FZA

Angeles City Foundation College of Nursing Angeles City
A FAMILY CASE ANALYSIS:
SUBMITTED BY:
Fualo, Lorriane Mercado, Joazelle Lorene Sarsagat, John Paulo
SUBMITTED TO:
Mary Candy Lou Lenon, R.N., M.N. Clinical Instructor Group 17 BSN III-5
September 24, 2010
I.
INTRODUCTION
To put the world right in order, we must first put the nation in order; to put the nation in order, we must first put the family in order; to put the family in order, we must first cultivate our personal life; we must first set our hearts right. - Confucius The first steping stone in order for people to develop into the next level it is necessary to create a more peaceful and unified society, each individual must understand his own capabilities of having motivation to share goodly with other people in order tap into their core of potential and achieve a level of self-realization and improvement, which is the ultimate key to creating a better community. These works and ways will now be a bigger and greater leap as a group. Then, with a small group, you can create a bigger one, an organization, a league, a society and community, a nation, and a world. Every member of this team must work hand in hand with one another and let others realize their own abilities of changing the world for the better. It may be a simple start yet a unified one. A small step yet deeper. This goes with any precious and crucial events in life, such is health. Healthy family come up with a healthy community and healthy community builds a healthy nation and a healthy nation is the world that everyone dreams of. No two communities are alike. A nurse exposed in the community learns how to interact and adapt to different kinds of people. The family is considered as the basic unit of care in community health nursing. It is in the family where a member develops his health values, beliefs and practices. It is a major influence in the health behaviors of an individual. With this, it is important that families in a community are aware of the things and practices pertaining to their health. A community is defined as a social group of people interacting with each other, determined by geographic boundaries, living together to attain certain and common goals, sharing the same interest, belief, intent, resources and preference. It is a group of families sharing others lives and resources through collaboration, cooperation and intense participation to stand and be of aid to all persons living in it. Together, with these persons, the health care team is in one with the mission and purpose of improving and
enhancing ones health through health promotion, disease prevention, and treatment o provide all their needs and concerns regarding health matters. Community Health Nursing (CHN) is a synthesis of nursing practice and public health practice applied to promoting and preserving the health of populations. The nature of this practice is general and comprehensive. It is not limited to a particular age or diagnostic group. It is not continuing, not episodic. The dominant responsibility is to the population as a whole. Therefore, nursing directed to individuals, families or groups contributes to the health of the total population. Health promotion, health maintenance, health education, coordination, and continuity of care are utilized in a holistic approach to the family, group and community. The nurses actions acknowledge the need for comprehensive health planning recognize the influences of social and ecological issues, give attention population at risk, and utilize the dynamic forces which influence change. (Benson and McDevitt, 1980). The focus of community health nursing is more on health promotion and is extended to benefit not only the individual but the whole family as mentioned and community. Since health promotion is the primary focus in community health nursing; nurses turn out to be educator by imparting health teachings to the family. It also help communities and families to cope with the discontinuities in health and threats in such a way as to maximize their potential for high level wellness, as well as to promote reciprocally supportive relationship between people and their physical and social environment. According to Maglaya (2004), the family is defined as the unit of the society which sets up the most basic values since it is where an individual first attaches and where he learns to love. It is a very important social institution which performs two major functions, reproduction and socialization. It is generally considered as a basic unit of community health nursing in a way that the family is the most basic group that builds up the community and in initiating a health changing action, the nurses must find their way first in promoting the family. According to National Statistical Coordination Board (NSCB) of 2009, about 47 percent of the household heads interviewed representative of about 8.7 million families considered themselves poor. Twenty six percent said that they were not poor, and 27 percent considered themselves on the borderline (Philippine Daily Inquirer, 2009). 3
Family case analysis is a means by which student nurses feel the pulse of the community through its basic structure, the family. It is a way of assessing persons within a family and plan for individualized care for each. The nursing process which includes assessment, diagnosis, planning, implementation and evaluation are important factors for the student nurses to accomplish the FCAs goals which are geared towards the familys optimum level of functioning in order for them to be productive and self-reliant members of the society in which they belong. In this way and approach, student nurses would help the community in general to further enhance their health condition and raise standards on health. And by the end of their exposure they have touched other peoples lives and have shared what they have to them. Prior to these, the group must be proficient to choose an assigned family for the case analysis. Some standards must be considered before selecting a family. These include: (a) a deprived family, (b) a family with four or more children, with at least 1 or 2 belonging to the 0 to 5 age bracket, (c) a family with visible poor environmental condition and (d) a family that gives permission to be taken as a case for the FCA project. The criteria mentioned were eventually met by the group and adopted a family at the Balibago, Pampanga. The family consists of six members including the mother together with her four children and their grandmother. With this, the group decided to use a pseudo name to respect the confidentiality and identity of each family member. The groups adopted family is named as the Fantacia Family . The home visits conducted by the group started from September 6, 2010 up to September 14, 2010, utilizing two days each week, therefore having a total of four home visits. The student nurses are challenged to take part in providing quality, appropriate nursing care. The student nurses must be able to be the familys partner in promoting and maintaining health. The goal of this study is to help the family achieve competence in health maintenance and in managing health crisis through acquisition of knowledge from the student nurses. The goal is not only centered in the family, but also in the student nurses as it aims to enrich and broaden their knowledge by providing an actual and hands-on experience in family health care.
A. Objectives of Family Case Analysis Student-centered i. Short-term After 1-2 home visits, the student nurses should have: y y y y y y y y Founded a family that will serve as the adopted family for FCA. Established rapport by introducing self to the family. Explained the purpose of home visits and the necessary follow-ups. Identified Actual and Potential Health Problems present in the family. Developed a good working relationship with each family member. Adapted accordingly with the family setting and surroundings. Identified the resources available in the family as well as the community. Gathered the familys individual demographic data, living condition, socioeconomic, cultural, and environmental predisposition. y y Assessed the health status present and past illness of each member. Detected health problems existing in the family and classify them as to health threat, health deficit or foreseeable problem. Rendered health teachings about personal hygiene and environmental sanitation. ii. Long-term After 3-5 home visits, the student nurses should have: y y y y y Diagnosed the actual and potential problems of the family member. Constructed appropriate plans of care in meeting the needs of the family Encouraged the family members to take part in the implementation process Explained the identified actual and potential problems with the Implemented the necessary actions to solve the problems and help the family achieve wellness state. y Evaluated the changes in the condition of the family after the whole period of nursing interaction. Learned life lessons and values from the family and community exposure
Family-centered i. Short Term After 1-2 days of home visits, the family should have: y y y y Established a good relationship with the student. Demonstrated approval in conducting home visits. Gained trust and confidence with the student nurses. Verbalized understanding regarding the purpose of home visits and the succeeding activities necessary to accomplish the Family Case Analysis. y Show cooperation in giving necessary information regarding their demographic, socio-economic ad health status. y y y y Expressed different problems that they encounter. Gained the necessary knowledge as they interrelate with student nurses. Determined their present and potential health needs of the family. Understood health teachings regarding identified problems and needs.
ii. Long Term After 3-5 home visits, the family should have: y Verbalized understanding of the rationale behind each intervention that the student nurses have planned to intervene. y Participated in the implementation phase of nursing intervention the family members and student nurses decided to worked on y y Carried out planned interventions Recognized the importance of good sanitary environment to the promotion and maintenance of health and prevention of illness. y Developed awareness regarding health seeking behaviors and how they promote and maintain health. y y Verbalized understanding of the health teachings imparted to them. Appreciated and practiced the various nursing measures taught to them by the student nurse like intake of inexpensive but nutrition foods, good personal hygiene, etc. y Performed suitable actions toward health problems in response to the nursing interventions rendered.
Research-Centered Specifically, the Family Case Analysis will aim to answer the following 1. How may the physical profile of the family be described as to: a. Type of family b. Composition of family 2. How may the profile of the family members described as to: a. Age b. Sex c. Ordinal position d. Educational attainment e. Present health status 3. How may the health profile of the family be assessed: a. Physical status b. History of past and present health illness c. Activities of daily living d. Nutritional status 4. How may the growth and development of children be assessed: a. Eric Ericksons Concept b. Sigmund Freuds Concept 5. 6. How may be the obstetrical history of the mother been described? How may the family be assessed as to: a. Socio-economic status b. Cultural status 7
c. Environmental sanitation 7. 8. How may the health problems be prioritized? How may the significance of the following factors to the health status of the family be described? a. Physical profile of the family b. Profile of the members c. Health profile of the members d. Growth and development of the children under 6 years of age e. Immunization status of the infant 9. How may the family nursing care plan of the family based on the analysis of data collected be described? 10. 11. How may the plans made with the family be implemented? How may the effectiveness of the plan be implemented?
A.
Entry, Climate of Acceptance and First Few Words On September 6, 2010, a group of 10 student nurses were tasked to have
a duty in Balibago Health Center. It was their first exposure with the families in the community. They made rounds to the community where they are assigned to and to look for a family who will qualify to the criteria that was instructed to them. It was not easy to find a family especially in a place which they are not familiar with. On their first day in the community, they had an orientation about their requirements and tasks that they will have to accomplish within 4 weeks and the student nurses were given the chance to look for a family to be adopted for the Family Case Analysis (FCA) at around 10:00 in the morning . The family that the group has chosen was very accommodating and welcoming. The group had chosen this family because the family is deprived with monetary resources, knowledge about health care. The family speaks Tagalog, which is their dialect, and they conversed with the group with ease and confidence. As the group entered the house, Mother Yuna guided them to their house. She preparing their food for their lunch and their children were playing when the student nurses arrived. They greeted Mother Yuna and Grandma Tifa, Magandang umaga po (Good Morning) while carrying smiles in their faces and the mother replied, Magandang umaga din (Good Morning), tuloy kayo (come in) . With those words, the group saw the humility of the family and its ability to welcome visitors; therefore, the group showed respect to the mother and to their house. The group introduced themselves, and said their purpose. There are three student nurses assigned to the Fantacia Family. One of which stayed inside the house to assess the house condition while the other two stayed outside to assess the families and for data gathering. The children were unresponsive at first because they still do not have trust with the student nurses. However, the mother was very comfortable with the presence of the other student nurses making it easy for the exchange of information. The group stayed at familys house for about 3 hours. They told the mother that they will be visiting again in the following week hoping for the cooperation of the whole mother especially their children.
II. FAMILY CONSTELLATION: The Fantacia Family A family constellation is attached in a Family Case Analysis and is presented to contain and provide a view of the crucial information that needs to be highlighted for the convenience of the critics. This data takes hold of the respective names of the family members which are to be kept of great confidentiality and are to be substituted by pseudonyms. Their respective ages, positions in the family, sexes, educational status and present health status will also be reflected on this report. Moreover, this file carefully examined to provide an overview or a brief summary of what is to be expected from the outcome of the entire Family Case Analysis.
Name: Tifa Age: 81 years old Position in the Family: Grandmother Gender: Female Educational Status: Grade 6 (not going to school)
Present
Health
Status:
During
the
assessment at Day 1, Tifa was seen smoking; however she immediately threw her cigarette upon seeing the student nurses. She wears a white shirt and dark blue pants. She has wrinkles on her cheeks and fore head. She has been noticed coughing. She consumes half pack of cigarette every day. She has dirty finger nails and toe nails. She has a short, black and white, soft hair and slightly oily. She was unable to read a print 14 inches apart. She was unable to hear the whispered words. The lips have symmetrical contour, no pallor noted but dark in color and smooth and has the ability to purse lips. She has dentures. Her tongue is dry. Vital signs: T: 36.3C/axilla P: 86 bpm R: 22 cpm BP: 130/90 mm Hg Nutritional status: Wt: 37 kg HT: 1.57 m BMI: 15.04 kg/m 2 (underweight)
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Name: Yuna Age: 42 years old Position in the Family: Mother Gender: Female Educational Status: Grade 6 (not going to school)
Present
Health
Status:
During
the
assessment at Day 1, Mother Yuna was wearing white sando and khaki shorts. She was carrying Tidus when the student nurses arrived. She looks tired because she just finished their laundry. She has a slouched posture, skinny, has fair complexion and was noted to have untrimmed finger and toe nails as well as presence of pediculosis with untidy appearance. Her teeth are yellow in color and there is presence of tooth decay and halitosis. There is noticed presence of dry lesions and rashes on her upper limb. Vital signs: T: 36.5C/axilla P: 85 bpm R: 21 cpm BP: 100/70 mm Hg Nutritional status: Wt: 35 kg HT: 1.5 m BMI:15.56kg/m (underweight)
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Name: Zidhaine Age: 13 years old Position in the Family: Third child Gender: Male Educational Status: Grade 3 (going to school)
Present Health Status: Seen on the 2nd day of home visit (Sept 7, 2010) wearing striped shirt, blue shorts and with slippers on. He has a fair complexion. He has no missing tooth but has tooth decays. He has 4 tooth decays: 2 on his right mandible, 2 on his right maxillary. He has dirty and long nails on his feet and hands. His feet are also notably dirty.
Vital signs: T: 36.9C/axilla
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P: 88 bpm R: 18 cpm Nutritional status: Wt: 36 kg Ht: 1.49 m BMI: 16.22 kg/m2 (underweight)
Name: Cloud Age: 10 years old Position in the Family: Fourth child Gender: Male Educational Status: Grade 2 (going to school)
Present Health Status: During the first home visit, he was wearing white t-shirt with black pants. He has a fair complexion. Have long and dirty fingernails. He had a presence of clear nasal discharge was noted. He has coughs and colds; with obstructed nasal airway passage. Has a dental decay. Vital signs: Temperature: 36.8oC / axilla Pulse Rate: 82 bpm Respiratory Rate: 21 cpm Nutritional status: Weight: 25 kg Height: 42 (1.28 m) BMI: 15.26 kg/m2 (Underweight) Seen on the first day of home visit (Sept 6, 2010) wearing orange shirt and black shorts. She has short, slightly curly hair. Fair complexion. She has tooth decay on her frontal incisors. 1 missing tooth and 6 dental carries. She showed loss of appetite, untrimmed nails, scars in the legs, with infestation of hair. She has long fingernails. She has dirty feet and nails. She has been coughing for one week on the first day of home visit.
Name: Aerith Age: 8 years old Position in the Family: Fifth child Gender: Female Educational Status: Grade 2 (going to school)
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Vital signs: T: 36.5C/axilla P: 89 bpm R: 21 cpm Nutritional status: Wt: 19 kg Ht: 1.19 m BMI: 13.48 kg/m (underweight) Name: Tidus Age: 2 years old Position in the Family: Youngest child Gender: Male Educational Status: Not going to school Present Health Status: During the first home visit, he was wearing sando only. He has long and dirty fingernails. He had a presence of clear nasal discharge was noted. He has also coughs and colds; with obstructed nasal airway passage. Has a dental decay and missing teeth.
2
Vital signs: Temperature: 36.3 C / axilla Pulse Rate: 92 bpm Respiratory Rate: 26 cpm Nutritional status: Weight: 10 kg Height: 29 (0.88 m) FNRI Weight Classification: Underweight
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The other two eldest children were not seen during the visits because according to the mother, they dont live with them and they both have their own families.
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III.HEALTH ASSESSMENT MRS. TIFA (Grandmother) (Initial home visit: September 6, 2010) APPEARANCE AND MENTAL STATUS Mrs. Tifa is 70 years old. She has a short, black and white, soft hair and slightly oily. She was wearing a white shirt, dark blue pajama pants and rubber slippers. Her skin is smooth, brown complexion, sweaty and wrinkled skin. Her fingernails and toenails are untrimmed. Upon interview, she is oriented to time, date, place and person and coherent in answering questions. Her height is 154 cm and weighs 33 kg and her initial vital signs are T=36.3C, PR= 86 bpm, RR=22 cpm and BP= 130/90 mmHg
PHYSICAL ASSESSMENT: SKIN: Mrs. Tifa has brown, uniform complexion with moist and wrinkled skin. There are no lesions and wound found. The skin is smooth and warm to touch and the skin turgor is good. NAILS: Upon inspecting the nails, fingernails are untrimmed. Her nails were pink in color and smooth in texture and with a capillary refill of less than 2 seconds. HAIR: The hair is short, black and white, soft and evenly distributed with no presence of dandruff. There is no presence of infestations. SKULL AND FACE: Skull is round and smooth in contour without presence of nodules or masses. The color of her face is symmetrical to the skin. Facial features are symmetrical and facial movements. EYES: Eyebrows are evenly distributed and symmetrically aligned with equal movements. Eyelashes are also equally distributed and curled slightly outward and upward. Eyelids close symmetrically with skin intact and no discharge or discoloration. Bulbar conjunctiva is transparent and sclera appears white. Palpebral conjunctiva is shiny, smooth and pink in color. 14
Lacrimal ducts have no edema or tearing upon palpation. Cornea is transparent, shiny and smooth with visible details of iris. Client blinks when the cornea is touched with the use of cotton. Pupils are equally round and reactive to light and accommodation. Client can see objects in the periphery when looking straight ahead and unable to read a print 14 inches apart. EARS: The color of the auricle is the same as the facial skin color, symmetrical in size and the position of both auricles is at the level of the eye. It is elastic and the pinna recoil when folded. There are no lesions found and no tenderness noted.
NOSE: The nose is symmetric, straight and clear discharges found in nares. The color of the nose is the same as the facial skin, no abnormalities of the shape can be seen. The air moves freely when she breaths on both nares and the nasal septum is in between the nasal chambers. There are no masses or swellings are palpated in maxillary and frontal sinuses.
MOUTH AND OROPHARYNX: The lips have symmetrical contour, no pallor noted but dark in color and smooth and has the ability to purse lips. She has dentures. Her tongue is dry, pink in color, at the central position, no lesions observed and moves freely. The soft palate is light pink and smooth while the hard palate is lighter pink. The uvula is positioned on the midline of soft palate. The oropharynx is smooth and pink and the tonsils have no discharges.
NECK: The neck is wrinkled and the color is the same as the facial skin and no lesions seen in the neck. There are no lymph nodes palpable. She is able to shrug her shoulder and turn her neck against the student nurse resistance. The trachea is in the center.
THORAX AND LUNGS: Skin is evenly distributed skin color, skin intact with uniform temperature. The chest shape and size is symmetrical and the anterior-posterior and transverse diameter in ratio of 1:2. The lungs are full and symmetric in expansion, quiet rhythmic sound and there is effortless respiration.
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HEART: Mrs. Tifas heart has no vibrations or pulsations are palpated on the aortic, pulmonic or tricuspid area. There is no presence of swishing sound like murmurs. Has regular rate and rhythm. And has identical pulse in radial and apical pulse.
ABDOMEN: There is no blemished in the skin, no pulsation, masses and no tenderness. The skin is intact and warm to touch. UPPER EXTREMITIES: The arm has brown complexion, no lesions or wounds found and soft to touch. Has smooth coordinated movement. No tenderness or swelling of muscles and bones noted. Has normal radial and brachial pulse.
> Fine Sensory Test The touch sensation is normal. She was able to discriminate sharp and dull sensations. She can also determine hot and cold sensations. > Fine Motor Test Finger to Nose Test: Can repeatedly and rhythmically touch her nose. Supination and Pronation of the Hand: Can alternately supinate and pronate her hands at rapid pace. Fingers to Fingers: Can perform with accuracy and rapidity.
LOWER EXTREMITIES: The legs are warm, brown in complexion and smooth in texture. The toenails are untrimmed, convex in curvature and the result for capillary refill is normal. The toenails are convex in curvature. There are no lesions found in both feet. There is no presence of contractures or deformities. The muscles have equal strength.
> Gait and Balance The client was able to maintain balance (Walking Gait). When she was asked to stand with feet together and arms resting at the sides, first with eyes open then closed. Client was able to maintain upright posture and foot stance (Romberg Test). She can also maintain heel-toe walking along a straight line.
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> Fine Motor Test She was able to maintain bilateral equal coordination. She can also move smoothly with coordination. CRANIAL NERVE ASSESSMENT
Cranial Nerve Cranial Nerve Number 1: Olfactory Nerve Cranial Nerve Number 2: Optic Nerve
Type and Function Type: Sensory Function: Smell
Assessment Procedure The student nurse asked the patient to close both of her eyes and asked to identify different aromas such as perfume and vinegar. The student nurse asked the client to read some printed words from a paper 14 inches apart and identify some colors.
Expected Result
Actual Result
Client will be The pt. was able able to identify to identify the mild the different aromas correctly. odors presented with eyes closed.
Type: Sensory Function: Vision
Client will be able to read what was written on the paper 14 inches apart and able to see objects and identify colors. Pupils will react to light and accommodation, able to close and open eyelids.
The pt. was unable to read and identify the picture shown to her at 14 inches apart.
Type: Motor Function: Extra-ocular movement Occulomo- of pupils tor Nerve
Cranial Nerve Number 3:
The client was asked to look at the straight direction. Then with the use of a penlight, light was focused on the right eye and was removed to determine any changes on the pupil size. Same assessment was done to the left eye. The client was asked to follow the direction of the penlight in an upward and downward movement without moving his head.
The pt. was able to follow the pen easily and correctly. Her pupil performed constriction and dilation. Her pupils were round and equally reactive to light and accommodation. The pt. was able to perform the ocular movements without moving the head.
Cranial Nerve Number 4: Trochlear Nerve
Type: Motor Function: Extra-ocular movement of eyes in downward and inward movement.
The client will be able to move eyes on an upward and downward direction without moving the head.
Type: Motor Student nurse made Client will be The pt. was able and Sensory use of a clean cotton able to elicit to blink after Function: wisp and gently corneal touched reflex cotton 17
Cranial Nerve Trigeminal Nerve
Type and Function Sensation of cornea, skin of face, and jaw movement.
Assessment Procedure stroked client's eyelashes to elicit corneal reflex. Also, the student nurse asked the client to close his eyes to determine if the object is sharp or dull upon introducing to face. The nurse also asked the client to move his jaw from side to side and chew. Student nurse asked the client to follow the direction of the penlight in a lateral movement.
Expected Result and identify the sensation of dull or sharp objects. The client must be able to close and open, move side to side his jaw and make some mastication.
Actual Result her eyes; she felt the cotton; and she also identified if the object is sharp or blunt. She can also move her jaw side to side and chew.
Cranial Nerve Number 6: Abducens Nerve Cranial Nerve Number 7: Facial Nerve
