INTRODUCTION

It is said that in community health nursing, the family will be considered as a client aside
from individual clients in the family. Family Nursing Care Plan is the outline of the care that the
nurse designs to systematically minimize or eliminate the identified health and family nursing
problems through clearly expressed formulated outcomes of care such as the goals and
objectives and deliberately chosen set of interventions, resources and evaluation criteria,
standards, methods and tools.
This study is focuses on Ramos family a residence of Malakas St., Pinyahan, Quezon City.
We chose this family as we identified the health problems in our group. They have the most
serious health problem among our group that needed an immediate family nursing care plan.
This study will also give them some solutions and actions for them to cope up with their health
problem. Also, through this method, we can provide awareness to the family that there’s
something we can do to help them.

We provided information for better understanding our patient’s situation. In this Family
diagnosis, we achieved added knowledge about the problem, where we gathered the family’s
health information.
 CHAPTER 1
INITIAL DATA BASE

A. Family Structure and Characteristics

Family Name: Ramos Family
Type of Family: Extended
For many Filipinos, it’s not a surprise at all to see extended families living together and
supporting each other as this has been their way of life since they were born.
Traditionally, families in the Philippines are commonly made up of extended family
members, which may include grandparents, aunts, uncles, nephews, and nieces. They have
stronger family ties and a more reliable support network when it comes to emotional, financial,
and moral support – especially when it matters most.

Family Members Age Sex Civil Status Relationship

Annabel Ramos 44 Female Single Mother
Ma. Solidad Antonio 37 Female Married Aunt
(Separated)
Vian Antonio 18 Female Single Cousin
Alexia Celis 15 Female Children Cousin
Janniyah Bandal 8 Female Children Cousin

This type of family is extended which the head of the family, Ms. Annabel Ramos (44),
live together with her sibling, Ms. Ma. Solidad Antonio (37) and her nieces, Vian Antonio (18),
Alexia Celis (15) and Janniyah Bandal (8). They live at Malakas St., Pinyahan, Quezon City. Based
on the interview, the siblings live together with their children because since they’re both single,
it is easier and convenient for them to share financial expenses.
One of the primary benefits of living with an extended family is that it reduces the
family’s financial strain as it's more affordable option. Also, cousins are childhood playmates
who grow up to be forever friends.

According to Ms. Annabel Ramos, family members are your first line of defense against
stress, sadness, and disappointment. Knowing that they’re around and you can reach them
24/7 can make you feel better in an instant. With this, other members of the family agree and
happy living together under the same roof.

B. Socio-Economic and Cultural Factors

Socio-economic and cultural factors are said to be one of the great influencers of a
person’s health. They are both constantly evolving over time. They affect a person’s quality of
living and perception towards health, illness, where to seek medical help, and the types of
treatment patients prefer. Here are the determinants and factors that affect a person’s health:

• Income and expenses – these include the occupation, adequacy to meet basic
necessities and the one who makes decisions about money in the family.
• Educational attainment – this can lead to more accurate health beliefs and
knowledge, and thus to better lifestyle choices, but also to better skills and
greater self-advocacy.
• Ethnic background and religious affiliation – beliefs and practices enhance
health and wellbeing. They affect the person’s perceptions of pain, symptoms,
and beliefs about the causes of illness and its course.
• Family Traditions – these are the events or practices affecting member’s health
or family functioning and they affect the perceptions of how to handle health,
illness and death in the family.
• Significant Others - Studies have shown, time and time again, that people who
are in satisfying relationships feel happier, have fewer problems with health, and
live longer.
• Relationship of the family to larger community – Nature and extent of
participation of the family in community activities.
• Physical Environment - important things to have a good helth includes harmful
substances, such as air pollution or proximity to toxic sites, access to various
health-related resources such as healthy or unhealthy foods, recreational
resources and medical care, and community design and the “built environment”
such as land use mix, street connectivity and transportation systems.
• Employment and working conditions - these have powerful effects on health
equity because good working conditions can provide social protection and
status, personal development opportunities, and protection from physical and
psychosocial hazards.
 Family Educational Occupation Place of Religion Income
Member Attainment Work
Annabel Ramos Bachelor Work from At Home Roman Php20,000 to
Degree Home Catholic Php35,000
Ma. Solidad Antonio Bachelor Part Time - At Home Roman Php35,000 to
Degree Work from Catholic Php45,000
Home
Part Time –
Online
Business
Vian Antonio College Student ____ Roman ____
Student Catholic
Alexia Celis High School Student ____ Roman ____
Student Catholic
Janniyah Bandal Elementary Student ____ Roman ____
Student Catholic

