family case analysis group13

8/8/2019 Family Case Analysis GROUP13

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ANGELES UNIVERSITY FOUNDATION

Angeles City

COLLEGE OF NURSING

COMMUNITY HEALTH NURSING:

FAMILY CASE ANALYSIS

An Assessment of Royale Family in Barangay Virgen Delos Remedios

Submitted by:

BSN II-3 GROUP 13A

Corpuz, Mary Ann Joyce I.

Esquejo, Charlaine Marie G.

Quiambao, Katherine Camille D.

Ramos, Quinn Gabriel Allen S.

Submitted to:

Mr. Sammy David, RN


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I. Introduction

In family life, love is the oil that eases friction, the cement that binds

closer together, and the music that brings harmony. Eva Burrows

Family is a network of people that provides love, support, advice, comforting,

their time, and friendship. It consists of a father, mother, children, grandparents, in-laws,

relatives, and friends. Within a family, there are times when conflicts cant be avoided.

The love of each family member is the oil that eases friction. When theres love for one

another, it solves conflicts. With love, the family is able to forgive, understand, and

reconcile. The cement represents the bonding and trials of the family. Even though the

parents are busy from work, they still need to have time for their children. When going

through trials, make sure to overcome it together. The music is the agreement in feeling,

action, ideas, and interests. It means a family that will always be there to listen to all your

problems and give you great advices, a family who accepts you for who you are, accepts

your similarities and differences, and trust. Love, bond, and trust are the most important

thing in a family. Family is the one who will always be there when others walk away,

will guide you through the right paths, will sacrifice anything for the sake of your

happiness and future, will never judge you, will be the first one to care for you when

youre sick, and most of all, family is the one who will love you unconditionally.

Nursing is a dynamic profession. Its scope covers a wide range of body of

knowledge which aims to promote optimum level of functioning and self reliance to

each individual, family, hence, the community. Therefore, nurses especially the

community help nurses have a big role in building a healthy family.

Family is the basic unit of the community, and they are the basic unit of care. It is

first initiated within the family, the care, and provision of our needs. Therefore, the

student nurses recognize that the quality of living of the family has close relationship to

the health of each family member.

Community Health Nursing is a vocational profession which is to give service to

the community with dedication to meet the health needs identified by the members of the

community and the members of the heath providers. It involves a complex process; the


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nurses must consider the resources of the family which would skillfully manipulate by

the nurse together with family to the advantage of each of the member of the family.

Family Case Analysis is a way for student nurses to reach out with the community

people to share knowledge and to alleviate their experienced problems. The student

nurses are given the opportunity to practice their nursing profession and share their

efforts to be an efficient nurse in the future. It is to upright the condition of the chosen

family resident in Barangay Virgen De Los Remedios is the main goal of the student

nurses. It is an opportunity for the student nurses to apply the learned concepts from the

academic to the reality of living depressed people.

They are residents of Barangay Virgen De Los Remedios, who are living in a

depressed area, comprises of not less than five family members, which needs

improvement with regards to their health and living condition. We chose this family

because they are the family willing to participate, chosen by the barangay health worker,

and fits in the criteria set by the group.

A. Objectives

a. Short Term: Student Centered

After 2 days of home visits to Barangay Virgen Delos Remedios, the student nurses will:

Familiarize themselves with the community.

Choose a family for their family case analysis.

Introduce themselves to the family and explain their purposes.

Gather information including demographic, socio-economic, cultural, and

environmental data.

Perform health assessment to each family member.

Identify the existing and potential problems that may affect the familys health

status.

b. Short Term: Client Centered

After 2 days of home visit to Barangay Virgen Delos Remedios, the family will:


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Participate regarding the purpose of home visits.

Provide complete and necessary information of each family member.

Identify health problems present in their family.

c. Long Term: Student Centered

After 6 weeks of home visit to Barangay Virgen Delos Remedios, the student nurses will:

Apply the therapeutic communication skills during the interview and gain the

cooperation of the family.

Understand the health planning and practices of the family.

Prioritize health problems jointly with the family.

Plan nursing interventions to solve identified problems.

Implement nursing interventions and health teachings.

Help the family realize the importance of availing health services.

d. Long Term: Client Centered

After 6 weeks of home visit to Barangay Virgen Delos Remedios, the family will:

Identify health problems present in their family.

Realize the importance of having a good health practices.

Comply with the health teachings rendered by the student nurses.

Maintain an environment that is conducive to health and environment.