Type: Motor Function: Extra-ocular movement of eyes in a lateral movement Type: Motor and Sensory Function: Movement of facial muscles and sense of taste on the anterior twothirds of the tongue Type: Sensory Function: Hearing and equilibrium
The clients eyes The pt. was able will be able to to move her eyes move in lateral symmetrically. movement without moving the head. Client will be able to raise eyebrows, frown, smile, show teeth, puff out cheeks, and identify various taste on the tip of tongue like sweet and salty. The client will be able to hear the ticking watch and will be able to show balance. The client was able to raise eyebrows, frown, smile, show teeth, puff out cheeks, and identified various taste on the tip of tongue like sweet and salty. The pt. was unable to hear the whispered words. She is able to show balance.
Student nurse asked the client to raise his eyebrows, smile, frown, show teeth, and to puff out his cheeks and to identify various taste on the tip of the tongue like sweet and salty.
Cranial Nerve Number 8: Vestibulocochlear or Acoustics
Student nurse placed a second-hand watch near the ears and asked the client if he could hear the watch tick. Then, he was also asked to stand on his own for several seconds. Student nurse asked the client to say AH; pressed the posterior tongue with a tongue depressor. Introduced the vinegar to the
Type: Motor and sensory Function: Swallowing Glossopha- and Gag ryngeal reflex,
The client will be able to elicit upward movement of soft palate when mouth is opened,
The client elicited upward movement of soft palate when mouth is opened, identified sour taste, and 18
Cranial Nerve
Type and Function pharyngeal movement and sense of taste on the posterior one-thirds of the tongue
Assessment Procedure
Expected Result
Actual Result to
tongue with eyes identify sour was able closed. Lastly, the taste, and able to swallow. student nurse asked swallow. the patient to swallow.
Cranial Type: Motor Student nurse asked Nerve and Sensory a question, and Number 10: Function: elicited gag reflex. Swallowing Vagus and Nerve speaking Cranial Type: Motor Nerve Function: Number 11: Movement of shoulder Accessory blades Nerve Student nurse asked the client to move her head from side to side and asked to elevate her shoulders against the resistance introduced by the student nurse. Student nurse asked the client to move tongue from side to side and in and out.
The client will be able to speak without hoarseness, and will elicit gag reflex. The client will be able to shrug shoulders and move head from side to side against applied resistance. The client will be able to protrude tongue and move it from side to side.
The client spoke without hoarseness, and elicited gag reflex.
The client was able to shrug shoulders and moved head from side to side against applied resistance. The client was able to protrude tongue and moved it from side to side.
Cranial Type: Motor Nerve Function: Number 12: Movement and strength Hypoglossa of tongue l Nerve
(Final home visit: September 21, 2010) APPEARANCE AND MENTAL STATUS
Mrs. Tifa was wearing a blue shirt with blue pants and slippers are on. Her hair is loose, soft and equally distributed. Her skin appears sweaty, with good skin turgor. Her nails are trimmed and clean. Upon interview, she is oriented to time, date, place and person and is coherent in answering the question. H iernitial vital signs were
taken and recorded as follows: T=36.5 oC, PR=88bpm, RR= 24 cpm, BP=120/80 mmHg
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PHYSICAL ASSESSMENT: SKIN: Mrs. Tifa has brown, uniform complexion with moist and wrinkled skin. There are no lesions and wound found. The skin is smooth and warm to touch and the skin turgor is good. NAILS: Upon inspecting the nails, fingernails are trimmed. Her nails were pink in color and smooth in texture and with a capillary refill of less than 2 seconds. HAIR: The hair is short, black and white, soft and evenly distributed with no presence of dandruff. There is no presence of infestations. SKULL AND FACE: Skull is round and smooth in contour without presence of nodules or masses. The color of her face is symmetrical to the skin. Facial features are symmetrical and facial movements. EYES: Eyebrows are evenly distributed and symmetrically aligned with equal movements. Eyelashes are also equally distributed and curled slightly outward and upward. Eyelids close symmetrically with skin intact and no discharge or discoloration. Bulbar conjunctiva is transparent and sclera appears white. Palpebral conjunctiva is shiny, smooth and pink in color. Lacrimal ducts have no edema or tearing upon palpation. Cornea is transparent, shiny and smooth with visible details of iris. Client blinks when the cornea is touched with the use of cotton. Pupils are equally round and reactive to light and accommodation. Client can see objects in the periphery when looking straight ahead and unable to read a print 14 inches apart. EARS: The color of the auricle is the same as the facial skin color, symmetrical in size and the position of both auricles is at the level of the eye. It is elastic and the pinna recoil when folded. There are no lesions found and no tenderness noted.
NOSE: The nose is symmetric, straight and no discharge found in nares. The color of the nose is the same as the facial skin, no abnormalities of the shape can be seen. The air moves freely when she breaths on both nares and the nasal septum is in between the nasal chambers. There are no masses or swellings are palpated in maxillary and frontal sinuses.
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MOUTH AND OROPHARYNX: The lips have symmetrical contour, no pallor noted but dark in color and smooth and has the ability to purse lips. She has dentures. Her tongue is dry, pink in color, at the central position, no lesions observed and moves freely. The soft palate is light pink and smooth while the hard palate is lighter pink. The uvula is positioned on the midline of soft palate. The oropharynx is smooth and pink and the tonsils have no discharges.
NECK: The neck is wrinkled and the color is the same as the facial skin and no lesions seen in the neck. There are no lymph nodes palpable. She is able to shrug her shoulder and turn her neck against the student nurse resistance. The trachea is in the center.
THORAX AND LUNGS: Skin is evenly distributed skin color, skin intact with uniform temperature. The chest shape and size is symmetrical and the anterior-posterior and transverse diameter in ratio of 1:2. The lungs are full and symmetric in expansion, quiet rhythmic sound and there is effortless respiration.
HEART: Mrs. Tifas heart has no vibrations or pulsations are palpated on the aortic, pulmonic or tricuspid area. There is no presence of swishing sound like murmurs. Has regular rate and rhythm. And has identical pulse in radial and apical pulse.
ABDOMEN: There is no blemished in the skin, no pulsation, masses and no tenderness. The skin is intact and warm to touch. UPPER EXTREMITIES: The arm has brown complexion, no lesions or wounds found and soft to touch. Has smooth coordinated movement. No tenderness or swelling of muscles and bones noted. Has normal radial and brachial pulse.
> Fine Sensory Test The touch sensation is normal. She was able to discriminate sharp and dull sensations. She can also determine hot and cold sensations.
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> Fine Motor Test Finger to Nose Test: Can repeatedly and rhythmically touch his nose. Supination and Pronation of the Hand: Can alternately supinate and pronate her hands at rapid pace. Fingers to Fingers: Can perform with accuracy and rapidity. LOWER EXTREMITIES: The legs are warm, brown in complexion and smooth in texture. The toenails are untrimmed, convex in curvature and the result for capillary refill is normal. The toenails are convex in curvature. There are no lesions found in both feet. There is no presence of contractures or deformities. The muscles have equal strength.
> Gait and Balance The client was able to maintain balance (Walking Gait). When she was asked to stand with feet together and arms resting at the sides, first with eyes open then closed. Client was able to maintain upright posture and foot stance (Romberg Test). She can also maintain heel-toe walking along a straight line. > Fine Motor Test She was able to maintain bilateral equal coordination. She can also move smoothly with coordination. CRANIAL NERVE ASSESSMENT
Expected Result
Actual Result
Client will be The pt. was able able to identify to identify the mild the different aromas correctly. odors presented with eyes closed.
Client will be able to read what was written on the paper 14 inches apart and able to see
The pt. was unable to read and identify the picture shown to her at 14 inches apart. 22
Cranial Nerve
Type and Function
Expected Result objects and identify colors.
Actual Result
Pupils will react to light and accommodation, able to close and open eyelids.
The pt. was able to follow the pen easily and correctly. Her pupil performed constriction and dilation. Her pupils were round and equally reactive to light and accommodation. The pt. was able to perform the ocular movements without moving the head.
Type: Motor Function: Extra-ocular movement of eyes in downward and inward movement. Type: Motor and Sensory Function: Sensation of cornea, skin of face, and jaw movement.
Cranial Nerve Number 5: Trigeminal Nerve
Student nurse made use of a clean cotton wisp and gently stroked client's eyelashes to elicit corneal reflex. Also, the student nurse asked the client to close his eyes to determine if the object is sharp or dull upon introducing to face. The nurse also asked the client to move his jaw from side to side and chew. Student nurse asked the client to follow the direction of the penlight in a lateral movement.
Client will be able to elicit corneal reflex and identify the sensation of dull or sharp objects. The client must be able to close and open, move side to side his jaw and make some mastication.
The pt. was able to blink after cotton touched her eyes; she felt the cotton; and she also identified if the object is sharp or blunt. She can also move her jaw side to side and chew.
Cranial Nerve Number 6: Abducens Nerve Cranial
Type: Motor Function: Extra-ocular movement of eyes in a lateral movement
The clients eyes The pt. was able will be able to to move her eyes move in lateral symmetrically. movement without moving the head. will be The client was 23
Type: Motor Student nurse asked Client
Cranial Nerve Nerve Number 7: Facial Nerve
Type and Function and Sensory Function: Movement of facial muscles and sense of taste on the anterior twothirds of the tongue Type: Sensory Function: Hearing and equilibrium
Assessment Procedure the client to raise his eyebrows, smile, frown, show teeth, and to puff out his cheeks and to identify various taste on the tip of the tongue like sweet and salty.
Expected Result able to raise eyebrows, frown, smile, show teeth, puff out cheeks, and identify various taste on the tip of tongue like sweet and salty. The client will be able to hear the ticking watch and will be able to show balance.
Actual Result able to raise eyebrows, frown, smile, show teeth, puff out cheeks, and identified various taste on the tip of tongue like sweet and salty. The pt. was unable to hear the whispered words. She is able to show balance.
Student nurse placed a second-hand watch near the ears and asked the client if he could hear the watch tick. Then, he was also asked to stand on his own for several seconds. Student nurse asked the client to say AH; pressed the posterior tongue with a tongue depressor. Introduced the vinegar to the tongue with eyes closed. Lastly, the student nurse asked the patient to swallow.
Type: Motor and sensory Function: Swallowing Glossopha- and Gag ryngeal reflex, pharyngeal movement and sense of taste on the posterior one-thirds of the tongue
The client will be able to elicit upward movement of soft palate when mouth is opened, identify sour taste, and able to swallow.
The client elicited upward movement of soft palate when mouth is opened, identified sour taste, and was able to swallow.
Cranial Type: Motor Student nurse asked Nerve and Sensory a question, and Number 10: Function: elicited gag reflex. Swallowing Vagus and Nerve speaking Cranial Type: Motor Nerve Function: Number 11: Movement of shoulder Accessory blades Nerve Student nurse asked the client to move her head from side to side and asked to elevate her shoulders against the resistance introduced by the student nurse.
The client will be able to speak without hoarseness, and will elicit gag reflex. The client will be able to shrug shoulders and move head from side to side against applied resistance.
The client was able to shrug shoulders and moved head from side to side against applied resistance.
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Cranial Nerve
Type and Function
Assessment Procedure Student nurse asked the client to move tongue from side to side and in and out.
Expected Result The client will be able to protrude tongue and move it from side to side.
Actual Result The client was able to protrude tongue and moved it from side to side.
Nutrition Status: At the age of 81 y/o, Mrs. Tifa has a height of 52 (1.57m) and a weighs 33 kg. BMI = weight in kg height in m = 37kg (1.57m)2 = 15.04 kg/m2
Asia-Pacific Obesity Guidelines BMI < 18.5 18.6 22.9 > 23.0 23.0 24.9 25.0 29.9 > 30.0 Interpretation Underweight Healthy Weight Overweight At risk Obese I Obese II
Mrs. Tifas BMI is 15.04 kg/m2 which is interpreted as Underweight according to the parameter of the Asia-Pacific Obesity Guidelines.
History of Past Illness
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Mrs. Tifa experienced cough and colds, fever and chicken pox for the past years. She takes Paracetamol when she had fever and no medication for her cough and colds. She managed her cough by stopping smoking and eating candies and then she would resume smoking. According to Mrs. Yuna, even she was a child, her mother always does this. She also used herbal medicines like Oregano to manage her cough sometimes. She prepares oregano through Boiling one cup of fresh leaves in 3 cups of water for 10 to 15 minutes. And then drinking the cup for about three times a day. History of Present Illness Mrs. Tifa was suffering productive cough and colds for about a week during the first home visit (September 6, 2010). She was not taking any medications for her cough but she uses other alternatives like drinking lots of water. She still didnt visit the health center to have a check up about her cough and colds.
Activities of Daily Living Mrs. Tifa usually gets up at 6 am and helps Mrs. Yuna in preparing the breakfast. After breakfast, she usually smokes or cleans the house. After that she will wonder around the community, sometimes going to the internet to have a contact to her son in abroad or just visit some neighbors. In the middle of the day, she usually comes back at lunch to see her grandchildren eat their lunch before going to school. She either eat lunch or not and then go back to sleep. About 1:30 or 2:00, she will stay in the house watching TV or keeping an eye to her grandchildren. At night, she will watch TV or have conversation to her family or neighbors and after taking her dinner, she will go to sleep at 10 pm. Mrs. Tifa smokes and she can consume half packet of cigarette a day. She started smoking at the age of 24. Therefore, there is a total of 57 pack years.
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MRS. YUNA (Initial home visit: September 6, 2010) APPEARANCE AND MENTAL STATUS
Mother Yuna, age 42 y/o, female, Filipino, affiliated under Roman Catholic, born March 8, 1968, stands 150cm and weighs 35kg. On the first day of assessment, Mother Yuna was seen carrying baby Tidus and wearing a loose white shirt paired with khaki shorts. She just finished washing clothes. Her posture is slouched in standing. She answers queries with appropriate response and affect. After assessment, mother was noted to have untrimmed finger and toe nails as well as presence of pediculosis with untidy appearance. Her vital signs were taken and recorded as follows: T=36.5rC, PR=85 bpm, RR=21 cpm, BP=100/70mmHg
PHYSICAL ASSESSMENT: SKIN: Mother Yunas skin color is fair. There is no edema and inflammations present. There is noticed presence of dry lesions and rashes on her upper limb. Her skin is warm to touch, slightly dry and with a good skin turgor. NAILS: She has dirty untrimmed finger and toe nails. But smooth in texture and nail beds are pink with good capillary refill. Nail beds returns to pink after blanching in 2 seconds. HAIR: Her hair is evenly distributed, and black in color. There is presence of dandruff on scalp, pediculosis on uncombed hair.
SKULL AND FACE: Her skull is rounded, normocephalic and with normal contour, smooth skull contour, no lesions and masses noted. She has symmetrical face features and no lesions or masses noted.
EYES: Her eyebrows are symmetrically aligned and evenly distributed with eyelashes curled, outward and long. The eyelids are intact without secretions or discharges. The bulbar 27
conjunctiva is transparent, the palpebral conjunctiva is shiny, smooth and pink in color and shiny with flat iris. Can move eyes and see objects in the periphery when looking straight.
EARS: Her auricles are symmetrical and have same color as the face. It is aligned with the outer canthus of the eye. Ear canals are seen with little amounts of dry cerumen. Not tender upon palpation, Pinna recoils after it is folded.
NOSE: Her nose is in proportion, uniform in color and no lesions. Sinuses are not tender when palpated and no discharge is noted.
MOUTH AND OROPHARYNX: Her lips are slightly brown in color, smooth in texture and elastic texture. She has pink tongue and moves freely. The palates and uvula are color pink with uvula at the midline. There are no discolorations and irritations and the oropharynx tonsils are pink in color. Her teeth are yellow in color and there is presence of tooth decay and halitosis.
NECK: Her neck is uniform in color, with coordinate smooth movement with equal muscle strength. Her head was able to move against resistance.
THORAX AND LUNGS: Skin is intact with uniform color. No inflammation, lesions, deformities, masses and tenderness noticed. She has no difficulty in breathing and has regular breathing pattern of quiet and rhythmic respiration. Chest has no masses or tenderness. Breathing pattern and heart beat are normal. Spine is aligned vertically. Her composure is slightly slouched due to household chores. Her back is uniform in color. Both shoulders are aligned.
HEART: She has a normal pulse of 85 bpm with full pulsation of the carotid artery upon palpation.
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ABDOMEN: Skin in her abdomen is uniform and rounded. With presence of tympanic sound over the stomach, with audible bowel sounds of 23 per min. upon auscultation, does not complain tenderness and pain upon palpation.
UPPER EXTREMITIES: The arm has brown complexion, no lesions or wounds found and soft to touch. Has smooth coordinated movement. No tenderness or swelling of muscles and bones noted. Has normal radial and brachial pulse.
> Fine Sensory Test The touch sensation is normal. She was able to discriminate sharp and dull sensations. She can also determine hot and cold sensations. > Fine Motor Test Finger to Nose Test: Can repeatedly and rhythmically touch her nose. Supination and Pronation of the Hand: Can alternately supinate and pronate her hands at rapid pace. Fingers to Fingers: Can perform with accuracy and rapidity. LOWER EXTREMITIES: The legs are warm, brown in complexion and smooth in texture. The toenails are untrimmed and dirty, convex in curvature and the result for capillary refill is normal. The toenails are convex in curvature. There are no lesions found in both feet. There is no presence of contractures or deformities. The muscles have equal strength.
> Gait and Balance The client was able to maintain balance (Walking Gait). When she was asked to stand with feet together and arms resting at the sides, first with eyes open then closed. Client was able to maintain upright posture and foot stance (Romberg Test). She can also maintain heel-toe walking along a straight line. > Fine Motor Test She was able to maintain bilateral equal coordination. She can also move smoothly with coordination.
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CRANIAL NERVE ASSESSMENT
Expected Result
Actual Result
Client will be The pt. was able able to identify to identify the mild the different aromas correctly odors presented with eyes closed.
Client will be The pt. was able able to read what to read the text was written on shown to her. the paper 14 inches apart and able to see objects and identify colors. Pupils will react to light and accommodation, able to close and open eyelids. The pt. was able to follow the pen easily and correctly. Her pupil performed constriction and dilation. Her pupils were round and equally reactive to light and accommodation. The pt. was able to perform the ocular movements without moving the head.
Type: Motor Function: Extra-ocular movement of eyes in downward and inward movement. Type: Motor and Sensory Function: Sensation of cornea, skin of face, and
Student nurse made use of a clean cotton wisp and gently stroked client's eyelashes to elicit corneal reflex. Also,
Client will be able to elicit corneal reflex and identify the sensation of dull or sharp objects.
The pt. was able to blink after cotton touched her eyes; she felt the cotton; and she also identified 30
Cranial Nerve
Type and Function jaw movement.
Assessment Procedure the student nurse asked the client to close his eyes to determine if the object is sharp or dull upon introducing to face. The nurse also asked the client to move his jaw from side to side and chew. Student nurse asked the client to follow the direction of the penlight in a lateral movement.
Expected Result
Actual Result
The client must if the object is be able to close sharp or blunt. and open, move side to side his jaw and make some mastication.
The clients eyes The pt. was able will be able to to move her eyes move in lateral symmetrically. movement without moving the head. Client will be able to raise eyebrows, frown, smile, show teeth, puff out cheeks, and identify various taste on the tip of tongue like sweet and salty. The client will be able to hear the ticking watch and will be able to show balance. The pt. was able to do all activities The pt. was able to identify all tasted food appropriate or correctly.
Student nurse placed a second-hand watch near the ears and asked the client if he could hear the watch tick. Then, he was also asked to stand on his own for several seconds. Student nurse asked the client to say AH; pressed the posterior tongue with a tongue depressor. Introduced the vinegar to the tongue with eyes closed. Lastly, the student nurse asked
The pt. was able to correctly repeat the whispered words.
Type: Motor and sensory Function: Swallowing Glossopha- and Gag ryngeal reflex, pharyngeal movement and sense
The client will be The pt. was able able to elicit to do all upward movement easily. movement of soft palate when mouth is opened, identify sour taste, and able to swallow. 31
Cranial Nerve
Type and Function
Expected Result
Actual Result
of taste on the patient to swallow. the posterior one-thirds of the tongue Cranial Type: Motor Student nurse asked Nerve and Sensory a question, and Number 10: Function: elicited gag reflex. Swallowing Vagus and Nerve speaking Cranial Type: Motor Nerve Function: Number 11: Movement of shoulder Accessory blades Nerve Student nurse asked the client to move her head from side to side and asked to elevate her shoulders against the resistance introduced by the student nurse. Student nurse asked the client to move tongue from side to side and in and out. The client will be able to speak without hoarseness, and will elicit gag reflex. The client will be able to shrug shoulders and move head from side to side against applied resistance. The client will be able to protrude tongue and move it from side to side. The pt. was able to speak clearly and did not have a difficulty in swallowing. The pt. was able to shrugs her shoulder. She turned his head in all movement.
The pt. was able to do all movement instructed.
(Final home visit: September 21, 2010) APPEARANCE AND MENTAL STATUS PHYSICAL ASSESSMENT: During the final assessment, Mother Yuna was seen on the yard carrying Tidus. She was wearing a white t-shirt with red pajamas and slippers on. We observed that she already has trimmed nails both on hands and feet, has a neat appearance with her hair fixed and ponytailed and answers our queries accordingly. Her vital signs taken and recorded as follows: T=36.2rC, PR=87 bpm, RR=23 cpm, BP=100/80mmHg SKIN: Mother Yunas skin color is fair. There is no edema and inflammations present. There is noticed presence of dry lesions and rashes on her upper limb. Her skin is warm to touch, slightly dry and with a good skin turgor. 32
NAILS She has trimmed finger and toe nails. But smooth in texture and nail beds are pink with good capillary refill. Nail beds returns to pink after blanching in 2 seconds. HAIR: Her hair is evenly distributed, and black in color. There is presence of dandruff on scalp, pediculosis on uncombed hair.
SKULL AND FACE: Her skull is rounded, normocephalic and with normal contour, smooth skull contour, no lesions and masses noted. She has symmetrical face features and no lesions or masses noted.
EYES: Her eyebrows are symmetrically aligned and evenly distributed with eyelashes curled, outward and long. The eyelids are intact without secretions or discharges. The bulbar conjunctiva is transparent, the palpebral conjunctiva is shiny, smooth and pink in color and shiny with flat iris. Can move eyes and see objects in the periphery when looking straight.
EARS: Her auricles are symmetrical and have same color as the face. Ear canals are seen with little amounts of dry cerumen. It is mobile, firm, and not tender.
NOSE: Her nose is in proportion, uniform in color and no lesions. Sinuses are not tender when palpated and no discharge is noted.
MOUTH AND OROPHARYNX: Her lips are slightly brown in color, smooth in texture and elastic texture. She has pink tongue and moves freely. The palates and uvula are color pink with uvula at the midline. There are no discolorations and irritations and the oropharynx tonsils are pink in color. Her teeth are slightly yellow in color and there is presence of tooth decay.
NECK: Her neck is uniform in color, with coordinate smooth movement with equal muscle strength. Her head was able to move against resistance.
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THORAX AND LUNGS: Skin is intact with uniform color. No inflammation, lesions, deformities, masses and tenderness noticed. She has no difficulty in breathing and has regular breathing pattern of quiet and rhythmic respiration. Chest has no masses or tenderness. Breathing pattern and heart beat are normal. Spine is aligned vertically. Her composure is slightly slouched due to household chores. Her back is uniform in color. Both shoulders are aligned.
HEART: She has a normal pulse of 87 bpm with full pulsation of the carotid artery upon palpation.
ABDOMEN: Skin in her abdomen is uniform and rounded. With presence of tympanic sound over the stomach and gas fluid sound upon percussion, does not complain tenderness and pain upon palpation.
UPPER EXTREMITIES: The arm has brown complexion, no lesions or wounds found and soft to touch. Has smooth coordinated movement. No tenderness or swelling of muscles and bones noted. Has normal radial and brachial pulse.