SOCIO ECONOMIC STATUS

Family Ramos depends on the monthly salary of Ms. Annabel Ramos and Ms. Ma.
Solidad Antonio, who both have Bachelor’s Degree. They don’t have problem when it comes to
their financial; wherein they both have enough income to sustain their family needs, education
of their children, house rent and other expenses.
One of the benefits of education is the possibility of earning a higher income. An
educated person has a better chance of getting a higher paying job. Health is more than just
health care—it is clear that education, among many other social determinants of health,
matters to health outcomes. The association between education and health has upstream
causes, such as the economic and social conditions young children experience before reaching
school age, the skills and networks they build as they mature, and the jobs and resources they
can access later in life.
 C. Environmental Factors
According to World Health Organization (WHO), environmental risk factors such as air,
water and soil pollution, chemical exposures, climate change, and ultraviolet radiation
contribute to more than 100 diseases and injuries worldwide. In 2012, an estimated 12.6
million people died as a result of living or working in an unhealthy environment, that’s nearly 1
in 4 global deaths. The Philippines is not spared from this burden with environmental risk
factors contributing to at least 22% of the reported disease cases and nearly 6% of reported
deaths in 2006.
Many things in the environment can affect our health. Hazardous substances found in
the air, soil and water can originate from a variety of sources, such as agricultural and industrial
activities, mining operations, landfills and leaky underground storage tanks. Health officials
work with individuals, communities, government agencies and industries throughout the state
to reduce or eliminate exposure to substances that could be harmful.
Environmental factors affect human health in important ways, both positive and
negative. Positive environmental factors sustain health, and promoting them is preventive
medicine. Negative environmental factors are threats to health, and controlling them is public
environmental health.
These are the following environmental factors found in Ramos Family:

Positive Environmental Factors Negative Environmental Factors

Home Structure - concrete (rented, well-
ventilated, spacious)
Adequate living space
Sleeping arrangement – 2 spacious rooms
Absence of accidents and fire hazards
Excreta disposal — flush type
Kind of neighborhood - urban
Communication and Transportation facilities
available – car, tricycle
Presence of mosquitoes and lizards
Garbage container - open
Domestic Animal - dog
Food storage – covered (easily to get spoiled)
Drainage Facility - none
Social and heal facilities available – Health
Center
 D. Health Assessment of Each Family
Family Member: Annabel Ramos

Date of Birth: December 16, 1976

Age: 44 years old
Gender: Female
HISTORY

Ms. Annabel Ramos is a 44-year-old single mother with an asthma that she got from her
mother. Asthma is said to be a breathing disorder characterized by inflammation of the airways
and recurrent episodes of breathing difficulty. In the case of Ms. Annabel Ramos is it hereditary.
There is a positive family history of Asthma, where she got it from her mother.

She had first menstruation (menarche) when she was 14 and got pregnant when she
was 27 years old. She gave birth through normal delivery with a baby girl.
When she was young, she had experienced some episodes of asthma attacks. Her
parents would bring her to the hospital and had her medication/s.
At present, she’s still taking the same medicine whenever she asthma attack.

Salbutamol Nebuliser Solution 2.5mg - is indicated for use in the routine management
of chronic bronchospasm unresponsive to conventional therapy and the treatment of
acute severe asthma.

Other than that, she doesn’t have any other illnesses.

