ANGELES UNIVERSITY FOUNDATION

COLLEGE OF NURSING
BACHELOR OF SCIENCE IN NURSING

COMMUNITY
HEALTH
NURSING
FAMILY CASE ANALYSIS GUIDE
QUESTIONS

GROUP 14
DIAZ, Ebeia Jubie
LAZO, Kathleen
PALAO, Prince Jobeth
TABOTABO, Michelle
YAMBAO, Channela Anne
CEPHALOCAUDAL ASSESSMENT
Integumentary
a. Skin
In the assessment of the skin, the color of the skin is (brown, pinkish, or fair) and skin appears
to be moisturized and has a good skin turgor. Skin is warm to touch and there are no presence
of lesions.

b. Nails
Nails are pink to light brown in color, smooth and round. There is no presence of clubbing in the
nails. When pinched, capillary refill returns to usual color in less than 4 seconds.

Head and Face

a. Head
Upon inspection, (state the color of the hair) is there a presence of white hair? is it a dyed hair?
No presence of dandruff, lice or lesions on the scalp. Hair is not dryand is symmetrically aligned.

b. Face
Facial features and movements are symmetrical and there is no presence of swelling, masses
and lesions upon inspection and palpation. He was able to perform different facial expressions,
and it is symmetrical when patient is smiling or talking.

c. Eyes and Vision

Inspection showed smooth, shiny and white-pinkish palpebral conjunctiva with absence of
discharge, swelling and lesions. Bulbar conjunctiva was transparent and capillaries were slightly
visible. Sclera is white in color. Has black iris and pupils equally round and reactive to light and
accommodation (PERRLA). Eyebrows are symmetrically aligned with its hair evenly distributed
and equal in movement. Eyelashes are evenly distributed and curled slightly outward.
d. Ears and Hearing
Upon inspection, ears were symmetrical; color was same as skin and able to hear normal voice
tones and positive result on watch tick test (able to hear the ticking of the watch in both
ears). Pinna recoils after it was folded and auricle is smooth with no lesions, lumps, or nodules.

e. Nose and Sinuses

Upon inspection, nose appears to be normal in shape, symmetrical, and has same color as skin.
Nasal mucosa was pink and moist and no difficulty in breathing noted. There is absence of
tenderness and lesions and no presence of secretions.

f. Mouth
Upon inspection, gums were pinkish in color with absence of swelling and pink in color Tongue
is in the central position and able to move freely and absence of lesions noted. Uvula is
positioned in the midline. Soft palate and hard palate were light pink in color and teeth are
complete. Throat is pink without lesions. Tonsils are present and without exudates.

g. Neck
Has the same color as skin with no presence of any difficulty movement when instructed to
move in different directions. Thyroid gland ascends when instructed to swallow and not visible.
Trachea is in the midline of the neck upon palpation

Thorax and Heart

a. Thorax
Appears to be symmetrical from posterior and lateral views upon inspection. Right and left
shoulders and hips were symmetrical and also chest expansion was symmetrical. Absence of
tenderness was noted upon palpation. No adventitious sounds noted and there was no
presence of secretion or tingling feeling on his breast. Sternum is position in the midline and
symmetrical with size and shape and absence of wheeze or crackles upon auscultation.

b. Heart
Normal pulse rate and regular in rhythm noted upon inspection. No blowing, swishing or other
sounds are heard and no murmurs auscultated.
Abdominal
a. Abdomen
Abdomen was uniform in color, symmetric contour and no distention. There is absence of
tenderness, lesions, and scars and no palpable masses.

Extremities
a. Upper Extremities
Upper extremities were symmetrical in shape, firm, smooth, coordinated muscle movement,
has even temperature upon palpation. Capillary refill time was less than three seconds and pink
nail beds noted. Absence of tenderness and deformities were noted upon inspection.No
scratches noted in the skin (arms)

b. Lower Extremities
Lower extremities were symmetrical in shape, firm, smooth, coordinated muscle movement
with equal size. Toes, feet, and legs were warm to touch bilaterally. Absence of tenderness,
lesions, and deformities noted upon inspection. Normal femoral pulses and lower leg is in
alignment with upper leg.