B. Entry, Climate of acceptance, first few words

July 2, 2010 Friday

It was our first day to encounter with the family for our family case analysis. The

group rode the jeepney to the community with eager of knowing the family for their

FCA. The group, along with the community health worker, walked around the

community to find their family. Even though the student nurses were sweating, feeling

hot, and tired, they were still able to put a smile on their face. Although it took a while,

the group was able to find their family that fitted the criteria for the family case analysis.


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Good morning po, Taga AUF po kami at naghahanap po kami ng family na

puwedeng ma-adapt para po sa FCA namin. Puwede po ba ang family niyo? the group

said. Ok lng. Halika pasok kayo, Lola replied. Lola grabbed chairs from the inside and

told us to sit down. Salamat po, group said with a smile on their faces. The first

question was Nay, ano po pangalan niyo? It was awkward at first but as time passed by,

the student nurses and Lola Deer got used it. She was very cooperative and willing to

participate in all the things we did.

First home visit:

July 2, 2010 Friday

It was the groups first time to visit their family. They established rapport by

greeting the family, introducing each of the members of the family, and explaining their

purposes for their home visits. The group was working as a team. Two student nurses

from the group were asking questions to Lola Beauty regarding the needed information

data including demographic, socio-cultural, and cultural data of the family. While two

student nurses from the group started to assess the children, Brother Prince and Sister

Princess. After the questions were done being asked, it was Lola Beautys turn to be

assessed by the student nurses. The group made an appropriate appointment for the

assessment of the father and mother.

Second home visit:

July 9, 2010 - Friday

The group conducted their second home visit, at around 8:00 in the morning.

Upon arriving at their house the mother stated pasok kayo., and the group goes inside

the house and started the things that should be done. The children are at the living room

as they play. Fortunately it was the time for us to interview and assess the vital signs and

physical assessment of each of the family members. Asked some questions to fill in some

datas that is essential in making of the family case analysis, also take the measurements

of their house which the group fond out that they have inadequate living space, for the

floor plan, their living room, the size of the windows which they have inadequate

ventilation and size of the bedroom at the same time documented them. The group


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noticed that Sister Princess have a swollen part near her left eye, we think that she is

beaten by a rat or a mosquito. Necessary information is gathered though an informal

interview or question and answer method. All the findings and information gathered were

document properly.

Third home visit:


On the third home visit, the group was tasked to identify the problems that are

present in their chosen family. First of the problem was identified was the presence of

asthma, Sister Princess experienced attacks of asthma since she was 8 month old as

verbalized by Lola Beauty. The group noticed that the two children were thin and light as

they carry them. Hordeolum or stye was present on both children. The group assisted

Lola Beauty in bathing the children. After bathing them, the group decided to feed the

children of bread and cookies because they did not already have their breakfast that time.

One of the member let Sister Princess sleep after few minutes of taking a bath. Health

teachings where also given to the family about the problems identified by the group.

They discuss all of these problems, whether they are perceived by the family or not. The

group emphasizes that prevention is more important than cure. The family was given

necessary information to improve their health status and maintain their health.

Final home visit:



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II. Family Constellation

LolaBeauty

49 yearsold

Grandmother Female 2nd Year Highschool

Upon the initialassessment, Lola Beauty

was cooperative,

coherent, and aware to

the place, time andperson. She was wearing

a white shirt and blueshorts, carrying Brother

Prince, and had her hair

tied up. She has presence

of dandruff and has dirtynails.

VS taken as follows:

Temp= 37.3CBP= 155/100 mmHg

PR= 90 bpmRR= 20 bpm

Papa

King

28 years

old

Father Male 1st Year High

school

Upon initial assessment,

Papa King was consciousand oriented as to date,

time and place. He was

wearing long maongshorts, has no top, and

with slippers. His mood

was appropriate to thesituation, he was

cooperative, and hascoordinated movements,straight posture and good

muscle tone.


BP= 130/100 mmHgT= 37.2C/axilla

P= 98 bpm

R= 20 bpm

Mother

Queen

25 years

old

Mother Female High School

graduate


Mama Queen was

conscious and oriented asto date, time, and place.

She was wearing a t-shirt,

pants, and shoes ready togo to work. Her mood

was appropriate to the

situation, she wascooperative, and

Name AgePosition in

the familyGender

Educational

StatusPresent Health Status


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coordinated movements.