Family Member: Annabel Ramos
Date of Birth: December 16, 1976
Age: 44 years old
Gender: Female
GORDON’S 11 FUNCTIONAL HEALTH PATTERNS
Health Perception and Health Management
Nutrition and Metabolism
Elimination Pattern
Activity and Exercise Pattern
Cognition and Perception
Sleep and Rest Pattern
Self- Perception and Self- Concept
Roles and Relationship
Sexuality and reproduction
Coping and Stress Tolerance
Values and Belief Religion
When sick or having asthma attack/s, she
goes to a private doctor to have a check-up
and takes her medicine.
Eats her meal three times a day, most of the
times she eats meats, fish, fruits and
vegetables. Drinks 8 or more glasses of water
a day.
She has 6 to 8 times of urination. She has at
least 1 bowel movement every day. Pale
yellow color of urine.
She has no regular exercise, she just staying
at home most of the day.
She doesn’t have problems in her senses; her
speech and recognition are good; gives
appropriate facial expression based on the
situation.
She sleeps 6 to 8 hours a day; has 2 days of
rest day from work.
She has a lot of good values and experiences
to share with others; she strongly believes in
herself.
She has a good and strong relationship with
her daughter, sister, and nieces.
She has 1 pregnancy with 1 living daughter;
she had her menarche at the age of 14.
She stays positive; keeps herself busy and
doesn’t want to be affected by the problems
she/they has/have.
Religion: Roman Catholic, believes in God and
goes to church (before), but now attends
online mass.
 DATA BASE: PHYSICAL EXAMINATION
(Head-to-Toe Assessment)
Family Member: Annabel Ramos

Date of Birth: December 16, 1976

Age: 44 years old
Gender: Female
Vital Signs

• Temperature: 36.8 °C
• Pulse Rate: 78 beats per minute
• Respiratory Rate: 15 beats per minute
• Blood Pressure: 120/80 mm Hg

AREA METHOD FINDINGS INTERPRETATION

Integumentary Inspection and Skin complexion is At 40 or 45, women
Skin Palpation fair. lose the
Has an equally warm subcutaneous fat
temperature on both under the cheekbone
arms and legs. Skin with causes a general
deflation of the skin.
still feels a little dry,
There is a loss of
supple, bouncy and
about 30-40% of the
firm.
collagen that is
responsible for the
youthfulness and the
tighter look of the
skin.
Hair Inspection Hair color is black Normal
and a little dry. Most women
Absence of alopecia experience a change
and hirsutism. in the texture and
appearance of their
hair as they age.
Nails Inspection Nail texture is soft Normal
and pinkish.
There is of signs of
nail breaking and
clubbing.
Head Inspection and Head is of a regular Normal
Skull and Face Palpation shape with no
 apparent lesions,
masses or foreign
bodies. Scalp no
evidence of skin
condition or
infestation, and
exhibited no
tenderness on
palpation. Cheeks are
not yet saggy, facial
movements are all
equal.
Eyes and Vision Inspection Eyes are aligned, has Normal
20-20 vision,
eyebrow is free of
scaling, pinkish
conjunctiva and
white sclera that is
normal. Extra ocular
movement (EOM) are
intact. There is no
presence of edema
and hollowness. No
evidence of increased
tearing. Pupils
equally rounded,
reactive to light and
accommodation.
Ears and Hearing Inspection and Size of ears and ear Normal
Palpation lobes are average, no
signs of deformities
and irregularities.
Mobile, firm not
tender; pinna recoils
after it is folded
Nose and Sinuses Inspection and Symmetrical, no signs Normal
Palpation of deformities.
Reddish color of the
nasal mucosa.
Absence of any
discharge, or swelling
of the mucosa,
ulcers, and polyps.
Mouth and Inspection Lips are smooth, Normal
Oropharynx reddish, and moist.
No signs of ulcers.
Gums are pinkish and
no sores.
Symmetrical tongue.
Papillae gets bigger
toward the rear of
the tongue. No signs
of ulcers or sores.
Tonsillar pillars,
tonsils are present,
uvula and pharynx.
Pinkish in color and
symmetrical.
Neck Inspection and Symmetrical with Normal
Neck Muscles Palpation head in central
position. Symmetrical
movement of neck
muscles. Movement
through full range of
motion without
complaint of
discomfort. Active
ROM; flexion,
extension, lateral
rotation and tilting.
Lymph nodes Palpation Lymph nodes Normal
non-palpable.
Trachea and Thyroid Palpation In midline position, Normal
gland non- palpable lobes,
not enlarged and
rises as patient
swallows.
Breast Inspection and Symmetrical breast Normal
Palpation and nipple. Absence
of lesions, discharge
and masses.
Chest Inspection Symmetrical Normal
respiratory effort
without the use of
accessory muscles.
Lungs Percussion and Breathing is good Normal
palpation with no other
sounds.
Cardiovascular Palpation and No extra heart Normal
System auscultation sounds and no
murmurs heard. No
jugular vein
distention at 45
degree. Point of
maximal impulse
(PMI) palpable in 5th
ICS, MCL left border
of sternum. Aortic
pulsation normal, no
bruits sound.
PULSES RADIAL POPLITEAL DORSALIS PEDIS POSTERIOR
TIBALIS
Right 2+ normal 2+ normal 1 + indicating a 1 + indicating a
faint, but faint, but
detectable pulse detectable pulse
Left 2+ normal 2+ normal 2 + suggesting a 2+ normal
slightly more
diminished pulse
than normal
AREA METHOD FINDINGS INTERPRETATION
Abdominal Inspection, Abdomen flat Normal
auscultation, contour. Negative
percussion and spleen percussion, no
palpation masses or
organomegaly. No
tenderness to
palpation. Kidney and
spleen are
nonpalpable. Normal
bowel sounds with
findings of; RLQ: 15
soft clicks/ min RUQ:
12 soft clicks/ min
LUQ: 14 soft clicks/
min LLQ: 12 soft
clicks/ min.
Genital / inguinal ____ ____ ____
Rectum, / anus ____
(client refused to
asses on this area)
MUSCULOSKELETAL
Head and neck
Left Upper Extremity
Right Upper Extremity
Spine
Right Lower Extremity
____ ____
It appears normal without evident masses,
lesions, foreign bodies or other
abnormalities. No tenderness to palpation.
The neck moves in flexion, extension,
rotation and lateral flexion. Neck and
shoulder are stable. Range of motion and
tone are within normal limits. Strength is 5/5
muscle is functioning normally and is able to
maintain its position even when maximum
resistance is applied.
It appears normal and symmetric with the
Right Upper Extremity. No evident masses,
lesions, foreign bodies or other
abnormalities. Joints are stable. Range of
motion, strength and tone within normal
limits. Strength is 5/5 means muscle is
functioning normally and is able to maintain
its position even when maximum resistance
is applied.
It appears normal and symmetric with the
Left Upper Extremity. No evident masses,
lesions, foreign bodies or other
abnormalities. Joints are stable. Range of
motion, strength and tone within normal
limits. Strength is 5/5 means muscle is
functioning normally and is able to maintain
its position even when maximum resistance
is applied.
It appears normal and aligned. No
deformities; No tenderness or swelling
It appears normal and symmetric with the
Left Lower Extremity. No evident masses,
lesions, foreign Right Lower Extremity bodies
or any abnormalities. No tenderness to
palpation. Strength is 5/5 means muscle is
functioning normally and is able to maintain
 its position even when maximum resistance
is applied.
Left Lower Extremity It appears regular and symmetric with the
Right Lower Extremity. No evident masses,
lesions, foreign bodies or any abnormalities.
No tenderness to palpation. Range of motion
and tone are within normal limits. Strength is
5/5 means muscle is functioning normally
and is able
Family Member: Ma. Solidad Antonio
Date of Birth: September 21, 1983