Musculoskeletal
a. Muscle tone
Upon inspection, normal structures noted in the bones, equal size on both side the body and
noted absence of tenderness and deformities on the joints. Posture is erect. He is able to shrug
shoulders against resistance.

Neurological
a. Mental Status and Level of Consciousness
Father Bobby was conscious and coherent & oriented with people, time, and place and was
able to answers the questions being asked by the group.
b. Sensory Function
Has a normal sensory functions upon assessment and was able to hear ticking off the clock
during the watch tick test and was able to identify "sharp" and "dull" sensation and was able to
identify sugar and salt through tasting.

c. Motor Function
Upon assessment, Father Bobby has normal motor functions, motor movement controlled and
was able to stand erect and walk around the house without difficulty. There was no presence of
tremors or problems with coordination.

Motor Function Test

Motor Function Assessment

Romberg's Test He was able to maintain an upright posture and foot stance

Heel-Toe Walking He was able to maintain a heel-toe along a straight line

without stumbling

Alternating Supination and He was able to alternately supinate and pronate hands at
Pronation rapid pace

Light Touch Sensation He was able to compare the light touch sensation or
symmetric areas of the body

Pain Sensation He was able to discriminate "sharp" or "dull" sensation

CRANIAL NEVRES
I – Olfactory - Correctly identifies scent with each nostril.
II – Optic - Client is able to read the newspaper.
III- Oculomotor - Eye moves in a smooth, coordinated motion in 4 directions.
IV- Trochlear - Eye moves in a smooth, coordinated motion using the superior oblique muscle.
V- Trigeminal
Sensory:
Client’s eyes blinks bilaterally.
Client identifies light touch, dull, and sharp sensations to forehead, cheeks, and chin.
Motor:
Client’s muscles contracts bilaterally.
VI- Abducens - Eyes move in a smooth, coordinated motion in all directions and using lateral
oblique muscle.
VII- Facial -
Sensory: Client identifies taste correctly.
Motor: Client was able to:

 Smile
 Frown
 Show teeth
 Blow out cheeks
 Raise eyebrows and tightly close eyes as instructed; facial movements are symmetrical.
VIII- Vestibulo-Cochiear
Client was able to hear the tick of the watch at 2 inches from both ears.
Client’s is able to maintain balance while walking.
Client is able to maintain balance while eyes are closed with minimal swaying.
IX- Glossopharyngeal
Client’s gag reflex intact.
Client’s swallows without difficulty.
Client is able to identify the taste.
X- Vagus
Client’s gag reflex is intact.
Client’s uvula and soft palate will elevate.
No hoarseness of voice will be noted from the client.
XI - Accessory
Client has symmetrical, strong contraction of trapezius muscles.
Client has strong contraction of sternocleidomastoid muscle on opposite side that head is
turned.
XII- Hypoglossal
Client has symmetrical tongue with smooth outward movement and bilateral strength.

SOCIO ECONOMIC, CULTURAL AND ENVIRONMENTAL ASSESSMENT

A. Type of family

 What type of family do you have?

 Are you married/unmarried but living together?
 Do you have any children? If yes, how many?
 Who lives in the house aside from the first family?
B. Dominant family member(s) in terms of decision-making especially to health care.

 Who is the member of the family that principally makes the decisions?
 Who is the concerned about the condition of each family member?
 Aside from the said member who principally makes the decision, who takes charge if
he/she is not present?
C. Source of income, expenditures-Adequacy to meet basic needs-Any financial assets available
in case of emergency

 Who among the family members are the source of income?

 How much is the total income do you have in a month?
 How do you divide your budget with the expenses daily, weekly and monthly?
 Do you think the budget that is allotted for the family monthly is enough?
 Do you have savings in case there is an emergency that will occur? If no, to whom you
ask money from?
D. Working hours

 How many hours do you work everyday?