VS taken as follows:BP= 110/90 mmHg

T= 35.8 C/axilla

P= 70 bpm

R= 16 bpmBrotherPrince

4 yearsold

Eldest Child Male Never been toschool

Upon initial assessment,Brother Prince was

wearing a blue shirt and a

blue shorts and a pair of

slippers. He was unableto express himself

through speech. He has

presence of dandruff andhas long, dirty nails. He

is slightly thin.

VS taken as follows:Temp= 35.8C

PR= 103 bpm

RR=29 bpm

Sister

Princess

1 year

and 7

months

Youngest

daughter

Female Never been to

school


Sister Princess was

wearing a yellowsleeveless shirt and white

shorts and a pair of

slippers. She was unableto express herself through

speech. She is slightlythin and has presence ofdandruff, wound on the

right forehead, has rashes

on the left side of the

neck, and has long, dirtynails.


Temp= 36CPR= 51 bpm

RR= 44 bpm

III. Health Assessment

1. Lola Beauty (Grandmother)


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Initial Assessment (July 2, 2010---Friday)

General Appearance

Upon the initial assessment, Lola Beauty was cooperative, coherent, and aware tothe place, time and person. She was wearing a white shirt and blue shorts, carrying

Brother Prince, and had her hair tied up. She has presence of dandruff and has dirty nails.

Vital Signs

BP= 155/100 mmHgTemp= 37.3C

PR= 90 bpm

RR= 20 bpm

Physical Assessment

Skin

Lola Beauty has fair complexion. She has a good skin turgor as evidenced by

when the skin was pinched at the arm; the skin goes back to its previous state. No edema

and no lesions noted upon inspection.

Hair and Scalp

Lola Beauty has a short black hair and it is evenly distributed upon inspection.

Has presence of dandruff and the scalp is rough upon palpation.

Nails

Nails are pinkish, convex curve with 160 angle, long and dirty. Has a normal

capillary refill time which is 2 seconds.

Skull

Skull is round and symmetrical in size and has no nodules or masses noted upon

palpation.

Face


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Facial movement has coordination and has balanced facial features. There is absence

of edema.

Eyes and Vision

Eyebrows evenly distributed, eyelids close symmetrically approximately 16 blinks

per minute, white sclera, pink palpebral conjunctiva and transparent bulbar conjunctiva,

pupils are well rounded and reactive to light and accommodation, absence of abnormal

secretions. During the Corneal Sensitivity Test, client blinks when cornea is touched

indicating that he has intact cranial nerve no. 5 (trigeminal). She can see and read

newsprint clearly.

Ears and Hearing

No abnormal discharges noted, ears are on the level of outer canthus of the eye, has

dark pinna and recoil after it is folded, with minimal cerumen. During the Whisper test,

the client is able to hear normal voice tone at a distance of 1-2 inches.

Nose

Air moves freely as Lola Beauty breaths through her nares, nasal septum intact and

in midline, no swellings and lesions, absence of abnormal discharges.

Lips

Dark pink in color, moist and smooth, able to purse lips, symmetry of contour.

Tongue

Central position, pink, moist, slightly rough, no lesions, with raised papillae, moves

freely, not tender, no palpable nodules.

Neck muscles

Lola Beautys sternocleidomastoid and trapezius muscles are equal in size, head

centered, coordinated smooth movements with no discomforts, equal muscle strength, is

able to turn the head to one side against the resistance of our hands, able to shrug

shoulders against the resistance of our hands, no palpable lymph nodes, trachea is on the

midline of the neck upon inspection, thyroid gland not visible on inspection, full

pulsation and symmetric pulse volume of the carotid artery, jugular vein not distended,

no enlargement of lymph nodes.

Lungs and Thorax


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Spine vertically aligned, spinal column is straight, full and symmetric chest

expansion, with normal breath sounds, no tenderness or masses noted upon palpation.

Heart

Normal heart sound (lub-dub upon auscultation), has a normal heart rate of

98 beats per minute and has regular rhythm and has a BP of 155/100 mmHg, no murmurs

heard upon auscultation.

NEUROLOGICAL ASSESSMENT

Mental Status - conscious, awake; knows his name; where he is currently and

who he is at the moment; answers questions asked to him accordingly; uses

Kapampangan whenever he answers the questions asked.

Sensory Function - able to distinguish a light touch using tip of cotton; able to

distinguish hot from cold water; pointed the place where the pricking pain was

pointed; can readily determine the position of fingers and toes.

Motor Function- has upright position and gait steady with opposing arm

swinging; walks unaided maintaining balance; can alternately supinate and

pronate at rapid pace; moves smoothly and coordinately.