Age: 37 years old

Gender: Female
HISTORY
Ms. Ma. Solidad Antonio is a 37-year-old single mother with no major illness.

She had first menstruation (menarche) when she was 13 and got pregnant thrice with 3
daughters aged 18, 15, and 8. She gave birth through normal delivery with all her daughters.
In the past, she may have fever, cough, and cold, but never became severe or serious
because of proper medication.

She makes sure that she’s eating healthy food by eating meats, fish, fruits and
vegetables. She drinks 8 or more glasses of water a day. She sleeps 5 to 6 hours a day with
enough rest.
Family Member: Ma. Solidad Antonio
Date of Birth: September 21, 1983
Age: 37 years old
Gender: Female
GORDON’S 11 FUNCTIONAL HEALTH PATTERNS
Health Perception and Health Management
Nutrition and Metabolism
Elimination Pattern
Activity and Exercise Pattern
Cognition and Perception
Sleep and Rest Pattern
Self- Perception and Self- Concept
Roles and Relationship
Sexuality and reproduction
Coping and Stress Tolerance
Values and Belief Religion
When feeling sick, she goes to a private
doctor to have a check-up
Eats her meal three times a day, most of the
times she eats meats, fish, fruits and
vegetables. Drinks 8 or more glasses of water
a day.
She has 7 or more times of urination. She has
at least 1 bowel movement every day. Pale
yellow color of urine.
She has an active and busy schedule; always
moving.
She doesn’t have problems in her senses; her
speech and recognition are good; gives
appropriate facial expression based on the
situation.
She sleeps 5 to 6 hours a day; has enough
rest.
She shares her values and perception with
her daughters; her self-confidence if strong.
She has a good and strong relationship with
her daughters, and other members of the
family.
She has 3 pregnancies with 3 living
daughters.; she had her menarche at the age
of 13.
She remains calm and think of a fast solution
to the problem/s; She stays positive.
Religion: Roman Catholic, believes in God and
goes to church (before), but now attends
online mass.
 DATA BASE: PHYSICAL EXAMINATION