> Fine Sensory Test The touch sensation is normal. She was able to discriminate sharp and dull sensations. She can also determine hot and cold sensations. > Fine Motor Test Finger to Nose Test: Can repeatedly and rhythmically touch her nose. Supination and Pronation of the Hand: Can alternately supinate and pronate her hands at rapid pace. Fingers to Fingers: Can perform with accuracy and rapidity. LOWER EXTREMITIES: The legs are warm, brown in complexion and smooth in texture. The toenails are trimmed, convex in curvature and the result for capillary refill is normal. The toenails are convex in curvature. There are no lesions found in both feet. There is no presence of contractures or deformities. The muscles have equal strength.
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> Gait and Balance The client was able to maintain balance (Walking Gait). When she was asked to stand with feet together and arms resting at the sides, first with eyes open then closed. Client was able to maintain upright posture and foot stance (Romberg Test). She can also maintain heel-toe walking along a straight line. > Fine Motor Test She was able to maintain bilateral equal coordination. She can also move smoothly with coordination.
Expected Result
Actual Result
Client will be The pt. was able able to identify to identify the mild the different aromas correctly odors presented with eyes closed.
Client will be The pt. was able able to read what to read the text was written on shown to her. the paper 14 inches apart and able to see objects and identify colors. Pupils will react to light and accommodation, able to close and open eyelids. The pt. was able to follow the pen easily and correctly. Her pupil performed constriction and dilation. Her pupils were round and equally reactive to light and accommodation.
The client was asked to look at the straight direction. Then with the use of a penlight, light was focused on the right eye and was removed to determine any changes on the pupil size. Same assessment was done to the left eye.
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Cranial Nerve Cranial Nerve Number 4: Trochlear Nerve
Type and Function Type: Motor Function: Extra-ocular movement of eyes in downward and inward movement. Type: Motor and Sensory Function: Sensation of cornea, skin of face, and jaw movement.
Assessment Procedure The client was asked to follow the direction of the penlight in an upward and downward movement without moving his head.
Expected Result The client will be able to move eyes on an upward and downward direction without moving the head.
Actual Result The pt. was able to perform the ocular movements without moving the head.
The pt. was able to blink after cotton touched her eyes; she felt the cotton; and she also identified if the object is sharp or blunt.
Type: Motor Function: Extra-ocular movement of eyes in a lateral movement Type: Motor and Sensory Function: Movement of facial muscles and sense of taste on the anterior twothirds of the tongue Type: Sensory Function:
The clients eyes The pt. was able will be able to to move her eyes move in lateral symmetrically. movement without moving the head. Client will be able to raise eyebrows, frown, smile, show teeth, puff out cheeks, and identify various taste on the tip of tongue like sweet and salty. The pt. was able to do all activities The pt. was able to identify all tasted food appropriate or correctly.
Student nurse placed The client will be The pt. was able a second-hand watch able to hear the to correctly repeat near the ears and ticking watch and the whispered 36
Cranial Nerve
Type and Function
Expected Result
Actual Result
Hearing and asked the client if he will be able to words. Vestibulo- equilibrium could hear the watch show balance. cochlear or tick. Then, he was Acoustics also asked to stand on his own for several seconds. Type: Motor and sensory Function: Swallowing Glossopha- and Gag ryngeal reflex, pharyngeal movement and sense of taste on the posterior one-thirds of the tongue Cranial Nerve Number 9: Student nurse asked the client to say AH; pressed the posterior tongue with a tongue depressor. Introduced the vinegar to the tongue with eyes closed. Lastly, the student nurse asked the patient to swallow. The client will be The pt. was able able to elicit to do all upward movement easily. movement of soft palate when mouth is opened, identify sour taste, and able to swallow.
Cranial Type: Motor Student nurse asked Nerve and Sensory a question, and Number 10: Function: elicited gag reflex. Swallowing Vagus and Nerve speaking Cranial Type: Motor Nerve Function: Number 11: Movement of shoulder Accessory blades Nerve Student nurse asked the client to move her head from side to side and asked to elevate her shoulders against the resistance introduced by the student nurse. Student nurse asked the client to move tongue from side to side and in and out.
The pt. was able to speak clearly and did not have a difficulty in swallowing. The pt. was able to shrugs her shoulder. She turned his head in all movement.
The pt. was able to do all movement instructed.
Mothers Obstetrical history Mother Yunas obstetric record is G6P6 (T6P0A0L6M0), with termed pregnancies of 6, no preterm pregnancy, no aborted fetus, six living children and no multiple pregnancies. She had 37
her first menstrual period when she was twelve years old. She has irregular menstruation which often lasts for 3 days. She consumes two pads per day when she has menstruation. She usually experiences menstrual cramps. During her first pregnancy, Mother Yuna told the student nurses that she did not have a hard time. She mostly craved for fruits like apples and bananas all the time. She delivered all her six children via normal delivery at home. In every pregnancy that she went through, she avoided drinking carbonated beverages like softdrinks, and she didnt eat salty food. She went for her pre-natal check-ups and she completed her Tetanus Toxoid vaccine. Nutritional Status Mother Yuna, age 42 y/o has a height of 150cm and weighs 35kg. BMI = weight in kg_
(height in m) = 35 kg __ 2.25 m
15.56kg/m
Based from the results of her BMI computation, Mother Yuna is considered under the classification of underweight. 38
History of Past Illness
Mother Yuna did not experience any serious illness since childhood. She verbalized having common colds, cough, fever, chicken pox and measles when she was young. Sometimes, she uses herbal medicines such as Lagundi and Oregano. If she experiences cough or colds, she self-medicates by drinking OTC medicine. She does not often go for a check-up. History of Present Illness
Mother Yuna is not presently diagnosed of any disease condition since she doesnt really go often for check-ups. She verbalized experiences of DOB, dysphagia and chest pain. Activities of Daily Living
Mother Yuna wakes up at 6AM. Then she proceeds to making coffee for her breakfast or bread whenever its available, clean the house and fix her childrens things. After that, she takes care of Tidus. At 10:30 AM, she cooks lunch and then after that, if she has enough time, she watches television. At noon, she eats lunch. After lunch time, either she prepares her kids to shool or she does the laundry. At around 6 pm or 7 pm, she prepares dinner, and after preparing and cooking, they eat dinner. After eating, she rests and watches TV with the whole family. After relaxing, she fixes all the things and approximately at 10:00PM she heads off to sleep.
Zidhaine (Initial home visit: September 6, 2010) He is not able to assess during the home visit because he had his class that morning.
(Second home visit: September 7, 2010) APPEARANCE AND MENTAL STATUS 39
Zidhaine is the eldest among the four children of the family and is 13 years old. He is wearing a blue short and striped shirt. His skin is smooth, dark complexion and good skin turgor. His hair is black in color and evenly distributed with no infestations noted. He has long and dirty fingernails. Presence of dental caries is noted. Upon interview, it is noted that he is oriented to time, date, place and person and is coherent in answering the questions. His initial vital signs were taken and recorded as follows: T=36.9 oC, PR= 88 bpm and RR= 18 cpm.
PHYSICAL ASSESSMENT: SKIN: Zidhaine skin is smooth, dark complexion, equally distributed with good skin turgor. There are no lesions or discharges found. NAILS: Upon inspecting the nails, fingernails are untrimmed and dirty. His nails were pink in color and smooth in texture and with a capillary refill of less than 2 seconds. HAIR: The hair is short, black, soft and evenly distributed with no presence of dandruff. There is no presence of infestations. SKULL AND FACE: Skull is round and smooth in contour without presence of nodules or masses. The color of her face is symmetrical to the skin. Facial features are symmetrical and facial movements. EYES: Eyebrows are evenly distributed and symmetrically aligned with equal movements. Eyelashes are also equally distributed and curled slightly outward and upward. Eyelids close symmetrically with skin intact and no discharge or discoloration. Bulbar conjunctiva is transparent and sclera appears white. Palpebral conjunctiva is shiny, smooth and pink in color. Lacrimal ducts have no edema or tearing upon palpation. Cornea is transparent, shiny and smooth with visible details of iris. Client blinks when the cornea is touched with the use of cotton. Pupils are equally round and reactive to light and accommodation. Client can see objects in the periphery when looking straight ahead and able to read a print 14 inches apart.
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EARS: The color of the auricle is the same as the facial skin color, symmetrical in size and the position of both auricles is at the level of the eye. It is elastic and the pinna recoil when folded. There are no lesions found and no tenderness noted.
NOSE: The nose is symmetric, straight and no discharges found in nares. The color of the nose is the same as the facial skin, no abnormalities of the shape can be seen. The air moves freely when she breaths on both nares and the nasal septum is in between the nasal chambers. There are no masses or swellings are palpated in maxillary and frontal sinuses.
MOUTH AND OROPHARYNX: The lips have symmetrical contour, no pallor noted, pink in color and smooth and have the ability to purse lips. He has 4 tooth decays: 2 on his right mandible and 2 on his right maxillary. His tongue is pink in color, at the central position, no lesions observed and moves freely. The soft palate is light pink and smooth while the hard palate is lighter pink. The uvula is positioned on the midline of soft palate. The oropharynx is smooth and pink and the tonsils have no discharges.
NECK: Neck muscles are equal in size and head is centered. Client can move head smoothly with no discomfort. Client can shrug shoulders against the resistance of student nurses hands. Lymph nodes are not palpable and trachea is in the midline of neck.
THORAX AND LUNGS: Chest is symmetric in size and spine is vertically aligned. Both lung fields are clear upon auscultation. Skin is intact with no palpable masses or nodules. Breathing is regular and normal.
HEART: Zidhaines heart has no vibrations or pulsations are palpated on the aortic, pulmonic or tricuspid area. There is no presence of swishing sound like murmurs. Has regular rate and rhythm. And has identical pulse in radial and apical pulse.
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ABDOMEN: There is no blemished in the skin, no pulsation, masses and no tenderness. The skin is intact and warm to touch. UPPER EXTREMITIES: The arm has dark complexion, no lesions or wounds found and soft to touch. Has smooth coordinated movement. No tenderness or swelling of muscles and bones noted. Has normal radial and brachial pulse.
> Fine Sensory Test The touch sensation is normal. He was able to discriminate sharp and dull sensations. He can also determine hot and cold sensations. > Fine Motor Test Finger to Nose Test: Can repeatedly and rhythmically touch his nose. Supination and Pronation of the Hand: Can alternately supinate and pronate his hands at rapid pace. Fingers to Fingers: Can perform with accuracy and rapidity. LOWER EXTREMITIES: The legs are warm, brown in complexion and smooth in texture. The toenails are untrimmed, convex in curvature and the result for capillary refill is normal. The toenails are convex in curvature. There are no lesions found in both feet. There is no presence of contractures or deformities. The muscles have equal strength.
> Gait and Balance The client was able to maintain balance (Walking Gait). When he was asked to stand with feet together and arms resting at the sides, first with eyes open then closed. Client was able to maintain upright posture and foot stance (Romberg Test). He can also maintain heel-toe walking along a straight line. > Fine Motor Test He was able to maintain bilateral equal coordination. He can also move smoothly with coordination.
42
Expected Result Client will be able to identify the different odors presented with eyes closed.
Actual Result The client identified the smell of the perfume and vinegar.
Client read what was written on the paper 14 inches apart and has identified colors.
Pupils had reacted to light and accommodation. He was also able to close and open his eyelids.
The client moved his eyes on an upward and downward direction without moving the head.
Student nurse made use of a clean cotton wisp and gently stroked client's eyelashes to elicit corneal reflex. Also, the student nurse asked the client to
Client will be able to elicit corneal reflex and identify the sensation of dull or sharp objects. The client must be able to close
The client elicited corneal reflex and had identified the sensation of dull or sharp objects. The client was able to close and open, move side 43
Cranial Nerve
Type and Function
Assessment Procedure close his eyes to determine if the object is sharp or dull upon introducing to face. The nurse also asked the client to move his jaw from side to side and chew.
Expected Result
Actual Result
and open, move to side his jaw and side to side his made some jaw and make mastication. some mastication.
Student nurse asked the client to follow the direction of the penlight in a lateral movement.
The clients eyes will be able to move in lateral movement without moving the head. Client will be able to raise eyebrows, frown, smile, show teeth, puff out cheeks, and identify various taste on the tip of tongue like sweet and salty. The client will be able to hear the ticking watch and will be able to show balance.
The clients eyes moved in lateral movement without moving the head.
The client was able to raise eyebrows, frown, smile, show teeth, puff out cheeks, and identified various taste on the tip of tongue like sweet and salty. The client heard the ticking watch and was also able to show balance.
Type: Motor and sensory Function: Swallowing Glossopha- and Gag ryngeal reflex, pharyngeal movement and sense of taste on the posterior
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Cranial Nerve
Type and Function one-thirds of the tongue
Expected Result
Actual Result
Cranial Type: Motor Student nurse asked Nerve and Sensory a question, and elicited gag reflex. Number 10: Function: Swallowing and Vagus speaking Nerve Cranial Type: Motor Nerve Function: Number 11: Movement of shoulder Accessory blades Nerve Student nurse asked the client to move her head from side to side and asked to elevate her shoulders against the resistance introduced by the student nurse. Student nurse asked the client to move tongue from side to side and in and out.
The client was able to shrug shoulders and moved head from side to side against applied resistance. The client was able to protrude tongue and moved it from side to side.
(Final home visit: September 21, 2010) He is not able to assess during the home visits because he had his class at the afternoon. Nutrition Status
Zidhaine, age 13 years old, has a height of 149cm (1.49 m), and weighs 36 kg. BMI = weight in kg height in m
= 36 kg (1.49 m)
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16.22 kg/m
Basing on the result of the computation on the above parameters, Zidhaine is classified as underweight. History of Past Illness
According to Mrs. Yuna, he experienced cough and colds, fever in the past. He already experienced chickenpox. If he has a fever, they managed it with tepid sponge bath and over the counter medicines. History of Present Illness
Zidhaine doesnt have any illness at present. Upon the student nurses assessment, hes at good health. Activities of Daily Living
Zidhaine wakes up at 8:00 in the morning and eats his breakfast. After that, he will either play with his friends or go to the internet shop. Usually, he will come back by 11:30 am to eat his lunch and prepare for school. Together with his siblings, he will stay at school from 1:00 to 5:00 pm. At 5:30 pm, he goes home and after resting, starts to make his assignments and watch TV afterwards. They will eat their supper at 7:00 pm and sleep at 9:00 pm.
CLOUD
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(Initial home visit: September 6, 2010) APPEARANCE AND MENTAL STATUS
Cloud, who was the second eldest among four children of the family, is 10 years old. He is a pure blooded Filipino born on October 14, 1990 in Balibago, Angeles City. He is wearing white t-shirt and black pants. His skin was smooth, has dark complexion His hair was black in color and evenly distributed. He has long and dirty fingernails. Presence of dental carries. Upon interview, it is noted that he is oriented to time, date, place and person and is coherent in answering the questions. His initial vital signs were taken and recorded as follows: T=36.5 oC, PR= 92 bpm, RR= 24 cpm, PHYSICAL ASSESSMENT: SKIN: Child Cloud was noted to have a dry skin and fair complexion. He has no edema on any part of the body. He has a good skin turgor. NAILS: Upon inspecting the nails, long and dirty fingernails were noted. His nails were pink in color and smooth in texture. Normal capillary refill of 2 seconds was noted. HAIR: He had a natural hair which is black in color. His hair was evenly distributed on his scalp. No dandruff, infection or infestations noted upon inspecting the hair in several areas. SKULL AND FACE: Skull is round and smooth in contour without presence of nodules or masses. Facial features are symmetrical and facial movements. EYES: Eyebrows are evenly distributed and symmetrically aligned with equal movements. Eyelashes are also equally distributed and curled slightly outward and upward. Eyelids close symmetrically with skin intact and no discharge or discoloration. Bulbar conjunctiva is transparent and sclera appears white. Palpebral conjunctiva is shiny, smooth and pink in color. Lacrimal ducts have no edema or tearing upon palpation. Cornea is transparent, shiny and smooth with visible details of iris. Client blinks 16 times per minute and when the cornea is touched with the use of cotton. Pupils are equally round and reactive to light and accommodation. Client can see objects in the periphery when looking straight ahead and is able to read a print 14 inches apart. 47
EARS: Auricles are same as the color of facial skin, symmetric and aligned with outer canthus of eye. It is mobile, firm, non tender and recoils after being folded. NOSE: Nose is symmetrical to the face; patent nasal passage with septum on the midline, moist and pink mucous membrane, no bleeding, whitish nasal discharges, and no masses palpated on the sinuses, no nasal flaring and can breathe easily. MOUTH AND OROPHARYNX: Lips are uniformly pink, soft and symmetrical. Client is able to purse lips when asked to. NECK: Neck muscles are equal in size and head is centered. Client can move head smoothly with no discomfort. Client can shrug shoulders against the resistance of student nurses hands. Lymph nodes are not palpable and trachea is in the midline of neck. THORAX AND LUNGS: Chest is symmetric in size and spine is vertically aligned. Both lung fields are clear upon auscultation. Skin is intact with no palpable masses or nodules. Breathing is regular and normal. Has normal respiratory rate of 21 cycles per minute. HEART: Heart rate is regular in rhythm upon auscultation without any murmurs. Peripheral pulses are symmetrical with that of the apical pulse as well. Has a pulse rate of 82 beats per minute. ABDOMEN: Skin is uniform in color. UPPER EXTREMITIES: Has uniform temperature. No lesions had noted. Patient's muscles are equal in size in both bodies. Has smooth coordinated movements and has equal strength. No tenderness or swelling of muscles and bones noted. Has normal radial and brachial pulse rate and rhythm.
> Fine Sensory Test The touch sensation is normal. He was able to discriminate sharp and dull sensations. He can also determine hot and cold sensations. 48
> Fine Motor Test Finger to Nose Test: Can repeatedly and rhythmically touch his nose. Supination and Pronation of the Hand: Can alternately supinate and pronate his hands at rapid pace. Fingers to Fingers: Can perform with accuracy and rapidity. LOWER EXTREMITIES: Has uniform temperature. No lesions were present. Muscles on both side of the body are equal in size. There is no presence of contractures or deformities. And muscles have equal strength. > Gait and Balance The client was able to maintain balance (Walking Gait). When he was asked to stand with feet together and arms resting at the sides, first with eyes open then closed. Client was able to maintain upright posture and foot stance (Romberg Test). He can also maintain heel-toe walking along a straight line. > Fine Motor Test He was able to maintain bilateral equal coordination. He can also move smoothly with coordination.
Cranial Nerve Cranial Nerve Number 1: Olfactory Nerve Cranial Nerve Number 2:
Assessment Procedure The student nurse asked the patient to close both of her eyes and asked to identify different aromas such as perfume and vinegar. The asked read words student nurse the client to some printed from a paper
Actual Result The client identified the smell of the perfume and vinegar.
Client will be able to read what was written on the paper 14
Client read what was written on the paper 14 inches apart and has
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Cranial Nerve Optic Nerve
Type and Function
Expected Result
Actual Result
14 inches apart and inches apart and identified colors. identify some colors. able to see objects and identify colors. The client was asked to look at the straight direction. Then with the use of a penlight, light was focused on the right eye and was removed to determine any changes on the pupil size. Same assessment was done to the left eye. The client was asked to follow the direction of the penlight in an upward and downward movement without moving his head. Pupils will react to light and accommodation, able to close and open eyelids. Pupils had reacted to light and accommodation. He was also able to close and open his eyelids.
The client moved his eyes on an upward and downward direction without moving the head.
The client elicited corneal reflex and had identified the sensation of dull or sharp objects. The client was able to close and open, move side to side his jaw and made some mastication.
Cranial Nerve Number 6: Abducens Nerve
Type: Motor Function: Extra-ocular movement of eyes in a lateral
The clients eyes will be able to move in lateral movement without moving the head.
The clients eyes moved in lateral movement without moving the head.
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Cranial Nerve Cranial Nerve Number 7: Facial Nerve
Type and Function movement Type: Motor and Sensory Function: Movement of facial muscles and sense of taste on the anterior twothirds of the tongue Type: Sensory Function: Hearing and equilibrium
Assessment Procedure Student nurse asked the client to raise his eyebrows, smile, frown, show teeth, and to puff out his cheeks and to identify various taste on the tip of the tongue like sweet and salty.
Expected Result Client will be able to raise eyebrows, frown, smile, show teeth, puff out cheeks, and identify various taste on the tip of tongue like sweet and salty. The client will be able to hear the ticking watch and will be able to show balance.
Actual Result The client was able to raise eyebrows, frown, smile, show teeth, puff out cheeks, and identified various taste on the tip of tongue like sweet and salty. The client heard the ticking watch and was also able to show balance.
Cranial Type: Motor Student nurse asked Nerve and Sensory a question, and elicited gag reflex. Number 10: Function: Swallowing and Vagus speaking Nerve Cranial Type: Motor Nerve Function: Number 11: Movement of shoulder Accessory blades Nerve Student nurse asked the client to move her head from side to side and asked to elevate her shoulders against the resistance
The client will be able to speak without hoarseness, and will elicit gag reflex. The client will be able to shrug shoulders and move head from side to side against applied
The client was able to shrug shoulders and moved head from side to side against applied 51
Cranial Nerve
Type and Function
Assessment Procedure introduced by student nurse.
Expected Result the resistance. The client will be able to protrude tongue and move it from side to side.
Actual Result resistance. The client was able to protrude tongue and moved it from side to side.
Student nurse asked the client to move tongue from side to side and in and out.
(Final home visit: September 21, 2010) APPEARANCE AND MENTAL STATUS
He is not able to assess during the home visits because he had his class at the afternoon.
PHYSICAL ASSESSMENT:
He is not able to assess during the home visit because he had his class at the afternoon. Nutrition Status
Cloud age 10, has a height of 42 (1.28 m), and weighs 25 kg. BMI = weight in kg height in m
= 25 kg (1.28 m)
15.26 kg/m
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Basing on the result of the computation on the above parameters, Cloud is classified as underweight. History of Past Illness
He experienced illnesses for the past years like fever, coughs and colds. He did not experience measles, chickenpox, or mumps yet. His parents provided him with a tepid sponge bath when he had a fever. And when he had coughs and colds, they are only self-medicating. History of Present Illness
Cloud doesnt have any illness at present. Upon the student nurses assessment, hes at good health. Activities of Daily Living
Cloud usually wakes up at 8:00 in the morning and eats his breakfast afterwards. He will then play with his friends outside. At 11:30 am, he will eat his lunch and prepare for his schooling afterwards. At 1:00 pm until 5:00 pm, he is at his school. He goes home at 5:30 pm and then do his home works after that he watches TV. He will have his dinner at 7:00 and sleeps afterwards at 9:00 pm.
Aerith 53
(Initial home visit: September 6, 2010) APPEARANCE AND MENTAL STATUS Aerith is the third to the eldest in the family and she is 8 years old. She is wearing an orange shirt and black shorts. Her skin is warm, moist and presence of scars in the legs. Presence of cough and colds and dental caries is noted. Her hair is black in color and equally distributed. There is also presence of infestation in the hair. Loss of appetite was also noted. Upon interview, it is noted that he is oriented to time, date, place and person and is coherent in answering the questions. His initial vital signs were taken and recorded as follows: T=36.5 oC, PR= 89 bpm, RR= 21 cpm.
PHYSICAL ASSESSMENT: SKIN: Aerith has brown, uniform complexion, and no edema noted. There are no lesions and wound found. The skin is smooth and warm to touch and the skin turgor is good.