Cranial Nerves

CRANIAL NERVE ASSESSMENT

TECHNIQUE

EXPECTED

OUTCOME

ACTUAL

FINDINGS

I: Olfactory

Type: Sensory

Function: Smell

Ask the client to

identify aromas

like cologne,

alcohol and

vinegar, with each

nostril separately

with eyes close.

The client will be

able to identify

different aromas

like cologne,

alcohol and

vinegar, unless

such condition

like cold is

present.

Lola Beauty was able

to identify the

aromas of cologne,

alcohol and vinegar.

II: Optic Ask the client to The client will be Lola Beauty was able


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Type: Sensory

Function: Vision

read words on a

piece of paper with

each eye first then

both eyes at 12-14

inches.

able to read the

words at 12-14

inches.

to read the articles in

the newspaper at 12-

14 inches.

III: Oculomotor

Type: Motor

Function: Upward and

downward movement of pupils

Ask client to look

straight ahead then

approach the pupil

with a penlight and

observe for pupil

constriction.

The clients eyes

will have a normal

reaction for

PERRLA.

Lola Beauty had a

normal reaction to

PERRLA.

IV: Trochlear

Type: Motor

Function: Extra-ocular

movement of eyes in oblique

movement

Ask client to hold

the head still and

follow the

thermometer as it

moves in the six

cardinal eye

movements.

The client will be

able to follow the

movement of the

thermometer.

Lola Beauty has

good coordination of

eye movements and

able to follow the

movement of the

thermometer.

V: Trigeminal

Type: Motor and Sensory

Function: Sensation of cornea,

skin of face and jaw movement

Ask the client to

make chewing

movements, open

the mouth against

resistance, move

jaw from side to

side and open

mouth widely.

Cotton is wisp at

the side of the

clients eyes.

The client will be

able to make

chewing

movements, open

the mouth against

resistance, move

jaw from side to

side and open

mouth widely.

Blinking Reflex

was noted.


to make chewing

movements, open the

mouth against

resistance, move jaw

from side to side and

open mouth widely.

Blinking Reflex was

noted to Lola Beauty

VI: Abducens

Type: Motor

Have the client to

hold his head

The client will be

able to follow the

Lola Beauty has



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IX: Glossopharyngeal


Function: Swallowing, gag

reflex, pharyngeal movement

and sense of taste of the

posterior one-third of the

tongue

Ask the client to

swallow then open

mouth widely and

say Ah. Ask the

client to identify

the taste (sugar)

placed on posterior

tongue.

Client will elicit

gag reflex. The

client will be able

to identify the

taste of sugar

placed on

posterior tongue.


to elicit gag reflex.

And the uvula moved

upward upon saying

Ah.

X: Vagus

Type: Motor

Function: Swallowing and

Speaking

Ask client to cough

and say its name.

The client will be

able to state his

name without

hoarseness of

voice.

Lola Beauty had an

effective coughing

and was able to state

her name without

hoarseness of voice.

XI: Accessory

Type: Motor

Function: Movement of

shoulder muscles

Ask client to

elevate shoulders

against the gravity

and turn head from

side to side.

The client will be

able to elevate

shoulders against

the gravity and

turn head from

side to side.


to elevate shoulders

against the gravity

and turn head from

side to side.

XII: Hypoglossal

Type: Motor

Function: Movement and

strength of tongue

Ask the client to

protrude the tongue

and move in

different directions.

The client will be

able to protrude

his tongue and

move in different

directions.


to protrude her

tongue and move in


HISTORY OF PAST AND PRESENT ILLNESS


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Currently, Lola Beauty is not experiencing any illness. He often acquired some

colds, cough and even fever. There are times when her blood pressure is high, but has

medicines to lower it down.

ACTIVITIES OF DAILY LIVING

TIME ACTIVITIES

7:00 am Wakes up

7:00-8:00 am Cleans the house and cooks breakfast

8:00-11:00 am Takes care of her grandchildren

11:00-12:00pm Prepares lunch

12:00-1:00 pm Eats lunch

1:00-5:30 pm Takes care of her grandchildren

5:30-6:30pm Prepares dinner

6:30-7:00 Eats dinner 7:00-9:00pm Watching TV with family

9:00 pm Rest and Goes to sleep

Eating pattern

Lola Beauty eats thrice daily. She eats whatever is available.

Sleeping pattern

Lola Beauty wakes up at 7:00 am and sleeps at 9:00 pm. She sleeps in the livingroom by herself. She sleeps 10 hours a day.

