrition, and understand and
avoiding activity levels. recognized the medications.
complications. early signs and
symptoms of CHD.

100
 HEALTH FAMILY GOAL OF OBJECTIVES INTERVENTION PLAN EVALUATION
PROBLEM NURSING CARE OF CARE
INTERVENTI NURSING METHOD OF RESOURCES
ON INTERVENTI NURSE-FAMI REQUIRED
ON LY CONTACT

Highly Knowledge After nursing 1.Will be able to Giving enough Home Visit Time and effort Goal met if the
Suggestive deficit interventions, understand what knowledge of student family was able
Malignancy as a regarding the patient will breast cancer is regarding: nurses and to:
potential show and its family
Health Threat
diagnosis of understanding treatment a.Providing members.
malignancy and of breast cancer, emotional a.Was able to
options for its treatment 2.Will be able to support: show
treatments, as and side-effects know how to do Provide understanding
evidenced by a proper reassurance and on how
questions and After nursing self-breast emotional important to do
requests for intervention the examination. support to the self-breast
information. family can patient and
examination.
differentiate the 3.Will be able to family to reduce
difference show anxiety and
between highly understanding fear. Be an b.Was able to
suggestive of on highly active listener show signs of
malignancy and suggestive and let them relief.
breast cancer. malignancy. share their
concerns, fears, c.Was able to
and frustrations.
share their
b.Managing concerns, fear,
pain: keep an and frustration.
eye on how the
patient reacts to d.Was able to
pain relief understand the
measures.
importance of

101
c. Explain the the procedures
importance of they need to
the procedure: take.
Explain why
these tests are
important and
how they will
help to confirm
the diagnosis.

d.Advocate for
the Patient:
Ensure the
patient's rights
and preferences
are respected,
especially
regarding
treatment
alternatives and
care decisions.

102
 Chapter IX

Summary, Evaluation and Recommendation

Summary and Evaluation

The “B” family has (5) five household members because (2) two of their children have been

separated. Mr. F.B the father and head of the family is 50 years old, and her wife Mrs. E.B is 49

years old. They have (5) five children: Ms. P.A.B 24 year old, Mr. F.B 21 years old, Ms. F.B 18

years old, Ms. M.F.B 9 years old, and Ms. N.F.B 5 years old, all of them are Roman Catholic

where they reside at Brgy. Malanday, Marikina City. The family's combined source of income is

₱ 10,000 per month to meet their basic needs expenses. But because of their situation, the income

did not suffice all their basic needs.

They live in a (1) one-story home that is mostly made up of concrete, cement, and wood. Inside

of their house the space is very limited due to the infrastructure of the house. They only have (1)

one window, their furniture and belongings are disorganized. Also, the house is situated in a

crowded neighborhood that is vulnerable to hazards, such as recently the strong typhoon Carina.

Overall, “B” family face challenges concerning their health and living. Addressing their concern

must have an effective approach or solution in order to improve their overall well-being. Through

strict observation, proper assessment, and nursing intervention will help them to know what and

how they will overcome the problems.

103
Recommendation

In this case study the student nurses have identified problems and recommendation solutions for

health promotion and management for the family.

Recommendations for the "B" family to encourage them to consult Professionals to

encourage them in meal planning as they have a problem with a concern of Unhealthy eating

habits due to inadequate food intake and introducing some nutritious foods that can contribute to

their overall health specially in the children. Also, advising them how to manage their home to

provide an adequate space for them that affects their daily living. recommending them by

contacting local community resources for assistance with employment and financial aid.

The case study of the "B" family serves as a guide to all future researchers to encourage

awareness and plans or strategies to address health concerns that occur in nursing practice.

Moreover, The family must be advised to strictly follow the health education given by them to

minimize the potential health risks.

104
 X. REFERENCES

El Omari, S., Karasneh, M. Social health insurance in the Philippines: do the poor really
benefit?. J Econ Finan 45, 171–187 (2021). https://doi.org/10.1007/s12197-020-09525

105
XI. APPENDICES PICTURE GALLERY

106