(Head-to-Toe Assessment)
Family Member: Ma. Solidad Antonio
Date of Birth: September 21, 1983
Age: 37 years old

Gender: Female
Vital Signs

• Temperature: 36.5 °C
• Pulse Rate: 81 beats per minute
• Respiratory Rate: 16 beats per minute
• Blood Pressure: 120/80 mm Hg

AREA METHOD FINDINGS INTERPRETATION

Integumentary Inspection and Skin complexion is At 30 or 39, women
Skin Palpation fair. lose the
Has an equally warm subcutaneous fat
temperature on both under the cheekbone
arms and legs. Skin with causes a general
deflation of the skin.
feels dry, but
There is a loss of
smooth.
about 30-40% of the
collagen that is
responsible for the
youthfulness and the
tighter look of the
skin.
Hair Inspection Hair color is brown Normal
and a little dry. Most women
Absence of alopecia experience a change
and hirsutism. in the texture and
appearance of their
hair as they age.
Nails Inspection Nail texture is Normal
smooth and pinkish.
 There is of signs of
nail breaking and
clubbing.
Head Inspection and Head is of a regular Normal
Skull and Face Palpation rounded with no
apparent edema,
lesions, masses or
foreign bodies. Scalp
no evidence of skin
condition or
infestation, and
exhibited no
tenderness on
palpation. Symmetric
facial movements.
Eyes and Vision Inspection Eyes are aligned, has Normal
20-20 vision,
eyebrow is
symmetrically
aligned, equal
movement, free of
scaling, and pinkish
conjunctiva. When
lids open, no visible
sclera above corneas
and upper and lower
borders of cornea are
slightly covered.
There is no presence
of edema and
hollowness. No
evidence of
increased tearing.
Pupils equally
rounded, reactive to
light and
accommodation.
Ears and Hearing Inspection and Color same as facial Normal
Palpation skin. Size of ears and
ear lobes are
average, no signs of
deformities and
irregularities. Mobile,
firm not tender;
 pinna recoils after it
is folded.
Nose and Sinuses Inspection and Symmetrical and Normal
Palpation straight, no signs of
deformities. Reddish
color of the nasal
mucosa. Absence of
any discharge, or
swelling of the
mucosa, ulcers, and
polyps.
Mouth and Inspection Lips are smooth, Normal
Oropharynx reddish, and moist.
No signs of ulcers.
Gums are pinkish and
no sores.
Symmetrical tongue.
Papillae gets bigger
toward the rear of
the tongue. No signs
of ulcers or sores.
Neck Inspection and Symmetrical with Normal
Neck Muscles Palpation head in central
position. Symmetrical
movement of neck
muscles. Active ROM;
flexion, extension,
lateral rotation and
tilting.
Lymph nodes Palpation Lymph nodes Normal
non-palpable.
Trachea and Thyroid Palpation In midline position, Normal
gland non- palpable lobes,
not enlarged and
rises as patient
swallows.
Breast Inspection and Generally Normal
Palpation symmetrical breast
and nipple. Absence
of lesions, discharge
and masses.
Chest Inspection Symmetrical Normal
respiratory effort
 without the use of
accessory muscles.
Lungs Percussion and Breathing is good Normal
palpation with no other
sounds.
Cardiovascular Palpation and No extra heart Normal
System auscultation sounds and no
murmurs heard. No
jugular vein
distention at 45
degree. Point of
maximal impulse
(PMI) palpable in 5th
ICS, MCL left border
of sternum. Aortic
pulsation normal, no
bruits sound.
PULSES RADIAL POPLITEAL DORSALIS PEDIS POSTERIOR
TIBALIS
Right 2+ normal 2+ normal 2+ normal 2+ normal
Left 2+ normal 2+ normal 2+ normal 2+ normal
AREA METHOD FINDINGS INTERPRETATION
Abdominal Inspection, Abdomen flat Normal
auscultation, contour. Negative
percussion and spleen percussion, no
palpation masses or
organomegaly. No
tenderness to
palpation. Kidney and
spleen are
nonpalpable. Normal
bowel sounds with
findings of; RLQ: 15
soft clicks/ min RUQ:
12 soft clicks/ min
LUQ: 14 soft clicks/
min LLQ: 12 soft
clicks/ min.
Genital / inguinal ____ ____ ____