Leisure time activities

When Lola Beauty has leisure time, she utilizes it for watching TV, listening to

the radio, cleaning the house or chatting with neighbors.

2. Papa King (Father)



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Eyes and Vision

Eyebrows evenly distributed, eyelids close symmetrically approximately 16

blinks per minute, white sclera, pink palpebral conjunctiva and transparent bulbar

conjunctiva, pupils are well rounded and reactive to light and accommodation, absence of

abnormal secretions. During the Corneal Sensitivity Test, client blinks when cornea is

touched indicating that he has intact cranial nerve no. 5 (trigeminal). He can see and read

newsprint clearly.

Ears and Hearing

No abnormal discharges noted, ears are on the level of outer canthus of the eye,

has dark pinna and recoil after it is folded, with minimal cerumen. During the Whisper

test, the client is able to hear normal voice tone at a distance of 1-2 inches.

Nose

Air moves freely as Daddy Jon breaths through his nares, nasal septum intact and

in midline, no swellings and lesions, absence of abnormal discharges.

Lips

Dark pink in color, moist and smooth, able to purse lips, symmetry of contour.

Tongue

Central position, pink, moist, slightly rough, no lesions, with raised papillae,

moves freely, not tender, no palpable nodules.

Neck

Papa Kings sternocleidomastoid and trapezius muscles are equal in size, head





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Lungs and Thorax



Heart

Normal heart sound (lub-dub upon auscultation), has a normal heart rate of 98

beats per minute and has regular rhythm and has a BP of 130/100 mmHg, no murmursheard upon auscultation.


Mental Status - conscious, awake; knows his name; where he is currently and

who he is at the moment; answers questions asked to him accordingly; uses

Kapampangan whenever he answers the questions asked.







Cranial Nerves

CRANIAL NERVE ASSESSMENT

TECHNIQUE

EXPECTED

OUTCOME

ACTUAL

FINDINGS

I: Olfactory

Type: Sensory

Ask the client to

identify aromas

The client will be

able to identify

Papa King was able

to identify the


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Function: Smell like cologne,

alcohol and

vinegar, with each

nostril separately

with eyes close.

different aromas

like cologne,

alcohol snd

vinegar, unless

such condition

like cold is

present.

aromas of cologne,


II: Optic

Type: Sensory

Function: Vision

Ask the client to

read words on a

piece of paper with

each eye first then

both eyes at 12-14

inches.

The client will be

able to read the

words at 12-14

inches.

Papa King was able

to read the articles in

the newspaper at 12-

14 inches.

III: Oculomotor

Type: Motor



Ask client to look

straight ahead then

approach the pupil

with a penlight and

observe for pupil

constriction.

The clients eyes

will have a

normal reaction

for PERRLA.

Papa King had a

normal reaction to

PERRLA.

IV: Trochlear

Type: Motor



movement

Ask client to hold

the head still and

follow the

thermometer as it

moves in the six

cardinal eye

movements.

The client will be

able to follow the

movement of the

thermometer.

Papa King has good

coordination of eye

movements and able

to follow the

movement of the

thermometer.

V: Trigeminal



skin of face and jaw movement

Ask the client to

make chewing

movements, open

the mouth against

resistance, move

jaw from side to

The client will be

able to make

chewing

movements, open

the mouth against

resistance, move

Papa King was able

to make chewing

movements, open the

mouth against

resistance, move jaw

from side to side and


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side and open

mouth widely.

Cotton is wisp at

the side of the

clients eyes.

jaw from side to

side and open

mouth widely.

Blinking Reflex

was noted.

open mouth widely.

Blinking Reflex was

noted to Papa King.

VI: Abducens

Type: Motor


movement of eyes in a lateral

movement

Have the client to

hold his head

steady and follow

the thermometer

direction.

The client will be

able to follow the

movement of the

thermometer.

Papa King has good

coordination of eye

movements and able

to follow the

movement of the

thermometer.VII: Facial


Function: Movement of facial

muscles and sense of taste on

the anterior two thirds of the

tongue

Ask the client to

smile, frown, raise

eyebrow, puff the

cheeks and show

teeth. Ask the

client to identify

the different tastes

(sugar) placed on

the anterior 2/3 of

the tongue.

The client will be

able to smile,

frown, raise

eyebrow, puff the

cheeks and show

teeth. The client

will be able to

identify the sugar

placed on the

anterior 2/3 of the

tongue.