NAILS: Upon inspecting the nails, long and dirty fingernails were noted. Her nails were pink in color and smooth in texture. Normal capillary refill of 2 seconds was noted. HAIR: Her hair is black in color, soft and evenly distributed. No presence of dandruff. Presence of infestation is noted. SKULL AND FACE: Skull is round and smooth in contour without presence of nodules or masses. Facial features are symmetrical and facial movements. EYES: Eyebrows are evenly distributed and symmetrically aligned with equal movements. Eyelashes are also equally distributed and curled slightly outward and upward. Eyelids close symmetrically with skin intact and no discharge or discoloration. Bulbar conjunctiva is transparent and sclera appears white. Palpebral conjunctiva is shiny, smooth and pink in color. Lacrimal ducts have no edema or tearing upon palpation. Cornea is transparent, shiny and smooth with visible details of iris. Client blinks when the cornea is touched with the use of cotton. Pupils are equally round and reactive to light and accommodation. Client can see objects in the periphery when looking straight ahead and is able to read a print 14 inches apart.
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EARS: Auricles are same as the color of facial skin, symmetric and aligned with outer canthus of eye. It is mobile, firm, non tender and recoils after being folded. NOSE: Nose is symmetrical to the face; patent nasal passage with septum on the midline, moist and pink mucous membrane, no bleeding, with no discharges and no masses palpated on the sinuses, no nasal flaring and can breathe easily. MOUTH AND OROPHARYNX: The lips have symmetrical contour, no pallor noted, pink in color and smooth and have the ability to purse lips. Presence of dental caries is noted. She has tooth decay on her frontal incisors. 1 missing tooth and 6 dental carries Her tongue is pink in color, at the central position, no lesions observed and moves freely. The soft palate is light pink and smooth while the hard palate is lighter pink. The uvula is positioned on the midline of soft palate. The oropharynx is smooth and pink and the tonsils have no discharges.
NECK: Neck muscles are equal in size and head is centered. Client can move head smoothly with no discomfort. Client can shrug shoulders against the resistance of student nurses hands. Lymph nodes are not palpable and trachea is in the midline of neck. THORAX AND LUNGS: Chest is symmetric in size and spine is vertically aligned. Both lung fields are clear upon auscultation. Skin is intact with no palpable masses or nodules. Breathing is regular and normal. HEART: Heart rate is regular in rhythm upon auscultation without any murmurs. Peripheral pulses are symmetrical with that of the apical pulse as well. Has a pulse rate of 82 beats per minute. ABDOMEN: There is no blemished in the skin, no pulsation, masses and no tenderness. The skin is intact and warm to touch. UPPER EXTREMITIES: Has uniform temperature. No lesions had noted. Patient's muscles are equal in size in both bodies. Has smooth coordinated movements and has equal strength. No tenderness or swelling of muscles and bones noted. Has normal radial and brachial pulse rate and rhythm.
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> Fine Sensory Test The touch sensation is normal. She was able to discriminate sharp and dull sensations. She can also determine hot and cold sensations. > Fine Motor Test Finger to Nose Test: Can repeatedly and rhythmically touch his nose. Supination and Pronation of the Hand: Can alternately supinate and pronate his hands at rapid pace. Fingers to Fingers: Can perform with accuracy and rapidity. LOWER EXTREMITIES: Has uniform temperature. No lesions were present. Muscles on both side of the body are equal in size. There is no presence of contractures or deformities. And muscles have equal strength. > Gait and Balance The client was able to maintain balance (Walking Gait). When she was asked to stand with feet together and arms resting at the sides, first with eyes open then closed. Client was able to maintain upright posture and foot stance (Romberg Test). He can also maintain heel-toe walking along a straight line. > Fine Motor Test She was able to maintain bilateral equal coordination. She can also move smoothly with coordination. CRANIAL NERVE ASSESSMENT
Cranial Nerve Cranial Nerve Number 1: Olfactory
Assessment Procedure The student nurse asked the patient to close both of her eyes and asked to identify different aromas such
Actual Result The client identified the smell of the perfume and vinegar. 56
Cranial Nerve Nerve Cranial Nerve Number 2: Optic Nerve
Type and Function
Assessment Procedure as perfume vinegar. and
Expected Result
Actual Result
The student nurse asked the client to read some printed words from a paper 14 inches apart and identify some colors.
Client read what was written on the paper 14 inches apart and has identified colors.
Pupils had reacted to light and accommodation. She was also able to close and open his eyelids.
The client moved her eyes on an upward and downward direction without moving the head.
Student nurse made use of a clean cotton wisp and gently stroked client's eyelashes to elicit corneal reflex. Also, the student nurse asked the client to close his eyes to determine if the object is sharp or dull upon introducing to face. The nurse also asked the client to move his jaw from side to side and chew.
The client elicited corneal reflex and had identified the sensation of dull or sharp objects. The client was able to close and open, move side to side her jaw and made some mastication.
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Cranial Nerve Cranial Nerve Number 6: Abducens Nerve Cranial Nerve Number 7: Facial Nerve
Type and Function Type: Motor Function: Extra-ocular movement of eyes in a lateral movement Type: Motor and Sensory Function: Movement of facial muscles and sense of taste on the anterior twothirds of the tongue Type: Sensory Function: Hearing and equilibrium
Assessment Procedure Student nurse asked the client to follow the direction of the penlight in a lateral movement.
Expected Result The clients eyes will be able to move in lateral movement without moving the head. Client will be able to raise eyebrows, frown, smile, show teeth, puff out cheeks, and identify various taste on the tip of tongue like sweet and salty. The client will be able to hear the ticking watch and will be able to show balance.
Actual Result The clients eyes moved in lateral movement without moving the head.
The client was able to raise eyebrows, frown, smile, show teeth, puff out cheeks, and identified various taste on the tip of tongue like sweet and salty. The client heard the ticking watch and was also able to show balance.
Cranial Type: Motor Student nurse asked Nerve and Sensory a question, and Number 10: Function: elicited gag reflex. Swallowing Vagus and Nerve speaking
The client will be able to speak without hoarseness, and will elicit gag reflex.
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Cranial Nerve
Type and Function
Assessment Procedure Student nurse asked the client to move her head from side to side and asked to elevate her shoulders against the resistance introduced by the student nurse. Student nurse asked the client to move tongue from side to side and in and out.
Expected Result The client will be able to shrug shoulders and move head from side to side against applied resistance. The client will be able to protrude tongue and move it from side to side.
Actual Result The client was able to shrug shoulders and moved head from side to side against applied resistance. The client was able to protrude tongue and moved it from side to side.
Cranial Type: Motor Nerve Function: Number 11: Movement of shoulder Accessory blades Nerve
(Final home visit: September 21, 2010) She is not able to assess during the home visits because he had his class at the afternoon.
Nutrition Status
Aerith, age 8, has a height of 119 (1.19 m), and weighs 19 kg. BMI = weight in kg height in m
= 19 kg (1.19 m)
13.48 kg/m
Asia-Pacific Obesity Guidelines BMI < 18.5 18.6 22.9 > 23.0 Interpretation Underweight Healthy Weight Overweight 59
Asia-Pacific Obesity Guidelines BMI 23.0 24.9 25.0 29.9 > 30.0 Interpretation At risk Obese I Obese II
Basing on the result of the computation on the above parameters, Aerith is classified as underweight. History of Past Illness
Aerith experienced fever and cough and colds before. Like his brothers, when she has fever, they used tepid sponge bath and over the counter drugs. Most of the times, they use Paracetamol. History of Present Illness
Aerith has cough for 1 week and was cured on the second home visit. To cure this, they decoct Oregano for her. Activities of Daily Living
Aerith wakes up at 8:00 in the morning and eats her breakfast afterwards. She then go out to play with her friends or asked to help in cleaning. She will eat her lunch at 11:30 am and get ready to school. She will be on school from 1 to 5 pm. After that, she will go home. After resting, she will do her assignments and study her lesson. If all her school work is done, she will watch TV. They will eat their lunch at 7:00 pm and go to sleep at 9 pm. If she is tired from school, she will sleep at 8 pm.
TIDUS (Initial home visit: September 6, 2010) APPEARANCE AND MENTAL STATUS 60
Tidus, youngest among the four children, is 24 months old. He is a pure blooded Filipino born on April 26, 2008 in Balibago, Pampanga. He is wearing white sando only. His skin was smooth, has fair complexion and has good skin turgor. Skin goes back to its previous state in less than 2 seconds upon pinching near his forearm. His hair was black in color and evenly distributed. He has short and clean fingernails. Presence of clear nasal discharge was noted. He has coughs and colds and an elevated temperature and some rashes on his face. His initial vital signs were taken and recorded as follows: T=36.9 oC, PR= 98 bpm, RR= 26 cpm. PHYSICAL ASSESSMENT: SKIN: Tidus has smooth skin and fair complexion. He has no edema on any part of the body. He has a good skin turgor. NAILS: Upon inspecting the nails, long and dirty fingernails were noted. His nails were pink in color and smooth in texture. Normal capillary refill of less than 2 seconds was noted. HAIR: He had a natural hair which is black in color. His hair was evenly distributed on his scalp. No dandruff, infection or infestations noted upon inspecting the hair in several areas. SKULL AND FACE: Skull is round and smooth in contour without presence of nodules or masses. Facial features are symmetrical. Presence of rashes on the face. EYES: Eyebrows are evenly distributed and symmetrically aligned with equal movements. Eyelashes are also equally distributed and curled slightly outward and upward. Eyelids close symmetrically with skin intact and no discharge or discoloration. Bulbar conjunctiva is transparent and sclera appears white. Palpebral conjunctiva is shiny, smooth and pink in color. Lacrimal ducts have no edema or tearing upon palpation. Cornea is transparent, shiny and smooth with visible details of iris. Pupils are equally round and reactive to light and accommodation.
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EARS: Auricles are same as the color of facial skin, symmetric and aligned with outer canthus of eye. It is mobile, firm, non tender and recoils after being folded. Presence of white cerumen was noted. NOSE: Nose is symmetrical to the face; nasal septum on the midline, moist and pink mucous membrane, no bleeding, with clear nasal discharges, and no masses palpated on the sinuses. MOUTH AND OROPHARYNX: Lips are uniformly pink, soft and symmetrical. Has a tooth decayed and missing teeth. NECK: Neck muscles are equal in size and head is centered. Client can move head smoothly with no discomfort. THORAX AND LUNGS: Chest is symmetric in size and spine is vertically aligned. Both lung fields are clear upon auscultation though he has coughs and colds. Skin is intact with no palpable masses or nodules. Breathing is regular and normal. Has normal respiratory rate of 26 cycles per minute. HEART: Heart rate of is regular in rhythm upon auscultation without any murmurs. Has a pulse rate of 92 beats per minute. ABDOMEN: Skin is uniform in color. UPPER EXTREMITIES: No lesions had noted. Patient's muscles are equal in size in both bodies. Has a smooth coordinated movement. No tenderness or swelling of muscles and bones noted. LOWER EXTREMITIES: No lesions were present. Muscles on both side of the body are equal in size. There is no presence of contractures or deformities. (Final home visit: September 21, 2010) APPEARANCE AND MENTAL STATUS Tidus, youngest among the four children, is 24 months old. He is a pure blooded Filipino born on April 26, 2008 in Balibago, Pampanga. He is wearing white sando only. His skin was 62
smooth, has fair complexion and has good skin turgor. Skin goes back to its previous state in less than 2 seconds upon pinching near his forearm. His hair was black in color and evenly distributed. He has short and clean fingernails. Presence of clear nasal discharge was noted. He has coughs and colds and some rashes on his face. His initial vital signs were taken and recorded as follows: T=36.3 oC, PR= 92 bpm, RR= 24 cpm PHYSICAL ASSESSMENT: SKIN: Tidus has smooth skin and fair complexion. He has no edema on any part of the body. He has a good skin turgor. NAILS: Upon inspecting the nails, clean and short fingernails were noted. His nails were pink in color and smooth in texture. Normal capillary refill of less than 2 seconds was noted. HAIR: He had a natural hair which is black in color. His hair was evenly distributed on his scalp. No dandruff, infection or infestations noted upon inspecting the hair in several areas. SKULL AND FACE: Skull is round and smooth in contour without presence of nodules or masses. Facial features are symmetrical. Still the presence of rashes on his face existed. EYES: Eyebrows are evenly distributed and symmetrically aligned with equal movements. Eyelashes are also equally distributed and curled slightly outward and upward. Eyelids close symmetrically with skin intact and no discharge or discoloration. Bulbar conjunctiva is transparent and sclera appears white. Palpebral conjunctiva is shiny, smooth and pink in color. Lacrimal ducts have no edema or tearing upon palpation. Cornea is transparent, shiny and smooth with visible details of iris. Pupils are equally round and reactive to light and accommodation. EARS: Auricles are same as the color of facial skin, symmetric and aligned with outer canthus of eye. It is mobile, firm, non tender and recoils after being folded. Presence of white cerumen was noted.
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NOSE: Nose is symmetrical to the face; nasal septum on the midline, moist and pink mucous membrane, no bleeding, with clear nasal discharges, and no masses palpated on the sinuses, with nasal flaring. MOUTH AND OROPHARYNX: Lips are uniformly pink, soft and symmetrical. Has tooth decay and missing teeth NECK: Neck muscles are equal in size and head is centered. Client can move head smoothly with no discomfort. THORAX AND LUNGS: Chest is symmetric in size and spine is vertically aligned. Both lung fields are clear upon auscultation though he has coughs and colds. Skin is intact with no palpable masses or nodules. Breathing is regular and normal. Has normal respiratory rate of 24 cycles per minute. HEART: Heart rate of is regular in rhythm upon auscultation without any murmurs. Has a pulse rate of 92 beats per minute. ABDOMEN: Skin is uniform in color. UPPER EXTREMITIES: No lesions had noted. Patient's muscles are equal in size in both bodies. Has a smooth coordinated movement. No tenderness or swelling of muscles and bones noted. LOWER EXTREMITIES: No lesions were present. Muscles on both side of the body are equal in size. There is no presence of contractures or deformities.
Erik Eriksons Psychosocial Stages
According to Erik Eriksons Psychosocial Stages, the developmental task of Child Tidus is in the toddler period which is to form a sense of autonomy versus shame and doubt. It is a 64
stage in which a child learns how to be independent and make decisions for self. They begin to develop their sense of autonomy by asserting themselves with the frequent use of the word NO. Temper tantrums results from their frustration by restraints to their behavior. This is evident to Child Tidus. He always says NO whenever we try to get his temperature. He also manifests frequent temper tantrums especially when his father tells him to behave. Sigmund Freuds Psychosexual Stages
According to Sigmund Freuds Psychosexual Stages, Child Tidus is in the stage of anal stage wherein a child learns to control urination and defecation. The child finds pleasure and sense of control in both the retention and defecation of feces. During our home visits, the student nurses did not observed if Child Tidus already learned to control urination and defecation. But according to Mrs. Yuna, whenever he defecates, he tries to wash himself and he was also able to control his urination and defecation.
Nutrition Status
Child Tidus, 24 months of age, has a weight of 10 kg. Below Normal 8.4-10.0 FNRI NUTRITIONAL STATUS TABLE Normal From To 10.1 15.7A Above Normal 14.7
Based on the FNRI nutritional status table, Child Tidus weight is below normal. History of Past Illness
He experienced illnesses for the past years like fever, coughs and colds. When he had a fever, his parents gave him Tempra three times a day. They also provided him with tepid sponge bath. On the other hand, he took Herbal medicine specifically Oregano once a day to treat his coughs and colds. He had not experienced mumps, measles, or chickenpox. History of Present Illness
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On the first day and second day of home visit, Child Tidus has an elevated fever and coughs and colds. They parents provided him with tepid sponge bath and gives him Tempra to normalize his temperature and decoct Oregano for his coughs and colds. Activities of Daily Living
Child Tidus usually wakes up at 8:00 in the morning and eats her breakfast afterwards. He will then play the whole day and watch TV. He eats his lunch at 11:30 and dinner at 7:00. He will sleep at 8:00 pm. He does also sleeps in the afternoon at around 1:00 in the afternoon.
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IV. SOCIO-ECONOMIC, CULTURAL AND ENVIRONMENTAL ASSESSMENT
This section provides the information necessary to determine the socio-economic, cultural and environmental status of the family members and their environment they live in which can be a factor regarding their health. Also included in this is the importance of assessing the significant others and their particular roles in the family will be able to give the student nurses a background on how each member handle their problems. A. Type of Family The Fantacia Family is considered an Extended Family. In this type of family, the members live together in one house, comprising of Grandmother Tifa, Mother Yuna, and her children, Zidhaine, Aerith, Cloud and Tidus. B. Dominant Family Members in terms of decision-making especially to health care Mother Yuna, being the head of the family, makes the overall decisions at home with regards to the familys health and in deciding when it comes to financial matters.
C. Source of Income and Expenditures The two eldest children of Mother Yuna works to contribute for the finances of the family although they dont live with Mother Yuna because they both have their own families already. Mother Yunas sister also gives monthly allowance to Grandmother Tifa. According to Mother Yuna, she is given Php 1,500 every month by her two children. Grandmother Tifa receives Php 4,000 monthly from her son. Approximately, they have a monthly income of P5,500. Monthly expenses of the Fantacia Family are as follows:
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EXPENSES Electric Bill Water Bill Food Others (Milk, Diaper, and Allowance)
AMOUNT P300.00 P600.00 P3000.00 P1000.00
Total expenses for a month: P4900.00
Extra money: P600.00
In accordance with this, the results show that they still have enough money to spend for other needs, however according to Mother yuna, the extra money is used to pay the debts from the stores where they acquire foods whenever their allowance isnt enough. According to Mother Yuna, she budgets their money so that they can always have extra cash. But sometimes they spend it all if there are emergency needs. Their extra money is used for additional expenses in their chidrens schooling.
Adequacy to meet basic needs
Dividing the total income of P5500.00 by the total number of family members which is six, each member will have an amount of P916.67. This indicates that the family belongs to the poor sector of society because they failed to meet the prescribed budget of NEDA, which is P2768.60 per month, per family member.
Any financial assets available in case of emergency In case of emergency, the family seeks help from their neighbors nearby beacuse
their relatives either has not enough income or they come from distant places. D. Working Hours There are no members working from the family.
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E. Ethnic Background and Religious Affiliation Grandmother Tifa and Mother Yuna were both born from Leyte. Mother Yunas late husband was born in Angeles, Pampanga where they met and fell in love. They married on May 8, 1986. Both of them are Roman Catholics. The family seldom goes to church because of busy schedule and no enough money for transportation. F. Significant others role in the family life
When it comes to needs like money, they always count on Mother Yunas brother. He helps the family if they experience any problems. G. Health habits and beliefs If one of the family members is sick, Mother Yuna sometimes uses herbal medicines such as Lagundi and Oregano leaves for cough. If not, she uses over-the-counter medications for it. She also believes that it is not okay to take a bath whenever she has menstruation because she mentioned that her sister-in-law experienced headache and confusion after taking a bath during her menstrual period. Their family also believes that guava leaves after circumcision can hasten the healing process. H. Familys involvement in the community activities According to the family, they are not really actively involved in the community activities that the barangay health center offers. However, the family goes to the barangay health center if needed, such as with immunizations and vaccines for their children.
I.
Family Utilization of Community Resources The family utilizes the community resources such as the free medicines,
immunizations and vaccine programs, especially for their children.
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J. Housing Condition The house of the Fantacia Family is their own, although the land is not theirs. Their house is made of concrete wood, cement, and a roof that merely overlaps the entire house just to protect the family from rain and other natural hazards. The family has very few pieces of furniture. They have chairs and a dining table made up of wood. They have two beds made up of wood which are too small for all of them to fit in. Instead of three beds, the family members would use a banig in order for the others to sleep. There is a noticeable dim environment even though there is a light bulb above, meaning that there is inadequacy of lighting inside the house. There are windows present but the air is obstructed for entrance because of curtains. The measurement of the windows is 25 inches in width and height. Toys were scattered on the floor and sharp objects such as knives are within reach of children with no proper storage and there is possibility of falling. There is presence of cockroaches, mosquitoes and flies roaming around the house. The floor measurement of the house length is 5 meters and the width of 3.7 meters. The total floor area is 18.5 square meters, if divided into 6, since there are 6 members of the family, will yield 3.08 square meters. According to the National Building Code of the Philippines, equal to or more than 3.5 square meters is the adequate living space for adults, and 1.5 square meters for children. For Mother Yuna and Grandmother Tifa, their living space of 3.08 square meters each is not enough or adequate. For the 4 children, having 3.08 square meters each is adequate for their living space. But the group has classified the house as having an inadequate living space for the members of the family, considering that there is still other furniture inside the house. K. Food Sources, storage, and cookies facilities Most of the familys food comes from nearby sari-sari stores and carinderias. The food that Mother Yuna cooks comes from a tilapapa that is just near their house. She cooks through burning woods. Since they dont have a refrigerator, they use plates to store leftover food and cover it with another plate.
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L. Water Supply The family has its own source of water supply which is from NAWASA. The family primarily get their water for cooking, taking a bath, and cleaning from this water source. They store the water for drinking on a pitcher and placed above a table. M. Toilet Facility The family doesnt have their own toilet to use, they use the toilet of their neighbor, it has filth and dirty stains near the toilet bowl. It does not have any water carriage but it has its own septic tank. The bathroom is not tiled. They just use a pail and dipper when taking a bath. Since the toilet is dirty inside out, its sanitary condition is considered poor. N. Drainage System The type of drainage system is opened, non-flowing or stagnant type of drainage beside their house. This could serve as breeding site for vectors of diseases.
Aside from the plastic bags used by the family for their trash, their other wastes are thrown in a sack or in a big drum of garbage uncovered at the backyard. O. Social and Health Facilities Available The community where the family resides has various social and health facilities. They have a day care center, elementary and high school institutions. They also have a basketball court and the barangay balibago center which is accredited by the Department of Health as a Sentrong Sigla health center. They offer services such as prenatal checkups, immunizations, family planning programs and the like. Carinderias, sari-sari stores and bakeries are also found in the vicinity of the community. The family fails to avail majority of the facilities because they are occupied with other matters and they lack money for transportation.
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P. Communication and Transportation Facilities Cellular phones are the only means of communication between the family members. Sometimes, Grandmother Tifa goes to internet cafes and uses the internet to communicate with her son from Pangasinan. Their means of transportation are jeepneys and tricycles.
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V. PROBLEM IDENTIFICATION
A. List of Problem Identified
Problem #1 : Health Deficit: Presence of Cough & Colds
4.17
Problem # 2: Presence of Health Deficit: DENTAL CARIES
4.17
Problem #3 : Health Threat: Family Size what family resources can adequately provide
3.34
Problem #4 : Health Deficit: Malnutrition
3.33
Problem #5: Health Threat: Presence of Poor Personal Hygiene
Problem # 6: Presence of Health Threat: Unhealthy Lifestyle & Personal Habits: Self-Medication
2.84
Problem # 7: Presence of Health Threat: LACK OF FOOD STORAGE FACILITIES
2.84
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2.84
Problem #8 : Presence of Health Threat: PRESENCE OF BREEDING PLACE FOR RODENTS AND INSECTS
Problem #9 : Health Threat: Poor Toilet Facility
2.84
Problem #10: Presence of Health Threat: POOR LIGHTING AND VENTILATION
2.5
Problem #11 : Presence of Health Threat: PRESENCE OF ACCIDENT HAZARDS: FALL HAZARDS
1.5
74
B. Problem Setting
Problem #1 Health Deficit: Presence of Cough & Colds
Criteria
Computation Score
Justification
Nature of the Problem
3/3 x 1
The nature of the problem is Health Deficit. And requires immediate intervention, which if not given immediate attention or solution can lead to health complications like pneumonia.
Modifiablity of the Problem
2/2 x 2
The
problem
is
easily
modifiable because:
Current knowledge, technology and intervention
Current Knowledge The family is aware of the presence of cough and colds and so they use oregano to treat it.
Family
Family Resources The family does have