Rectum, / anus ____ ____ ____

(client refused to
asses on this area)
 MUSCULOSKELETAL
Head and neck
Left Upper Extremity
Right Upper Extremity
Spine
Right Lower Extremity
It appears normal without evident masses,
lesions, foreign bodies or other
abnormalities. No tenderness to palpation.
The neck moves in flexion, extension,
rotation and lateral flexion. Neck and
shoulder are stable. Range of motion and
tone are within normal limits. Strength is 5/5
muscle is functioning normally and is able to
maintain its position even when maximum
resistance is applied.
It appears normal and symmetric with the
Right Upper Extremity. No evident masses,
lesions, foreign bodies or other
abnormalities. Joints are stable. Range of
motion, strength and tone within normal
limits. Strength is 5/5 means muscle is
functioning normally and is able to maintain
its position even when maximum resistance
is applied.
It appears normal and symmetric with the
Left Upper Extremity. No evident masses,
lesions, foreign bodies or other
abnormalities. Joints are stable. Range of
motion, strength and tone within normal
limits. Strength is 5/5 means muscle is
functioning normally and is able to maintain
its position even when maximum resistance
is applied.
It appears normal and aligned. No
deformities; No tenderness or swelling
It appears normal and symmetric with the
Left Lower Extremity. No evident masses,
lesions, foreign Right Lower Extremity bodies
or any abnormalities. No tenderness to
palpation. Strength is 5/5 means muscle is
functioning normally and is able to maintain
its position even when maximum resistance
is applied.
 Left Lower Extremity It appears regular and symmetric with the
Right Lower Extremity. No evident masses,
lesions, foreign bodies or any abnormalities.
No tenderness to palpation. Range of motion
and tone are within normal limits. Strength is
5/5 means muscle is functioning normally
and is able

Family Member: Vian Antonio

Date of Birth: February 1, 2002
Age: 18 years old
Gender: Female
HISTORY
Ms. Vian Antonio is an 18-year-old college student with no major illness.

She had first menstruation (menarche) when she was 13.

In the past, she may have fever, cough, and cold, but never became severe or serious
because of proper medication.
 She has an active lifestyle. She eats healthy food like meats, fish, fruits and vegetables.
She drinks 8 or more glasses of water a day. She sleeps 8 hours or more a day with enough rest.
She works out 3 times a week for 30 minutes.

Family Member: Vian Antonio

Date of Birth: February 1, 2002
Age: 18 years old
Gender: Female

GORDON’S 11 FUNCTIONAL HEALTH PATTERNS

Health Perception and Health Management
Nutrition and Metabolism
When feeling sick, she goes to a private
doctor to have a check-up
Eats her meal three times a day with snack in
between, most of the times she eats meats,
fish, fruits and vegetables. Drinks 8 or more
glasses of water a day.
 Elimination Pattern
Activity and Exercise Pattern
Cognition and Perception
Sleep and Rest Pattern
Self- Perception and Self- Concept
Roles and Relationship
Sexuality and reproduction
Coping and Stress Tolerance
Values and Belief Religion
She has 5 or more times of urination. She has
at least 1 bowel movement every day. Pale
yellow color of urine.
She works out 3 times a week for 30 minutes;
makes sure to have an active lifestyle.
She doesn’t have problems in her senses; her
speech and recognition are good; gives
appropriate facial expression based on the
situation.
She sleeps 8 hours a day; has enough rest.
She values her parent’s teachings and
perception in life; she has a strong self-
esteem.
She has a good and strong relationship with
her mother, and other members of the
family.
She has never got pregnant and started her
menarche at the age of 13.
She makes sure to solve her problem/s right
away and stays clam during stressful
situation.
Religion: Roman Catholic, believes in God and
goes to church (before), but now attends
online mass with family.