Papa King was able

to smile, frown, raise

eyebrow, puff the

cheeks and show

teeth. He was also

able to identify the

taste of sugar on the

anterior 2/3 of his

tongue.

VIII: Vestibulocochlear/

Acoustics

Type: Sensory

Function: Hearing and

Equilibrium

Have the client to

walk with both

eyes close and

repeat the

whispered few

words at the

clients back.

Allow client to

stand with feet

The client will be

able to walk with

both eyes close

and repeat the

whispered few

words at the

clients back. The

client will be able

to perform

Papa King was able

to walk with both

eyes close and repeat

the whispered few

words whispered to

him. He was also

able to perform

Rombergs Test with

equilibrium.


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Currently, Papa King is not experiencing any illness. He often acquired some

colds, cough and even fever.

ACTIVITIES OF DAILY LIVING

TIME ACTIVITIES

6:30 am Wakes up

7:00-9:00 am Works as a street sweeper

9:00-12nn Rest and goes to sleep

12:00-1:00 pm Eats Lunch

1:00-2:00pm Get ready for work

2:30-10:00 pm Works as a Guard Vendor

10:30 pm Goes home11:00 pm Rest and goes to sleep

Eating pattern

Papa King eats thrice daily. He eats whatever is available.

Sleeping pattern

Papa King wakes up at 6:30 am and sleeps at 11:00 pm. He sleeps with his wife and 2

children. He sleeps 7 hrs a day.


When Papa King has leisure time, he utilizes it for sleep, rest, watching TV, listening

to the radio, playing basketball or with the kids.

3. Mama Queen (Mother)


General Apperance


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Upon initial assessment, Mama Queen was conscious and oriented as to date,

time, and place. She was wearing a t-shirt, pants, and shoes ready to go to work. Her

mood was appropriate to the situation, she was cooperative, and coordinated movements.

Vital Signs

BP= 110/90 mmHg

T= 35.8 C/axilla

P= 70 bpm

R= 16 bpm

Skin

Mama Queen has brown complexion, with evenly distributed body hair consistent

from head, neck, arms down to the legs and with other parts upon inspection. No edema

and no lesions noted upon inspection. Herskin is moist with the same temperature on

upper and lower extremities upon palpation. She has a good skin turgor as evidenced by

when the skin was pinched at the arm, the skin goes back to its previous state.

Hair and Scalp

Mama Queen has a straight long dark brown hair and it is evenly distributed upon

inspection. Has no dandruff and infestations of lice, no evidence of flaking and no areas

of hair loss. The scalp is smooth upon palpation.

Nails

Nails are pinkish, convex curve with 160 angle, short and clean. Has a normal

capillary refill time which is 2 seconds.

Skull

Skull is round and there are no presence of nodules and masses.


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Face

Facial movement has coordination and has balanced facial features. There is

absence of edema.

Eyes and Vision

Eyebrows evenly distributed, eyelids close symmetrically approximately 17

blinks per minute, white sclera, pink palpebral conjunctiva and transparent bulbar

conjunctiva, pupils are well rounded and reactive to light and accommodation, absence of

abnormal secretions. During the Corneal Sensitivity Test, client blinks when cornea is

touched indicating that she has intact cranial nerve no. 5 (trigeminal). She can see and

read newsprint clearly.

Ears and Hearing

No abnormal discharges noted, ears are on the level of outer canthus of the eye,

has brown pinna and recoil after it is folded, with minimal cerumen. During the Whisper

test, the client is able to hear normal voice tone at a distance of 1-2 inches.

Nose

Air moves freely as Mommy Mariel breaths through her nares, nasal septum

intact and in midline, no swellings and lesions, absence of abnormal discharges.

Lips

Pink in color, moist and smooth, able to purse lips, symmetry of contour.

Tongue

Central position, pink, moist, slightly rough, no lesions, with raised papillae,

moves freely, not tender, no palpable nodules.

Neck


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Mama Queens sternocleidomastoid and trapezius muscles are equal in size, head







Lungs and Thorax



Heart

Normal heart sound (lub-dub upon auscultation), has a normal heart rate of 80

beats per minute and has regular rhythm and has a BP of 110/90 mmHg, no murmurs

heard upon auscultation.


Mental Status - conscious, awake; knows her name; where she is currently and

who she is at the moment; answers questions asked to her accordingly; uses

Kapampangan whenever she answers the questions asked.