75
resources Resources
resources by using herbal medicines as an alternative treat cough and colds that they get in their neighbor.
of the Nurse Resources of the Nurse Community Resources The student nurses gave health teachings like emphasize the importance of maintaining a clean surrounding and proper hand washing to prevent crosscontamination.
Community Resources The family may visit the community health center and seek guidance and help with regards to the problem.
Preventive Potential
2/3 x 1
0.67
The
problem has
a low
preventive potential because : Gravity/Severity of the Problem Gravity of the Problem

76
Duration of the Problem Current management Exposure to The problem is not considered severe because they make use of herbal medicines for treating cough and colds. any high risk of group Duration of the Problem The problem is for about 3 months before the student nurses arrived as verbalized by Mrs. Yuna.
Current Management The family uses herbal plants to treat their cough and colds. Exposure of any high risk group
The members of the family are exposed to the said problem
The family recognizes it as a
77
Salience
1/2 x 1
0.5
problem but does views it as not needing immediate attention because it is natural for them that the cough and colds to occur.
Total
4.17
78
Problem # 2: Presence of Health Deficit: DENTAL CARIES
Criteria
Computation Score
Justification
3/3 x 1
The nature of the problem is Health Deficit. It is considered an alteration or disability that makes it affect other aspects in the health of the family. All of the members of the family has dental caries and some had their missing teeth.
2/2 x 2
The
problem
is
easily
modifiable because: Current Knowledge The family is knowledgeable about the problem and cleans their teeth everyday as their intervention in trying to alleviate the problem. And still, they verbalized that they are shy to show their teeth. Family resources Family Resources The resources of the family
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like physical and manpower Resources resources are present. Necessary materials to treat the problem are also present of the Nurse inside the house (e.g. toothbrushes and toothpaste). Community Resources Resources of the Nurse The effort, knowledge, time of student nurses is present within the three visits. The group was able to provide health teaching about proper brushing of teeth in the morning and in the afternoon, avoiding too many sweets.
Community Resources The facilities and the community organization supports are present that can help managing the problem. Programs such as proper hygiene and self-care are being discussed and oriented to the public. Also the
80
community had their own dentist clinic
2/3 x 1
0.67
The
problem has
a low
preventive potential because : Gravity/Severity of the Problem Duration of the Problem Current management Exposure to Gravity of the Problem The problem of the family is severe because the problem was affected to all family members. Also, the problem has been long experienced by the family in which bad breath and dental caries are noted.
any high risk of group
Duration of the Problem The members of the family have this problem for almost 2 years now, as stated by Mrs. Yuna, on the other hand, has this problem for more than 25 years which
81
contributed to the low preventive potential of the problem.
Current Management The family tries brushing their teeth at least every day, thus, preventive potential is increased.
Exposure of any high risk group The problem is deemed to be susceptible for the problem because what one member eats, is what the other eats.
Salience
1/2 x 1
0.5
The family sees and acknowledge the problem but does not recognize the problem as something needing immediate attention, thats why brushing of teeth twice a day is poorly observed and diet is not closely being monitored.
82
Total
4.17
83
Problem #3 Health Threat: Family Size beyond family resources can adequately provide
Criteria
Computation
Score
Justification
2/3 x 1
0.67
The problem is a health threat because if the family is not able to suffice the needs of the individual member, each can have decreased ability to cope with lifes processes. Food, for example, is lacking, the children may have decreased energy level to cope with the pressures in their studies.
Modifiability of the Problem
1/2 x 2
The problem has partially modifiability because:
Current knowledge, technology and intervention Family