 If you don’t have any work, what do you do in your leisure time?
 How do you spend your free time with your family?
E. Ethnic background and religious affiliation

 Where is the family originally located from?

 If you came from another place, why did you transfer?
 What is the religion of the family?
 Do you have any beliefs that you practice?
 How do you practice your religion?
F. Significant others’ role/s in the family life?
  What kind of support or contribution your signicant other/s give you? (Economical,
Financial, Emotional)
 If financial what kind?

G. Health habits and beliefs

 What interventions or in simple way, what are the practices you do whenever someone
is sick (ex: fever, wounded, high blood pressure?
 Do you seek a physician as soon as medications given or interventions provided seems
to have no effect? If yes, where? If not, what are the reasons why you do not seek
Physicians as soon as possible especially if it is needed? Or do you seek a “doctor
quack”?
 Instead of a physician or community health nurses at a Health center?
What are the example interventions or suggested practice your quack doctor suggests?
(Site examples and ask for its rationale)
 Do you buy medications over the counter and self medicate the sick? If yes, please
indicate the usual medications taken and the conditions that these medicines believe to
treat.
H. Family’s involvement in community activities

 If your barangay is conducting activities or programs do you or someone in your family

actively participates?
 What are the usual programs that your barangay conducts and you are aware of?
I. Family’s utilization of community resources

 What are the resources your barangay have? (Health center, barangay hall, basketball
court, playground, grocery stores, etc.)
 What are the resources said above you used or usually visit?
J. Housing
1. Type of Building

 What is the house made from? Is it made of concrete, wood, galvanized iron, hollow
blocks.
 Does the house provide an adequate space?
How many adults, children, infant are living in their house
2. Sleeping Arrangement

 Where does each member of the family sleeps?

 Are they comfortable in their place?
  Do they sleep in a foam, sofa, bed, “papag” or floor?
 Is their sleeping arrangement safe for them especially to the children/infant?
3. Adequacy of Furniture

 What are the specific furnitures present in the house? Name them each and describe.
4. Presence of insects and rodents

 Do you notice vectors and possible diseases in their are?

 Where do you see these insects to be possibly dwelling or living?
 What measurements can they do to avoid the presence of rodents, vectors and possible
diseases?
5. Accident hazards

 What are the things or conditions that may precipitate to the family? Enumerate and
describe why do you think these may precipitate among the families.
 Ask if the family/ anyone from them had experienced injury, falls, fire, and accident?
 How it had started/happened and how they have recovered from it?
6. Food sources, storage and cooking facilities

 What are your typical food sources?

 How do you usually prepare your food?
 If they are usually cooking for their food, in what type of preparation? (How they buy ,
store, and cooking management)
 What are the usually foods they eat?
 How many times do they eat per day?
 Do they consume adequate fluids needed?
 What are the types of food they avoid and why? (Is it about just their preference, price,
or tradition and beliefs)
7. Water supply

 What is the main source of your water supply (for hygiene and household chores)
 What is the main source of your drinking water
 Where do you store your drinking water?
 Inspect their drinking / hygiene water. State your observations here.
8. Toilet facility

 Ask what type of toilet practice they have? Is it a usual toilet CR, cat hole, throw method
(balot) etc.
 Let them explain their practice in terms of toilet facility and their ownership if it is a
owned or shared bathroom.
  Evaluate their toilet facility/practice is it poor, fair or good?
 Ask the type (open or closed, flowing or stagnant) and sanitary condition of the
household’s drainage system they have.
9. Social and health facilities available

 Ask if the family is using club houses, basketball courts, function halls, health center,
hospitals, clinics etc.
 Ask how they are using the facilities they have mentioned (specific time, event, and
need)
10. Communication and transportation facilities

 What are the family’s way of transportation?

If they commute? What type of public transport they usually use? (PUVs, tricycles, bus,
jeepney etc.)
 How far they do they usually travel using this transportation facilities?
 Let them enumerate the ways in which the family communicates with the other
members of the family or their significant others. It may be through cellular phones,
land line, internet, etc.