Cranial Nerves

CRANIAL NERVE ASSESSMENT EXPECTED ACTUAL


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TECHNIQUE OUTCOME FINDINGS

I: Olfactory

Type: Sensory

Function: Smell

Ask the client to

identify aromas

like cologne,

alcohol and

vinegar, with each

nostril separately

with eyes close.

The client will be

able to identify

different aromas

like cologne,

alcohol and

vinegar, unless

such condition

like cold is

present.

Mama Queen was


aromas of cologne,


II: Optic

Type: Sensory

Function: Vision

Ask the client to

read words on a

piece of paper with

each eye first then

both eyes at 12-14

inches.

The client will be

able to read the

words at 12-14

inches.

Mama Queen was

able to read the

articles in the

newspaper at 12-14

inches.

III: Oculomotor

Type: Motor



Ask client to look

straight ahead then

approach the pupil

with a penlight and

observe for pupil

constriction.

The clients eyes

will have a

normal reaction

for PERRLA.

Mama Queen had a

normal reaction to

PERRLA.

IV: Trochlear

Type: Motor



movement

Ask client to hold

the head still and

follow the

thermometer as it

moves in the six

cardinal eye

movements.

The client will be

able to follow the

movement of the

thermometer.

Mama Queen has


eye movements and

able to follow the

movement of the

thermometer.

V: Trigeminal



Ask the client to

make chewing

movements, open

The client will be

able to make

chewing

Mama Queen was

able to make

chewing movements,


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skin of face and jaw movement the mouth against

resistance, move

jaw from side to

side and open

mouth widely.

Cotton is wisp at

the side of the

clients eyes.

movements, open

the mouth against

resistance, move

jaw from side to

side and open

mouth widely.

Blinking Reflex

was noted.

open the mouth

against resistance,

move jaw from side

to side and open

mouth widely.

Blinking Reflex was

noted to Mama

Queen.

VI: Abducens

Type: Motor


movement of eyes in a lateral

movement

Have the client to

hold his head

steady and follow

the thermometer

direction.

The client will be

able to follow the

movement of the

thermometer.

Mama Queen has


eye movements and

able to follow the

movement of the

thermometer.

VII: Facial


Function: Movement of facial

muscles and sense of taste on

the anterior two thirds of the

tongue

Ask the client to

smile, frown, raise

eyebrow, puff the

cheeks and show

teeth. Ask the

client to identify

the different tastes

(sugar) placed on

the anterior 2/3 of

the tongue.

The client will be

able to smile,

frown, raise

eyebrow, puff the

cheeks and show

teeth. The client

will be able to

identify the sugar

placed on the

anterior 2/3 of the

tongue.

Mama Queen was

able to smile, frown,

raise eyebrow, puff

the cheeks and show

teeth. She was also


taste of sugar on the

anterior 2/3 of her

tongue.

VIII: Vestibulocochlear/

Acoustics

Type: Sensory

Function: Hearing and

Have the client to

walk with both

eyes close and

repeat the

The client will be

able to walk with

both eyes close

and repeat the

Mama Queen was

able to walk with

both eyes close and

repeat the whispered


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Equilibrium whispered few

words at the

clients back.

Allow client to

stand with feet

together and arms

resting at the sides,

first with eyes

open and then

closed (Rombergs

Test).

whispered few

words at the

clients back. The

client will be able

to perform

Rombergs Test

with equilibrium.

few words whispered

to her. She was also

able to perform

Rombergs Test with

equilibrium.

IX: Glossopharyngeal


Function: Swallowing, gag

reflex, pharyngeal movement

and sense of taste of the

posterior one-third of the

tongue

Ask the client to

swallow then open

mouth widely and

say Ah. Ask the

client to identify

the taste (sugar)

placed on posterior

tongue.

Client will elicit

gag reflex. The

client will be able

to identify the

taste of sugar

placed on

posterior tongue.

Mama Queen was

able to elicit gag

reflex. And the uvula

moved upward upon

saying Ah. She

was also able to

identify the taste of

sugar placed on her

posterior tongue.

X: Vagus

Type: Motor

Function: Swallowing and

Speaking

Ask client to

cough and say its

name.

The client will be

able to state his

name without

hoarseness of

voice.

Mama Queen had an

effective coughing

and was able to state

her name without

hoarseness of voice.


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XI: Accessory

Type: Motor

Function: Movement of

shoulder muscles

Ask client to

elevate shoulders

against the gravity

and turn head from

side to side.

The client will be

able to elevate

shoulders against

the gravity and

turn head from

side to side.

Mama Queen was

able to elevate

shoulders against the

gravity and turn head

from side to side.