x
Current Knowledge: The family does not recognize the problem existing because Mrs. Yuna who serve as the provider of care was prioritizing the most immediate needs.
84
resources Resources of the Nurse
They also do not feel the insufficiency because they have been deprived of being provided
with the secondary necessities in life such as own storage facilities and the like.
Community Resources
Family Resources: The family has no adequate resources to make the best intervention to the problem. They also do not have the knowledge to put up a business or plant a vegetable garden.
Nurse Resources: Knowledge and time of the student nurses are available to establish awareness and recognition of the problem. They are also knowledgeable for the teachings to help the family think of other profitable livelihood or handicraft. They could also encourage proper budgeting of money and give alternative goods that they can buy like instead of meat, they can buy
85
tokwa.
Community Resources: The community resources are also available where they could provide teachings and encourage vegetable planting or attend mothers classes that. At times. Teach about livelihood.
2/3 x 1
0.67
The
problem
has
low
preventive potential because:
Gravity/Severity of the Problem
Gravity: The problem is severe because malnutrition occurred to all members of the family just to
Duration of the Problem
save money and the familys income is small and would not reach the prescribed amount of money in each individual.
Current management
>Prescribed amount: P2,768.60 >Family: P916.67 Duration:
Exposure to any high risk of
The problem has existed for a years before the student nurses
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group
arrived.
Current Management: Mrs Tifa sends monthly pension and money from her children monthly. However it is still insufficient to make their income above poverty line.
Exposure of any high-risk group: Since the whole family is residing in the house and all of them have individual needs, they are all belonging to the high risk group. So due to deficiency the family are prone to different diseases.
Salience
2/2 x 1
The family recognizes the existence of the problem and it requires prompt intervention.
Total
3.34
87
Problem #4 Health Deficit: Malnutrition
Criteria
Computation Score
Justification
3/3 x 1
The problem is a health deficit because malnutrition is already present, yet the family still fails to achieve and maintain an optimum level of health. There is an instance of failure in health maintenance.
1/2 x 2
Current knowledge, technology and intervention Family resources Resources of the Nurse
X X
Current Knowledge: The family has lack of knowledge that malnutrition is present among the family members. And they are not doing anything to solve the problem since they are unaware.
Family Resources: The family does not have enough money to buy nutritious food for the
88
4 children. But even though the family is low in financial resources that cannot hinder them in providing Community Resources Nurse Resources: The student nurses can give health teaching on the family especially Mrs. Yuna about preparation of foods that are healthy stressing on their children with adequate nutrition.
nutritious foods like fruits and vegetables, which the children need during their growing years.
Community Resources: The community provides knowledge to the family regarding proper ways of feeding their children and they can attend to seminars or programs such as feeding programs, school teaching and mothers class prepared by the community with the collaboration of the student nurses.
1/3 x 1
0.33
The problem has a low preventive potential because:
89
Gravity: Gravity/Severity of the Problem The problem is severe since the problem has already been existing to all family members especially to Mrs. Yuna where shows that she is more Duration of the Problem lighter than her eldest children and her daughter, Aerith, which shows the malnourished of them all.
Current management Duration: The problem has existed for a long Exposure to any high group Current Management: No current management is done to address the problem since the family is unaware of this. The family can remedy the problem by providing them alternatives such as buying inexpensive but nutritious foods. risk of time ago before the student nurses arrived.
Exposure of any high-risk group: The problem has a low preventive potential since there is a greater number of the total individuals living
90
in the house affected. If the problem is not reversed early, the children may be exposed to infections and be prone to different diseases.
Salience
2/2 x 1
The family does perceive malnutrition as a problem or a condition needing immediate attention since the fact that they had no adequate money to sustain all the nutrients required to them.
Total
3.33
91
Problem #5: Health Threat: Presence of Poor Personal Hygiene
Criteria
Computation
Score
Justification
2/3 x 1
0.67
The problem is a health threat to the family as this problem predisposes to health deficits such as cough and colds and other hygiene related health deficit.
2/2 x 2
The problem has easily modifiability because:
Current knowledge, technology and intervention Family resources Family Resources: The family has physical Resources of the Nurse resources specifically cleaning articles such as soap, shampoo, toothpaste, and toothbrush. Current Knowledge: Mrs. Yuna is fully aware of the said problem especially to her children
92
Community Resources
Nurse Resources: The student nurses knowledge will enable them to provide the family with health teachings regarding personal hygiene such as cutting their finger and toenails, washing their hands and brush their teeth.
Community Resources: Community offers Mothers Class where the family could learn about good personal hygiene.
1/3 x 1
0.33
The
problem has
a low
Gravity: The problem is already severe as the almost of the family members are
Duration of the
observed to have a poor personal hygiene.

93
Problem Duration: Current management The problem on poor personal hygiene already exists for 2 years already as Exposure to any high group risk of Mrs. Yuna tries to limit all of their consumption due to limited financial resources, thus affecting the family hygiene.
Current Management: As a management the family still makes sure that they take a bath for at least once a day.
Exposure of any high-risk group: All of the family members are the high risk group of the said problem as all of them have a poor personal hygiene thus all of them are susceptible to acquire health deficit.
94
Salience
0/2 x 1
Prior to the student nurses do their interventions; the family does not see their poor personal hygiene as a problem at all so they did not do any immediate attention.
Total
95
Problem #6: Presence of Health Threat: Unhealthy Lifestyle & Personal Habits: SelfMedication
Criteria
Computation
Score
Justification
2/3 x 1
0.67
The problem is a health threat because it can lead to

future health problems. Selfmedication can endanger the health condition of a family member if they dont know the right dosage of a medication.
1/2 x 2
Current knowledge, technology and intervention Family resources Resources of the Nurse
Current Knowledge:
The family doesnt have the knowledge on the proper medication to be given on particular illness.
Family Resources:
The family does have other alternatives such as herbal medicines for the treatment of fever, coughs, and colds that 96
they get from their neighbor
Community Resources
Nurse Resources:
The student nurses knowledge will enable them to provide the family with the proper teachings about self-medication and
adverse effects.
Community Resources:
Community offers Mothers Class where the family could learn about ways to treat an illness, and the Health Center which can provide free checkups and consultations.
2/3 x 1
0.67
The problem has a moderate preventive potential because:
Gravity:
The problem is not severe because the family didnt manifest any signs of anaphylactic reactions.
97
Duration: Current management The problem has prolonged duration as evidence by verbalization of Mrs. Yuna that since they had not Exposure to any high group risk of adequate money to consult doctor they perform selfmedication.
Current Management: As a management the family still consults a physician whenever there is severe illness. Exposure of any high-risk group:
All of the family members are the high risk group of the said problem because all of them are prone to acquired illness by using inappropriate taking of medicines.
Salience
1/2 x 1
0.5
The problem is perceived by the family but does not need
98
an immediate attention. Total

2.84
99
Problem # 7: Presence of Health Threat: LACK OF FOOD STORAGE FACILITIES
Criteria
Computation
Score
Justification
2/3 x 1
0.67
The problem is considered a Health Threat because of its possibility of contaminating the food of the entire family
due to not properly stored and they might ingest this contaminated food which can cause different GI diseases.
1/2 x 2
The problem has moderate preventive potential because:
Current Knowledge The family is knowledgeable about the problem and tries to solve the problem by covering left-over food or merely eating all the food.
Family resources
X Family Resources
100
Resources
Although the family cannot afford to buy the best facility for food storage such as the refrigerator, they can utilize containers and cover it properly as their storage of food.
of the Nurse
Community Resources
Resources of the Nurse The student nurses are equipped with the knowledge that they have imparted to the family emphasized the
importance of having their foods properly stored to prevent contamination and spoilage
Also provide health teachings and make them recognize the problems that may arise, like contamination of food, if they will not keep their food in a proper storage.
Community Resources
The community have minigrocery store where the family can buy food containers
(Tupperware)
101
2/3 x 1
0.67
The
problem has
a low
Gravity of the Problem

The problem is not that severe since it has no reported detrimental effect yet from the family members.
Current management

The problem occurred for 5 years since the family never had a proper food storage facility.
Exposure
to
any high risk of group Current Management

The family tries to cover their food with plates.
Exposure of any high risk group The whole family is considered a susceptible group because all of them are exposed to the problem
102
because they can acquire Amoebiasis or any helminthic disease if they didnt store their food to proper place.
Salience
1/2 x 1
0.5
The family sees this problem not needing immediate attention since they prioritize their other needs over having a good food storage facility such as having something to eat.
Total
2.84
103
Problem # 8: Presence of Health Threat: PRESENCE OF BREEDING PLACE FOR RODENTS AND INSECTS
Criteria
Computation
Score
Justification
2/3 x 1
0.67
The nature of the problem is considered a Health Threat, which is scored 2 out of three. Also, the problem is a threat, meaning, any deficit or disability is not present but the possibility of having it may occur if preventive measures will not be started immediately.
1/2 x 2
The
problem
is
partially
modifiable because:
Current Knowledge The family is knowledgeable, and intervenes about the problem by sweeping and cleaning the house whenever they see it necessary.
104
Family resources
Family Resources
The family does not have any pesticides or mosquito repellants. They only use
Resources of the Nurse
physical method of eliminating these insects.
Community Resources

The group has the proper knowledge to impart to the family for them to prevent and minimize vectors such as using of mosquito nets and removal of garbage or stagnant water in the house that can be a breeding site for vectors. Also, the time, effort and willingness of the group are observed.
Community Resources
The community has antidengue projects such a providing anti-mosquito pesticide smoke.
2/3 x 1
0.67
The
problem has
a low
105
preventive potential because : Gravity/Severity of the Problem Gravity of the Problem The gravity of the problem is low since no one in the Duration of the Problem family has acquired any of the potential vector diseases brought about by the rodents, mosquitoes, and Current management flies.
Duration of the Problem Exposure to The problem has been existing for a long time now, thats why the preventive potential to solve the problem is low. any high risk of group
Current Management According to Mrs. Yuna, they know about the presence of the problem and able to clean the house occasionally. They also try to
106
segregate the garbage before it is collected.
Exposure of any high risk group
The children and all of the family members are affected since they live in the same house. All of them are susceptible in acquiring vector diseases. Also, because most of the family members are young-aged, their immune system is not yet fully developed and is at major risk of having infections.
Salience
1/2 x 1
0.5
The family recognizes this and sees it as a problem but they do not see it to need immediate attention. Thats why regular and routine cleaning of the house is not practiced. And lumps
107
of old and new clothing are not organized properly. This may caused breeding sites for some vectors.
Total
2.84
108
Problem #9: Health Threat: Poor Toilet Facility
Criteria
Computation
Score
Justification
2/3 x 1
0.67
The problem is a health threat since unsanitary toilet could greatly affect the health of the family members through transmission of microorganisms. Unclean toilet facility could serve as breeding places for insects, rodents and vectors.
1/2 x 2
Current knowledge, technology and intervention Family resources

x x
Current Knowledge: The family is aware of the poor sanitary status but not able to provide intervention about it because of lack of resources to fix the toilet facility.
Family Resources:
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The family does not have any resources such as toilet cleaners, tissue paper which could help in cleaning their toilet. This is due to the financial problems of the family, wherein
Community Resources
instead of buying these materials they would rather spend their money in buying food for the family. They also dont have manpower to fix their toilet.
Nurse Resources: The student nurses give health teachings like the possible diseases that they can get from poor toilet facility like cholera and typhoid fever. And emphasize the importance of maintaining a clean toilet facility and proper hand washing.
Community Resources: The family may visit the community authorities and seek guidance and help with regards to the problem of toilet facility.
110
There are hardware stores available in the community.
2/3 x 1
0.67
The
problem
has
low
Gravity: The problem is not considered severe because there are no records of diseases caused by
fecal oral route by the family members.
Current management
Duration: The problem existed since the family decides to reside in that house.
Exposure to any high group risk of Current Management: The family is not doing any interventions to resolve the problem since they lack resources
Exposure of any high-risk
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group: The members of the family are exposed to the said problem because they are using this toilet facility.
Salience
1/2 x 1
0.5
It is identified by the family but immediate actions are not necessary because of lack in financial resources and the family rather spends the money to food, medicine and education.
Total
2.84
112
Problem # 10: Presence of Health Threat: POOR LIGHTING AND VENTILATION
Criteria
Computation Score
Justification
2/3 x 1
0.67
The nature of the problem is considered a Health threat because in poor lighting, the family cant see their way and fall accidents and minor injuries may happen. In poor ventilation, the family may develop respiratory disorders from the smoke theyd inhale.
1/2 x 2
The
problem
is
moderately
modifiable because: Current Knowledge
Current knowledge, technology and intervention Family resources X
The family has the knowledge and perceives the problem but do not need an immediate attention. Since they are already used with the said situation and due to lack of financial support and resources. They open theyre electric fan so they cannot inhale the smoke. Family Resources
Resources
The family has physical resources