DATA BASE: PHYSICAL EXAMINATION

(Head-to-Toe Assessment)

Family Member: Vian Antonio

Date of Birth: February 1, 2002
Age: 18 years old
Gender: Female

Vital Signs

• Temperature: 36.6 °C
• Pulse Rate: 78 beats per minute
 • Respiratory Rate: 16 beats per minute
• Blood Pressure: 110/80 mm Hg

AREA METHOD FINDINGS INTERPRETATION

Integumentary Inspection and Skin complexion is At the age of 18 and
Skin Palpation fair. having a healthy
Has an equally warm living reflects
temperature on both through a person’s
arms and legs. Skin skin.
feels smooth, glows,
and firm.
Hair Inspection Hair color is black, Normal
bouncy, and shiny. Most women with
Absence of alopecia proper lifestyle and
and hirsutism. hair regimen has a
healthy hair.
Nails Inspection Nail texture is Normal
smooth. Convex
curvature shaped;
angle of nail plate
about 160°. Absence
of breaking.
Head Inspection and Symmetric features; Normal
Skull and Face Palpation palpebral fissures
equal in size. No sign
of edema. Symmetric
facial movement.
Eyes and Vision Inspection Has 20-20 vision, Normal
eyebrows are
symmetrically
aligned, equal
movement, free of
scaling, and pinkish
conjunctiva. When
lids open, no visible
sclera above corneas
and upper and lower
borders of cornea are
slightly covered.
Absence pf edema
and hollowness. No
evidence of
increased tearing.
 Pupils constrict when
looking at near
object; pupils dilate
when looking at far
objects.
Ears and Hearing Inspection Color same as facial Normal
skin. Symmetrical,
Auricle aligned with
outer canthus of eye.
Nose and Sinuses Inspection and Symmetrical and Normal
Palpation straight. No
discharge or flaring.
Uniform color. Not
tender; no lesions.
Nasal Septum intact
and in midline.
Mouth and Inspection Moist, smooth, soft, Normal
Oropharynx glistering, and elastic
texture. Teeth are
clean and complete.
No sores and ulcers.
Neck Inspection and Muscles equal in size; Normal
Neck Muscles Palpation head centered.
Coordinated, smooth
movements with no
discomfort. Head
flexes, hyperextends,
laterally flexes, and
laterally rotates.
Lymph nodes Palpation Not palpable. Normal
Trachea and Thyroid Inspection and Central placement in Normal
gland Palpation midline of neck;
spaces are equal on
both sides. Glands
not visible and
ascends during
swallowing.
Breast Inspection and Generally Normal
Palpation symmetrical breast
and nipple. Absence
of lesions, discharge
and masses.
Chest Inspection Symmetrical Normal
respiratory effort
without the use of
accessory muscles.
Lungs Percussion and Quiet, rhythmic, and Normal
palpation effortless
respirations.
Cardiovascular Inspection No pulsations in Normal
System Palpation and aortic and pulmonic
auscultation areas. Pulsations
visible in apical area.
PULSES RADIAL POPLITEAL DORSALIS PEDIS POSTERIOR
TIBALIS
Right 2+ normal 2+ normal 2+ normal 2+ normal
Left 2+ normal 2+ normal 2+ normal 2+ normal
AREA METHOD FINDINGS INTERPRETATION
Abdominal Inspection, Unblemished skin. Normal
auscultation, Uniform color. No
percussion and signs of stretch
palpation marks. Flat, rounded,
or scrap hold. No
evidence of
enlargement of liver
or spleen. Symmetric
contour. Symmetric
movements caused
by respiration. No
visible vascular
pattern. Audible
vowel sounds.
Absence of friction
rub. Tympany over
the stomach and gas-
filled bowels,
dullness, especially
over the liver and
spleen, or a full
bladder. No
tenderness; relaxed
abdomen with
smooth, consistent
tension.
Genital / inguinal ____ ____ ____
Rectum, / anus ____
(client refused to
asses on this area)
MUSCULOSKELETAL
Head and neck
Left Upper Extremity
Right Upper Extremity
Spine
Right Lower Extremity
____ ____
It appears normal without evident masses,
lesions, foreign bodies or other
abnormalities. No tenderness to palpation.
The neck moves in flexion, extension,
rotation and lateral flexion. Neck and
shoulder are stable. Range of motion and
tone are within normal limits. Strength is 5/5
muscle is functioning normally and is able to
maintain its position even when maximum
resistance is applied.
It appears normal and symmetric with the
Right Upper Extremity. No evident masses,
lesions, foreign bodies or other
abnormalities. Joints are stable. Range of
motion, strength and tone within normal
limits. Strength is 5/5 means muscle is
functioning normally and is able to maintain
its position even when maximum resistance
is applied.
It appears normal and symmetric with the
Left Upper Extremity. No evident masses,
lesions, foreign bodies or other
abnormalities. Joints are stable. Range of
motion, strength and tone within normal
limits. Strength is 5/5 means muscle is
functioning normally and is able to maintain
its position even when maximum resistance
is applied.
It appears normal and aligned. No
deformities; No tenderness or swelling
It appears normal and symmetric with the
Left Lower Extremity. No evident masses,
lesions, foreign Right Lower Extremity bodies
or any abnormalities. No tenderness to
palpation. Strength is 5/5 means muscle is
 functioning normally and is able to maintain
its position even when maximum resistance
is applied.
Left Lower Extremity It appears regular and symmetric with the
Right Lower Extremity. No evident masses,
lesions, foreign bodies or any abnormalities.
No tenderness to palpation. Range of motion
and tone are within normal limits. Strength is
5/5 means muscle is functioning normally
and is able
Family Member: Alexia Celis
Date of Birth: April 24 2005