XII: Hypoglossal

Type: Motor

Function: Movement and

strength of tongue

Ask the client to

protrude the

tongue and move

in different

directions.

The client will be

able to protrude

his tongue and

move in different

directions.

Mama Queen was

able to protrude her

tongue and move in


MOTHERS OBSTETRICAL HISTORY

Mama Queen has been living with Papa King for 4 years now. Her Obstetric

History is G4P4 (4004). She started having her menstrual cycle when she was 12 years

old. All of her children were born via normal delivery and they were all delivered at the

hospital. According to her, she had completed her tetanus toxoid vaccine.


Currently, Mama Queen is not experiencing any illness. She often acquired some

colds, cough and even fever several times due to some factors that are still unknown over

the past years according to her; she just acquired it sometimes when her other family

members have it.

Eating pattern

Mama Queen eats thrice daily. She eats whatever is available.

Sleeping pattern


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Mama Queen wakes up at 6:00 am and sleeps at 11:00 pm. She sleeps with her

husband and 2 children. She sleeps 7 hours every a day.


She utilizes it for sleep, rest, watching TV, listening to the radio, or chatting

with neighbors.


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IV. Socio-Economic, Cultural, and Environmental Assessment

A. Type of Family Structure

The Royale Family is an extended type of family, composed of parents: Papa

King and Mama Queen, children: 4-year old Brother Prince and 1-year old SisterPrincess, and Lola Beauty living with them. When Papa Prince and Mama Princess are at

work, Lola Beauty is the one taking care of their kids. Although the family is not lucky

enough to have a wealthy and comfortable living, they still manage to surpass every

challenging situation that they encounter by having a positive outlook in life.

B. Dominant family members in terms of decision making especially to health care

In terms of decision making, whether related to health care or not, Papa King and

Mama Queen are the decision makers in the family.

C. Source of Income, Expenditures

The familys source of income is Papa Kings wage from being a street sweeper

and a barangay tanod in their community and Mama Queens wage from being a

saleslady at LCN Enterprises. The family has adequate financial for the basic needs of the

family. In case of emergency, they use the money that the mother had kept/saved.

D. Working hours

Papa Prince works from 7 am to 9 am as a street sweeper, 2 hours a day, 2pm-

10pm as a guard vendor, and 10 pm to 6 am as a barangay tanod while Mama Queen

works from 8 am to 5 pm as a saleslady at LNC Enterprises.

E. Ethnic background and Religious Affiliation

The familys religion is Roman Catholic, so very few restrictions are being

implemented. They dont attend the Holy Mass often.

F. Significant others role in the family life

Lola Beauty is taking care of the kids whenever Papa King and Mama Queen are

not around.


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cabinet for medicines, plates, and glasses. At the back of their house is where the kitchen

and bathroom are located. There are presence of ants, spiders, and cockroaches. For the

lighting conditions, the family use incandescent bulbs as their source of light during

evenings. However, inadequacy in daytime lighting is very evident, as there is only one

window.

K. Food sources, storage, and cooking facilities

The family usually buys cooked food at the carinderia while Lola Beauty prepares

the rice. They seldom cook for their own food. When they ran out of gas for their stove,

Lola Beauty prepares rice in the front porch where the pile of charcoal is used. Food

storage comprises of food covered in plates.

L. Water Supply (source, ownership, portability, storage)

The family has a level 3 water system. They own such water supply facility. For

the kids, they boil the water first before they let the kids drink it while the adults in the

family drink the water from the household tap. The type of water storage is pitchers or

jars with cover.

M. Toilet facility (type, ownership, sanitary condition)

Their toilet facility is at the back of the house. The family has a septic tank

without water carriage so it has to be mechanically flushed by pouring water in it. It is in

good condition because the surrounding area of the bowl is clean and no discoloration or

foul odor is evident.

N. Drainage system (type, sanitary, condition)

Their drainage system is located on the front yard of the house. Its type is of open

and flowing nature. The garbage disposal container is sack and it is uncovered.

O. Social and health facilities available

The community where the family resides has various social and health facilities.

They have a basketball court wherein certain activities such as sports fest are being


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carried out and the Barangay San Remedios Health Center which offers an array of

services such as immunization, family planning programs, and prenatal care.

P. Communication and transportation facilities

In the family, Papa King and Mama Queen have cell phones for communication.

The family commutes by riding a tricycle or public utility jeepney to go to places. They

can also walk if the destination is just considerably near.

family case analysis group13

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