113
of the Nurse
such as light bulb but it is not enough to make to their house adequately lighting. And also they had small
Community Resources
windows only.
Resources of the Nurse The student nurses made the family more aware of the inadequacy of the familys lighting condition by stating and enumerating hazards that can happen if they will not take immediate intervention to resolve the problem. The student nurses also discussed the risk factors that could affect their health.
Community Resources The community has no program about the problem so they cant help the family to be aware of the problem. The community also has cheap available hard wares where the family can buy their needed materials for lighting and they could also use gas lamps as an alternative, but needs an extra care.
114
1/3 x 1
0.33
The
problem
has
very
low
Gravity of the Problem The problem is severe because they could not stay inside the house
especially in afternoon where the sun is high. They try enduring the heat and the poor lighting. Yet, student nurses find the condition of
Current management
the house not conducive. This makes the problem have a low preventive potential.
Exposure
to Duration of the Problem Their house is old and never been renovated especially their ceiling part which contributes to long time of living in risk condition.
any high risk of group
Current Management Attributable to financial constraints the family cannot provide the required number of bulbs and watts to supply and attain the good and desired lighting condition.
115
Exposure of any high risk group All of the family members are exposed in the problem as they were all living in the house.
Salience
1/2 x 1
0.5
They recognize the problem but dont intervene with it as they have no materials and financial resources to fix it.
Total
2.5
116
Problem #11: Presence of Health Threat: PRESENCE OF ACCIDENT HAZARDS: FALL HAZARDS
Criteria
Computation
Score
Justification
2/3 x 1
0.67
The problem is a health threat because of paper boxes attached to their ceiling it may consider as hazards that may cause potential harm to family. The problem is also a health threat because of the presence of protruding nails and pointed utensils in the kitchen and on the wall that are within childrens reach. This could cause an accident in the future..
0/2 x 2
The problem has low modifiability because:
Current knowledge, technology and
Current Knowledge:
The family is aware but does not do proper interventions to resolve the problem. 117
intervention Family resources X Family Resources: The family has no adequate resources to solve the problem and they cannot Resources of the Nurse Nurse Resources: The health teachings can be Community Resources X given by the student nurses regarding the threat that the problem poses on the safety of the members of the family. The student nurses provided health teachings and pointed out the possible accidents that they may encounter. They also advised to fix and clean the area which is accident prone. Student nurses also cleaned and fixed some of the things needing an intervention. afford to change their ceiling.
Community Resources:
118
The community does not have any programs regarding proper structuring of homes and houses.
1/3 x 1
0.33
The
problem has
a low
Gravity: The problem has a low preventive potential because it has existed for a long time and the family has not done anything yet to avoid such consequences. The accidents that each of the family member is at risk of is not being given any attention because they said they cannot do anything this time. The problem can be alleviated or lessen if due managements are to be done such as proper arrangement of things inside and outside the house.
Current management
Exposure to any high group risk of
119
Duration: The problem has prolonged duration as evidence by verbalization of Mrs. Yuna that it had became a normal scene to them for years. As a result, the preventive potential is low.
Current Management: There is no evident current management done by the family due to lack of knowledge regarding the problem and no financial resources.
Exposure of any high-risk group: The family members may be at risk of having injuries if they would not pay any attention to the identified problems.
120
Salience
1/2 x 1
0.5
The problem is perceived by the family but does not need an immediate attention because of financial constraints and manpower to fix the problem.
Total
1.5
121
Problem # 1 Health Deficit: Presence of Cough & Colds Inability to provide adequate nursing care to the sick, or at risk member of the family Inability to provide a home environment which is conducive to health maintenance and personal development
Cues
Analysis of the Problem
Objective
Intervention
Rationale
Method of Family Contact
Resources Required
Expected Outcome
S: Yan, sina Tidus, Aerith at Cloud laging sinisipon at inuubo AVB Mother Yuna
Inability provide adequate nursing care the sick, or risk member the family
to
Short Term:
to at of
O: The following were manifested:
Inability to provide a home environment which is
>After 3-4 hours of nursing the intervention, the 2. Discuss possible family will causes of understand and illness. demonstrate the health teachings given to prevent the occurrence of 3. Discuss the colds and cough importance of and the Vitamin C rich complications that foods.
1. Assess client s condition
> To have a base line data > To give the family a scientific basis regarding the illness > For faster recovery and increase body
> Home visit
> Clinic visit
> Nurses resources like health teachings and visual aids.
Short Term: > The family shall have understands and demonstrated measures to prevent the occurrence of cough and colds and the complications that might occur.
> Community resources for care like the presence of RHU, herbal
122
> nasal secretions flowing down from nose > presence of adventitious breath sounds upon chest auscultation > with nonproductive cough
conducive to health maintenance and personal development
might occur. 4. Encourage to drink Long Term: calamansi juice or eat >At the end of tamarind. home visits, the family will 5. Encourage demonstrate to do a regular compliance to the exercise health teachings every given by the morning. student nurses to prevent cough and colds AEB absence of cough 6. Encourage to have an 8and colds. hour sleep and avoid stress. 7. Wash hands frequently and maintain a good hygiene.
resistance. >To improve immune system and faster recovery. >To strengthen the immune system and the ability of the body to fight infection. >Stress weakens the immune system. > To prevent passing of cough and colds that is transferred through droplets. > To replace lost body fluids and
medicines.
> Family resources such as willingness to listen to the given health teachings.
Long Term: > The family shall have demonstrated compliance to the health teachings given by the student nurses.
8. Encourage increase fluid
123
intake.
liquefy secretions > Herbal medicines are available and accessible in the community.
9. Discuss with the family and encourage them to use of herbal medicines like lagundi. 10. Discuss to the family the different preventive measures.
11. Refer the mother and child to RHU.
> To protect the family from the recurrence of the problem. > For proper medical assistance.
124
Problem #2 1 level of Assessment: HEALTH DEFICIT: DENTAL CARIES 2nd level of Assessment: Inability to make decision with the respect to taking appropriate health action due to low salience of the problem. CUES ANALYSIS OBJECTIVES NURSING INTERVENTION RATIONALE METHOD OF FAMILY CONTACT Home Visit RESOURCES REQUIRED EXPECTED OUTCOME
st
S> O> All members of the family had have tooth decay and Mrs. Yuna and Tifa had missing teeth
Inability to make decision with the respect to taking appropriate health action due to low salience of the problem.
Short Term: 1. Explore the -To obtain the After 3-4 hrs. of familys idea baseline data home visit, the of how dental for the family will caries occur, teachings to verbalize their be given to the family understanding knowledge on the health about it and teaching the their provided on the management importance of dental hygiene. 2. Discuss to -To increase the family the family awareness present Long Term: health status After 3-5 days that they of home visit, have the family will 3. Explain the -This will help demonstrate in possible compliance on health risk of encouraging the health dental caries the family to teaching by comply to brushing the health teeth after
Student Nurse Resources: Knowledge and skill of the student nurse and use of therapeutic communication.
Short Term: The family shall have verbalized understanding on the health teaching provided on the Familys importance of Resources: dental Cooperation of hygiene. the family Long Term: The family shall have demonstrated compliance on the health teaching by brushing the teeth after meals.
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meals.
teaching 4. Encourage -to prevent the family to further dental brush teeth caries. after meals. It should be three times a day and should be in upward to downward movement and brushing also the interior part of teeth. 5. Provide the family with health teachings regarding personal hygiene especially mouth care and frequency of cleaning -To promote personal hygiene to the family
6. Encourage to >To strengthen increase
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intake of calcium-rich foods like milk, calamansi, cheese, tofu and leafy green vegetables. 7. Encourage the family to regularly visit the dentist for check up or the health center for consultation
the teeth and prevent further dental caries.
-To facilitate in knowledge of their health status by examining their conditions.
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Problem #3 Health Threat: Family Size beyond what family resources can adequately provide Inability to provide a home environment conducive to health maintenance and personal development due to inadequate family resources specifically financial constraints Method of family contact Resources Required Expected Outcomes
Analysis of the Problem S> Inability to O>family provide a expenses home outnumbers environment the family conducive to income health >Monthly maintenance income: and personal P5500.00 development > Allotted due to money per inadequate individual: family P916.67 resources >inadequate specifically food supply financial >The family constraints doesnt have any work and they only get from the pension of Grandma Tifa and remittance from her children.
Cues
Objectives Short term: After 3-4 hours of home visit, the family will be able to be learn how to budget their money for everyday needs. Long term: After 4-5 home visits, the family will be able to show proper handling of money.
Interventions
Rationale
1. Assess for >to have a families flow of baseline data Home visits income to determine the problem 2. Explain to the family the importance of saving money. >To let the family save some money for the future
Nurses Short Term: knowledge and The family time shall have budget their Familys money for participation everyday needs. and time. Long term: The family shall have showed proper handling of money.
3. Encourage >for the family family to think to increase ways to their income improve their source of income 4. Provide health teachings on preparing cheap but nutritious foods 5. Discuss >to lessen quantity of expenses without altering the quality of food >to help the
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practical ways to improve budgeting of the family income 6. Inform the family that it is more practical to pay for preventive interventions than curative ones.
family to sustain the needs of the family members >To prevent the waste of resources especially financially.
7. Encourage the >To increase family to their monthly actively income. participate in the communitys livelihood programs like vegetable farming.
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Problem # 4 Health Deficit: Malnutrition Inability to provide adequate nursing care to the dependent or vulnerable/at risk member of the family a. Lack of knowledge and skill in carrying out the necessary interventions or care b. Inadequate family resources for care, specifically financial constraints
Cues
Analysis of the problem
Objectives
Interventions
Rationale
Methods of family contact
Resources Required
Expected Outcome
S>
O> The members of the family weighs below the normal range. >Mrs. Tifa:
Wt: 37 kg HT: 1.57 m BMI:15.04kg/m
Inability to provide adequate nursing care to the dependent or vulnerable/at risk member of the family.
Short term:
After 3-4 hours of nursing interventions, the family will be able to verbalize understanding and demonstrate the health -lack of teachings knowledge given by
The family shall have Physical knowledge verbalized 2. Identify causes > To assessment and skills understanding and effects of increase knowledge; of health malnutrition like time teachings motivate family to having low and effort the given by Interview body weight, address situation as soon as enumerating decrease - health resistance to possible. causes, teachings diseases and effects and Health easy fatigability. prevention of teachings 3. Discuss to the malnutrition family signs and the and symptoms > These would
1. Assess the >To obtain height and baseline data. weight of the family.
Home visits
Student Nurses:
Short term:
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enumerating causes, >Mrs. Yuna: effects and prevention of Wt: 35 kg malnutrition HT: 1.5 m and the 2 BMI:15.56kg/m importance of knowing the >Zidhaine: food pyramid Wt: 36 kg guide in choosing Ht: 1.49 m what type of BMI: 16.22 2 foods are kg/m -inadequate appropriate to family >Cloud: take and resources other for care, Weight: 25 kg alternatives specifically Height: 42 which they financial (1.28 m) can afford. constraints
BMI: 2 kg/m 15.26
and skill in carrying out the necessary interventions or care (providing cheap but nutritious food).
make them aware of the s/sx if they are present so as to increase familys awareness of the problem for early identification and for them to take 4. Identify, teach appropriate and explain to interventions as the family the early as possible. food pyramid. > To be able to make them aware of the proper serving for the diff. food group to promote their health and wellness.
of malnutrition
importance of knowing the time food pyramid and effort guide in choosing what type of cooperation foods are of the appropriate to family take and members other alternatives which they can afford.
Family:
Long term: The family shall have demonstrated compliance on the health teachings and interventions given.
>Aerith:
Wt: 19 kg Ht: 1.19 m BMI: 2 kg/m 13.48
Long term: After 4-7 days of home visits, the family will be able to demonstrate
5. Discuss with the family food that are high in nutrients and cost less like tofu and leafy green vegetables that provide sometimes can >To alternatives for be seen in their some food that yard. they cant afford and to minimize
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>Tidus:
Weight: 10 kg Height: (0.88 m) 29
compliance on the health teachings and interventions given.
6. Instruct the financial mother about expenditures. food production like washing vegeta bles and fruits before cooking and eating. >To maintain or 7. Give the family preserve the food that would nutritional help in contents of food. achieving the desirable body weight. 8. Instruct them to wash hands before eating. > For them to recognize the 9. Refer the family foods that could to RHU. provide nutrients for the body. 10. Encourage the family to have children >To prevent deworm. ingestion of bacteria and parasites.
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>For possible parasitism and early interventions. >To treat possible parasitism. Problem # 5 Health Threat: Presence of Poor Personal Hygiene Inability to take appropriate health actions due to: inadequate financial resources to avail proper hygiene practices and resources Analysis of the Problem Method of family contact Resources Required
Cues
Objectives
Interventions
Rationale
Evaluation
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S> O> -The members are seen wearing dirty clothes -The members of the family have long and dirty fingernails and toenails -The members of the family has dental caries and missing tooth
-Inability to take appropriate health actions -inadequate financial resources to avail proper hygiene practices and resources
Short Term: 1. Assess for After 3-4 hours signs of poor of home visits, personal the family will hygiene be able to identify the 2. Determine factors importance of associated with good personal poor personal hygiene to their hygiene health 3. Discuss the Long Term: importance of At the end of having good the home visit, personal hygiene. the family will demonstrate maintenance of good personal hygiene as 4. Give health evidenced by teachings taking a bath regarding different practices on good daily, tooth personal hygiene. brushing and wearing comfortable 5. Discuss the clothing, following: trimmed fingernails and toenails. A. Instruct them to take a bath at least once a day.
-to know health Home visit threats
-to know factors contributing to health threat -to provide health teachings that will let them maintain a good personal hygiene.
Family resources: -open to new information and involvement of nursing interventions Student nurses resources: -Time & effort to explain proper hygiene practices and adequate knowledge about the diseases in a poor personal hygiene
Short Term: The family shall have identified the importance of good personal hygiene to their health.
-to provide general comfort and clean body.
Long Term: The family shall have demonstrated maintenance of good personal hygiene and applied health teachings given as evidenced by taking a bath everyday and proper cleanliness in their bodies.
-to provide a presentable look. -to minimize the occurrence of cross infection and parasitism.
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B. Instruct them to frequently wash hands and trimmed fingernails & toenails and tooth brushing at least thrice a day.
-to prevent formation of cavities/ plaques and to maintain a good oral hygiene and prevent bad breath.
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Problem #6 Unhealthful Lifestyle and Personal Practice: Self Medication Inability to recognize the problem due to lack of knowledge, and attitude which hinders recognition of the problem METHOD OF FAMILY CONTACT Home visits
CUES S> O> presence of medicines (Paracetamol and Neozep) on their table
>selfmedicating but when the condtion is severe hy go to the physician
ANALYSIS OF THE PROBLEM Inability to recognize the problem due to lack of knowledge, and attitude which hinders recognition of the problem.
OBJECTIVES Short term:
NURSING RATIONALE INTERVENTIONS
RESOURCES REQUIRES Participation of the family Health teachings of the nurse
EXPECTED OUTCOMES Short term: The family shall have understand the importance of having the right prescription of medicines.
After 3-4 hours 1. Assess level of of home visit, the knowledge of family will be able the family. to understand and demonstrate the importance of having the right prescription of medicines. 2. Instruct the family to place Long term: After 4-5 home visits, the family will be able to demonstrate the proper following of prescribed drugs the medicines in the right where will place children not reach it.
-To determine what nursing care and Health teachings needed >To prevent ingestion and over dosage of medicines by children.
Long term: The family shall be able to demonstrate the proper following of prescribed drugs by their physician.
>Using Paracetamol and NSAIDs
- to prevent 3. Provide health
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by their physician.
teachings on taking the right prescription of a doctor for medication
further implications of medicating without the prescription of a doctor
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PROBLEM # 7 1 level of assessment: HEALTH THREAT: LACK OF FOOD STORAGE FACILITIES 2nd level of assessment: Inability to make decisions with respect to taking appropriate health action due to: A. failure to comprehend the magnitude of the problem B. low salience of the problem
st
CUES
ANALYSIS OF THE PROBLEM
OBJECTIVES
NURSING INTERVENTION
RATIONALE
METHOD OF FAMILY CONTACT
RESOURCES OF REQUIRED
EXPECTED OUTCOME
S> Wala kaming ref.Pero tinatakpan naman namin yung mga natitirang pagkain. AVB Yuna Mrs.
Inability make decisions
to Short Term: After 1 day of home visit, the mother will be able recognize proper
1.
Observe for -to
assess food
HOME VISITS With health teachings
Knowledge the nurses,
of Short Term: The shall mother have
number of proper current food facilities storage storage facilities
student
with respect to taking appropriate health action due to:
communication skills of the student nurses, time and effort of the family, student and nurses and the
recognized the importance proper storage. of food
to 2. Assess for use -to determine the of alternative present in methods used by the family to
importance of methods food storing food
a. failure to storage comprehend
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the O> Leftover food covered with only >No storage materials available such Tupper wares as food is magnitude of the problem b. low of LONG TERM: After 4-7days 3. Instruct to
store food the -In order to keep establish
Material resources were used. such
family kitchen
as cheap plastic LONG TERM: The family shall have exhibited
plates salience
of home visits, the family will food health teachings given.
utensils arrangement.
in proper place. Explain the of food
the problem
exhibit proper 4.
-to
storage importance storage regarding prevention food-borne illnesses
increase
proper storage the health teachings given. aid
food with of
with the aid of proper
awareness and knowledge
of
regarding the benefits proper storage of food
5.
Encourage -to
provide for on food
alternative to store
choices food ways
methods on how alternative properly such as storing using two plates properly
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that firmly close over one another
6. Encourage the purchase of simple plastic for proper storage of food
-to access proper storage facilities.
have to food
Problem # 8 1st level of assessment: HEALTH THREAT: PRESENCE OF BREEDING PLACES FOR INSECTS AND RODENTS
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2nd level of assessment: Inability to provide Home Environment Conducive to Health Maintenance and Personal Development due to Family Inadequate Knowledge of Preventive measures CUES ANALYSIS OF THE PROBLEM OBJECTIVES NURSING INTERVENTION RATIONALE METHOD OF FAMILY CONTACT RESOURCES OF REQUIRES EXPECTED OUTCOME
S>
Inability
to SHORT TERM: 1. of and
Assess
the -
To
obtain
HOME VISITS With health teachings
Knowledge, time
Short Term: and The family have
provide home After 3-4 hours environmental O> presence environment of garbage disposal the health as maintenance front development nursing condition of the family and location health possible improper conducive to interventions teachings, able
baseline data
endeavor of the shall with the the risk
student nurses identified the factor cooperation of underlying to family this problem, also,
the of breeding sites to 2. Educate the -to made realize
evidenced by and personal family will be
members.
houses open due drainage, which candy wrappers. familys has inadequate preventive measures.
to verbalize understanding
family about the them risk factors, the
on the harmful causes and the importance of of management on eradicating and insects, vectors and as insects importance and how this vectors, rodents, of insects may arise
trash such as knowledge of effects
rodents and the rodents,
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>presence of cockroaches, mosquitoes and roaming around house. the flies
having a good, clean environment. LONG TERM: After the last
well as their implication that cause problem. can Long Term: the shall taken appropriate measures to eradicate or solve problem. this insects to use maintain good family have can
home visit, the 3. Encourage the -it family will be family able demonstrate understanding on information given preventing insects evidenced removal . from by 4. Provide health possible hazards on that the problem possible can cause effects multiplying, as in the
to garbage container environment with cover or and the maintenance of from garbage prevent dump it properly.
Awareness the
of teachings on the of the family
breeding sites.
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5.
Instruct
the - To destroy of place prevent spread disease occurrence of and
family to removing breeding any form stagnant water
7. Encourage the -to family to their environment of regularly.
decrease insects, and of
clean the presence rodents exercise physical activities
serves as an
Problem #9
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Health Threat: Poor Toilet Facility Inability to provide a home environment, which is conducive to health maintenance and personal development due to: a. Inadequate family resources specifically financial constraints b. Failure to see benefits of investment in home environment improvement
Cues
Analysis of the Problem
Objectives
Interventions
Rationale
Method of Family Contact
Resources Required
Expected Outcome
S:
Inability to provide a home environment, O: which is conducive to >The toilet health bowl is dirty maintenance and personal development >The due to: surrounding of the toilet is >Inadequate unclean family resources specifically
Short Term: After 1 day of home visit, the family will understand and demonstrate activities that will maintain having a clean toilet facility and verbalize
1. Assess the cause of the family especially their toilet facility
>To be able to identify different problems and gather baseline data needed for planning implementation of cure
Home Visits
>Knowledge, skills and health teachings of the student nurse and therapeutic communication.
Short Term: The family shall have understand and demonstrate d activities that maintain having a clean toilet facility and verbalize understandin g of the different
2. Explain the >To prevent the importance occurrence of of having a diseases. clean toilet facility.
>Familys understanding, cooperation, participation
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> There was noted odor >Failure to see benefits of investment home >Inadequate in supply of environment hygiene kit improve-ment such as toilet tissue and toilet cleaners
financial constraints
understandi ng of the different health teachings and intervention s needed to improve their current toilets condition AEB clean inside and outside the toilet.
3. Encourage the family to clean their toilet regularly (at least every other day)
>To eliminate the microorganisms present in the toilet and to maintain proper sanitation thus preventing the occurrence of diseases
and compliance to the health teachings
health teachings and interventions needed to improve their current toilets condition
Long Term:
4. Demonstrate to the family proper hand washing technique with soap and water and instruct them to do it after using the toilet
>To prevent crosscontamination of micro-organisms
Long Term: The family shall have noted an improvement in their toilet facility as evidenced by absence of dirt at the
After 4-5 days of home visits, the family
5. Inform the >To maintain family regarding the cleanliness and proper sanitation cleaning
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will note an improvemen t in their toilet facility as evidenced by absence of dirt at the toilet bowl and clean toilet surrounding
agents that are economical which they might use to clean the toilet bowl
of the toilet facility without compromising the familys financial limitation
toilet bowl and clean toilet surrounding
PROBLEM #10
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1st level of Assessment: HEALTH THREAT: POOR LIGHTING AND VENTILATION 2nd level of Assessment: Inability to provide a home environment which is conducive to health maintenance and personal development due to limited family resources and financial constraint
CUES
ANALYSIS OF THE PROBLEM
OBJECTIVES
NURSING INTERVENTION
RATIONALE
METHOD OF FAMILY CONTACT
RESOURCES REQUIRED
EXPECTED OUTCOME
S> O> it is hot inside house the family the of
Inability provide home
to Short Term : a After 3-4 hrs. Of NI/home
1. Explore the -To obtain a familys a lighting condition 2. Assess and determine measures and number baseline data good teachings family -To whether house adequate know the has to ideas about for the health be given to the
HOME VISIT
Student
Nurse Short Term: The family have
Resources:
environment which health maintenance is conducive to
Knowledge and shall skills lighting ventilation promotion on
visits the family will understand the importance of adequate and lighting
the understood the of and and adequate and lighting of ventilation, and the cause and effect of poor
effects of poor importance
>clothes are
and personal
ventilation, and the cause/effect
health teachings
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scattered
development of poor lighting to and ventilation and demonstrate activities problem in the limited family
of windows lighting and bulbs. ventilation -To
and
lighting
and
everywhere due
ventilation and demonstrated activities improving Family Resources: Time and effort to follow the health teachings problem in the
motivate
>
lack of resources constraint
3. Discuss with them and give the the consequenc lightning family the knowledge to their adequacy light ventilation of and change
financial means
and financial improving
es of poor perception on > poor and dim lighting >Inability to read inside >windows 25 in inches height Long Term : After 2-3 days of NI/home visits, the family would be able to of improve ventilation and lighting in their home >no through teachings -To free the air 4. Instruct the that mother to fix obstructed or arrange from scattered clothes and to pass through some are scattered everywhere is and ventilation
Long Term : The shall able improve family have to the
and width > use
clothes that provide light to
dim lights
ventilation and lighting in their home and
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available housing materials
provided. 5. Encourage the family to open windows even if it is not raining the
-To
facilitate
showed understanding of the health teachings.
the movement of air in and out house of the
-To
facilitate
the movement 6. Encourage modify structures of the windows and remove unnecessar y materials blocks that of air. of air in and of the house the family to out
the passage
Problem #11
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1st level of Assessment: HEALTH THREAT: ACCIDENT HAZARDS: FALL HAZARDS 2 level of Assessment: Inability to provide a home environment which is conducive to safety living due to accidental hazards. CUES OBJECTIVES RATIONALE METHODO EXPECTED ANALYSIS NURSING RESOURCES
nd
OF THE PROBLEM
INTERVENTION
F FAMILY CONTACT
REQUIRED
OUTCOME
S>
Inability provide home
to a
Short Term: After 3-4 hours of NPI, the family will understand and provide measures in the problems that could lead to accidental hazards.
1. Assess level of -To determine knowledge the family. of what nursing care Health teachings needed. and
HOME VISIT
Student Nurse Resources: Time and effort, knowledge and skills on preventing accident hazards
Short Term: The family shall have understood and provided measures in the problems that could lead to accidental hazards.
O> > Toys environment were which is scattered on conducive to the floor safety living due accidental hazards. > as are reach Sharp objects such knives within of to
2. Inform family of safe environment
the about a
-To help the family the importance of having safe Familys Resources: Time and effort, environment -To prevent know
the importance having
Long Term:
children with
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no
proper
After 4-5 days 3. Employ of NPI, the family will be able to put in order or repair the problems that lead to accident hazards. 4. Show safety measures
some the occurrence of in any untoward accidents.
cooperation of the family, financial resources and construction materials and manpower
Long Term: The family was able to put in order or repair the problems that lead to accident hazards.
storage and possible falling
implementing safe environment
-To make the fall family of problem. aware the
hazards in the environment
-To 5. Instruct to keep the objects container drawer. sharp in a or
prevent
possible injuries and to keep it not
within reach of children.
-To make the 6. Discuss the family aware
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possible
of the possible
condition that accidents that might happen might happen. if the stairs remain unstable. -To better view 7. Instruct family the the stair and to prevent
provide good accidents. lighting in the stairs. -To 8. Encourage the family to fix the railings. provide and the self-
stability of the railings make family reliant.
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VII. FAMILY COPING INDEX
Legend: 1- No competence 3- Moderate competence 5- Complete competence INITIAL CATEGORY y Physical Independence 1 3 X 5 1 FINAL 3 5 Initial: For the initial visit, the mother she was not able to give enough care to her children because she is busy doing household chores. Aerith and Tidus were seen with poor hygiene. But the family was cooperative enough and willing to make changes for the betterment of their living. JUSTIFICATION
Final: For the final visit, the family complied with the health teachings given by the students AEB the mother was able to provide hygiene to her family and still encourage them to promote cleanliness. And cooperative enough and willing to make changes for betterment. They started cleaning their house and removed unnecessary articles or things that are not being used anymore. Clothes are kept, clean and in order at the final visit and no presence of spider webs were seen.
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y Therapeutic Competence
Initial: During the initial visit, the family was able to distinguish different medications and their purposes. They even do self-medication attimes. They may know the purpose of the medication yet they do not know the exact dose and frequency that should be administered.
Final: For the final home visit, the family have a still have the same therapeutic competence since they didnt consult the health center even the student nurses encouraged them to do so. They still used OTC medications.
y Knowledge of Health Condition
Initial: During the initial visit, has some general knowledge of some common diseases or condition, but they are only partially informed. They know where they acquire a certain disease but often times they do not know whether it is communicable or not.
Final: The family was able to understand the importance of knowing the principles behind intake of medications. Also the student nurses also added more 154
information about the condition they already know and what more interventions can be done such as ear wicking. The students also informed the whole family about the importance of proper hygiene to prevent any causes of disease especially to the children. The family understood and even provided and demonstrated methods to prevent further complications and developing diseases. They increase their fluid intake and vitamin C like calamansi. y Application of Principles of General and Personal Hygiene X Initial: During the assessment in the initial home visit, the children were observed of having dirty long nails and they were bare-footed. However, the hygiene of the older people like Mrs. Yuna and Grandma Tifa were slightly fine than the children. The whole house is slightly in good condition but there were sites of the house that are hazardous for the whole family like breeding sites of mosquitoes and cockroaches.
Final: X The family showed proper hand washing and increased their attention to personal hygiene. Brushing of the teeth were demonstrated by children and Mrs. Yuna demonstrated cleaning of house regularly.
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y Health Care Attitudes
Initial: During the initial visit, the family accepts health care in some degree. The family accepts medical care in illness but not general preventive measures such as improving the ventilation to prevent potential cross contamination. The family does not always visit the health center for check-up. They do self-medication. They also fail to integrate other preventive measures such as maintaining cleanliness in the environment and with that of their personal hygiene.
Final: For the final home visit, the family was able to understand and recognizes need for medical care in illness and for the usual preventive services. The family is now aware on prioritizing the maintenance of health and prevention of diseases with the help of the health teaching given by the student nurses. But still, they didnt consult the health center so the student nurses gave the family a score of 3.
y Emotional Competence
Initial: During the initial visit, Mrs. Yuna do her responsibilities well. However, she focuses more on the house choirs leaving the other two children unattended. Mr. Brown does his responsibilities very well, by providing the financial needs of the whole family.
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Final: During the last home visit, the family was seen to be emotionally competent especially the mother in dealing health and non-health crisis; able to solve problems immediately and being considerate for the needs and wishes of every member of the family especially her children. But then again the fact that they are in the below poverty line they still affect in terms of making decisions.
y Family Living Patterns
Initial: The family seldom does things together since Mrs. Tifa is go outside the house to chat with her children and nevertheless, once they are together, they make the most of their time to share moments as a family such as chatting with each other and doing household choirs.
Final: The group gave the family a final score of 5 (five), their closeness and respect, and love for one another never changed. The group had never encountered any problem or complaint of serious fighting among them. Mrs. Yuna, on the other hand, appears more able to tolerate her temper in handling the children as evidenced by her calm tone and gentle approach. Furthermore, the interaction inside the house is 157
continuous; theres no sense of alienation in each of the family members. y Physical Environment X Initial: The house requires some repair or painting but over all, it is fundamentally sound. Their electric wirings are hanging around their ceiling. And their source drinking supply was close to a stagnant water. Their neighborhood is fine and the children have many playmates around.
Final: Because of limited financial resources, there were only slight improvements done inside the house. The student nurses arrange the electric wirings for them not hanging and not to be easily reached by the children. However, the problem with drinking supply still exist but health teachings were given by the students.
y Use of
Initial: The family knows and uses some of the available resources in the community. The family sometimes goes to the health center to get some medicines or to avail of any services provided. Mrs. Yuna also added that she sometimes participates whenever there are community programs like 158
Community
Facilities
Mothers Class.
Final: The nurses gave more health teachings about the proper utilization of the community resources. The student nurses provide Mothers Class. These resources can greatly help the family not just in terms of their health, but also in terms of their good environment and in developing the social skills. Still, the family didnt use or go to the health center for consultation so the score given is 3.
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VIII. LEARNING DERIVED Doing this FCA was tiring and challenging. Not only because of time constraints but also because for the first time, we have a smaller group to work on. I am one of the lucky ones to have a group of three and I am fortunate to have group mates who are responsible and hard-working individuals. This would be my third FCA and I noticed that unlike before, I understand how to do these now. I thought before we began that it would be hard to do this because its been awhile since Ive done my last FCA. I learned a lot in doing this FCA and have the opportunity to do some parts of the FCA that I didnt before. In terms of the community where we looked our adopted family, it still surprises me that if you just turn to a street or corner, you would see a different world than what we are used to. The place looks like a province but not far from us. It gives a sense of responsibility for me as a student to do something to help those who are in need of caring and understanding. Especially when I saw the children of our adoptive family and their neighbours children that I felt that something must be done to help them even a small thing that I can do. It was a bit disappointing to assess these children and learned that they are malnourished, especially when I learned the BMI of Aerith, because the Health Center is already extending their effort and power to help the poor but somehow they just didnt go there. That made me realizes how important our job to go to this depressed areas and reach out to them to show that there are still people that can help them. We manage to always complain how hot and how tiring to go to these communities but if we just looked at it, there is a reward for that hard work and sometimes we didnt notice it but we save a life. For example is checking the BP. If someone asked us to get their BP, I never thought that it would be a matter of life and death to get their BP because how do they know that their BP is higher than before. This is what I learned in our community and appreciate it a lot because I can feel I was a step closer to my goals. - Lorriane P. Fualo
Nursing is the art and science of rendering care to individuals who are sick and well. It is a profession that requires not only the knowledge of the students but also their skills and capability of touching the lives and hearts of their patients. I have been through
160
community health nursing before and this is my third time when it comes to assessing a family. This experience of being a community health nurse gives me the privilege of extending my knowledge, my hands and my care to these individuals who are less fortunate. This part of being a community nurse makes me realize how fortunate I am of having a life that is much better than theirs. Community health Nursing thought me to identify problems and render some interventions that could somehow change or alleviate the identified problem. This activity also gave me the chance to be with people who needs attention that somehow they are deprived of. Our first day with our adopted family, as we saw the children they were so dirty, they were thin and as I have seen Mother Yuna and Grandmother Tifa, it was really obvious that they are malnourished, and I felt in my heart that these poor individuals needed someone that could make their living different than the other. If only I could give them money and buy what they want, I would, but since I only have enough I hope that someone with a big heart could pay attention to these poor individuals. I have learned through this experience that if I would be putting-up my own family, id better be sure that I have all the means to give their wants and needs, since its my choice. However, i could never blame anybody else for having poor conditions like what the Fantacia family experiences. This experience has really taught dozens of things in my life, in my heart and in my chosen profession. It gave me more passion and interest in my chosen course. The experience I have taught me to understand things using the heart and not the mind. The mind only gives knowledge, but the heart expresses love and affection, trust and learning these are what the community needs; a heart that feels and a hand that touch and help. -Joazelle Lorene Mercado
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Great things begin with small ones, in the same way that fire starts in a flicker of light.
Notice that in illuminating a dark room, a candle is used. A match should be ignited and light the candle through its fire. That tiny fire is able to light up the whole room. Likewise, it is essential to prioritize the needs of the family because it is like the candle in a society. The nurse that gives health teachings to them is like the match that gives fire to the candle. After having been given the simple and yet powerful health teachings, the families are empowered and are able to disseminate what they have learned to the community. In the process, the community is lightened up and improved towards productivity. We had this opportunity when started out duty in the community. We were assigned in Balibago. It was just like any other barangay here in Pampanga. After a brief orientation about the community and the health center, the duty began. Having a duty in a community consist of conducting a Family Case Analysis, a Chat Session, and School Teaching. The first two are not new to us. But still, it was the same tiring, brain-draining, time-consuming. you get the picture. But when you look past the difficulties youd see the learning you can get from it. Communication skills and social skills are honed. I learned how to interact with new people and to be confident in front of them. Making a Family Case Analysis also teaches you to what to prioritize and become more disciplined. It takes every time and effort you can give for the Family Case Analysis to be complete. Being exposed in the community also taught me to appreciate the life I have. Before, whenever I would see news of people in the depressed area, I would give a little care. I would feel sad whenever I couldnt obtain a certain gadget I want. What I didnt know is that there are people who are more unfortunate than I am. With those realizations, I began to see that I have indeed a wonderful life that I should be thankful. -John Paulo Sarsagat
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IX. SOCIOGRAM AND DOCUMENTATION LEGENDS:
-Student Nurse
Family
-Rapport
-Home Inspection
-Physical Assessment -
Health Teaching
-Implementation
-Evaluation
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First Home Visit (September 6, 2010)
During the first day of home visit, the student nurses build rapport and trust to the members of the family and explain the purpose of the study. It became easy for the student nurses to establish rapport because the family warmly accepted them. Afterwards, the student nurses started taking and recording the vital signs of the members of the family and assessed the health of the members. They were able to meet and assess the family except for the two children who are in school during the first home visit. The student nurses also interviewed the family where in they gave the necessary data needed by the student nurses.
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Second Home Visit (September 7, 2010)
On the second day of home visit, the student nurses were able to meet the whole family and they started obtaining vital signs, weight, height and physical assessment of each member. They also obtained information about their socioeconomic status, present and past illness and activities of daily living. They started assessing the living condition of the family and started looking for problems needing prioritization.
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Third Home Visit (September 13, 2010)
On the third home visit, the student nurses started giving health teachings and discussed to the family the potential problems that theyve identified. They continued on assessing and recording the health of the family. They also performed implementation process to eradicate some problems.
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Fourth Home Visit (September 20, 2010)
On the fourth Home visit, the student nurses continued their health teachings and implementation in the family. They also interviewed the family for incomplete data and assessed the familys health.
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Final Home Visit (September 21, 2010)
On the Final Home Visit, the student nurses assessed the house and the family members if theyve followed the health teachings given. Theyve only met three members of the family because the other three went to school. Further health teachings were done and reminded them to take care before saying their goodbyes and thanking the family for their hospitality to the group.
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Angeles City Foundation College of Nursing Angeles City

A FAMILY CASE ANALYSIS:

Fualo, Lorriane Mercado, Joazelle Lorene Sarsagat, John Paulo

September 24, 2010

Vital signs: T: 36.9C/axilla

Type and Function Type: Sensory Function: Smell

Type: Sensory Function: Vision

Type: Motor Function: Extra-ocular movement Occulomo- of pupils tor Nerve

Cranial Nerve Number 3:

Cranial Nerve Number 4: Trochlear Nerve

Cranial Nerve Number 5:

Cranial Nerve Trigeminal Nerve

Cranial Nerve Number 8: Vestibulocochlear or Acoustics

Cranial Nerve Number 9:

The client spoke without hoarseness, and elicited gag reflex.

Type and Function Type: Sensory Function: Smell

Type: Sensory Function: Vision

Type and Function

Expected Result objects and identify colors.

Type: Motor Function: Extra-ocular movement Occulomo- of pupils tor Nerve

Cranial Nerve Number 3:

Cranial Nerve Number 4: Trochlear Nerve

Cranial Nerve Number 5: Trigeminal Nerve

Cranial Nerve Number 6: Abducens Nerve Cranial

Type: Motor Function: Extra-ocular movement of eyes in a lateral movement

Type: Motor Student nurse asked Client

Cranial Nerve Nerve Number 7: Facial Nerve

Cranial Nerve Number 8: Vestibulocochlear or Acoustics

Cranial Nerve Number 9:

The client spoke without hoarseness, and elicited gag reflex.

Type and Function

History of Past Illness

CRANIAL NERVE ASSESSMENT

Type and Function Type: Sensory Function: Smell

Type: Sensory Function: Vision

Type: Motor Function: Extra-ocular movement Occulomo- of pupils tor Nerve

Cranial Nerve Number 3:

Cranial Nerve Number 4: Trochlear Nerve

Cranial Nerve Number 5: Trigeminal Nerve

Type and Function jaw movement.

Cranial Nerve Number 8: Vestibulocochlear or Acoustics

The pt. was able to correctly repeat the whispered words.

Cranial Nerve Number 9:

Type and Function

The pt. was able to do all movement instructed.

CRANIAL NERVE ASSESSMENT

Type and Function Type: Sensory Function: Smell

Type: Sensory Function: Vision

Type: Motor Function: Extra-ocular movement Occulomo- of pupils tor Nerve

Cranial Nerve Number 3:

Cranial Nerve Cranial Nerve Number 4: Trochlear Nerve

Cranial Nerve Number 5: Trigeminal Nerve

Cranial Nerve Number 8:

Type and Function

The pt. was able to do all movement instructed.

History of Past Illness

(Second home visit: September 7, 2010) APPEARANCE AND MENTAL STATUS 39

CRANIAL NERVE ASSESSMENT

Type and Function Type: Sensory Function: Smell

Type: Sensory Function: Vision

Type: Motor Function: Extra-ocular movement Occulomo- of pupils tor Nerve

Cranial Nerve Number 3:

Cranial Nerve Number 4: Trochlear Nerve