Age: 15 years old

Gender: Female

HISTORY

Ms. Alexia Celis is a 15-year-old high school student with no major illness.
She had first menstruation (menarche) when she was 13.
In the past, she may have fever, cough, and cold, but never became severe or serious
because of proper medication.

She has an active lifestyle. She eats healthy food like meats, fish, fruits and vegetables.
She drinks 8 or more glasses of water a day. She sleeps 8 hours or more a day with enough rest.
She has regular exercise.
Family Member: Alexia Celis
Date of Birth: April 24 2005
Age: 15 years old
Gender: Female
GORDON’S 11 FUNCTIONAL HEALTH PATTERNS
Health Perception and Health Management
Nutrition and Metabolism
Elimination Pattern
Activity and Exercise Pattern
Cognition and Perception
Sleep and Rest Pattern
Self- Perception and Self- Concept
Roles and Relationship
Sexuality and reproduction
Coping and Stress Tolerance
Values and Belief Religion
When feeling sick, she goes to a private
doctor to have a check-up
Eats her meal three times a day with snack in
between, most of the times she eats meats,
fish, fruits and vegetables. Drinks 8 or more
glasses of water a day.
She had 7 to 9 times of urination. She has at
least 1 bowel movement every day. Pale
yellow color of urine.
She has regular exercise; busy with her online
classes.
Speak well and clear, doesn’t have any
sensory deficit.
She sleeps 8 hours a day; has enough rest.
She strongly believes in herself. Motivated.
She has a good and strong relationship with
her mother, sisters, aunt and cousin.
She has never got pregnant and started her
menarche at the age of 13.
She keeps herself busy doing her school
activities and she enjoys watching television.
Religion: Roman Catholic, believes in God and
goes to church (before), but now attends
online mass with her family.
 DATA BASE: PHYSICAL EXAMINATION

(Head-to-Toe Assessment)
Family Member: Alexia Celis
Date of Birth: April 24 2005
Age: 15 years old

Gender: Female
Vital Signs

• Temperature: 36.6 °C
• Pulse Rate: 79 beats per minute
• Respiratory Rate: 15 beats per minute
• Blood Pressure: 100/70 mm Hg

AREA METHOD FINDINGS INTERPRETATION

Integumentary Inspection and Skin complexion is Normal
Skin Palpation fair.
Has an equally warm
temperature on both
arms and legs. Skin
feels smooth, glows,
and firm.
Hair Inspection Hair color is brown, Normal
bouncy, and shiny.
Evenly distributed
Thick and silky hair
Absence of hirsutism.
Nails Inspection Smooth texture Normal
Intact epidermis
Prompt return of
pink or usual color
when nails press.
Head Inspection and Symmetric features; Normal
Skull and Face Palpation palpebral fissures
equal in size. No sign
of edema. Symmetric
facial movement.
Eyes and Vision Inspection Has 20-20 vision, Normal
eyebrows are
symmetrically
aligned, equal
movement, free of
scaling, and pinkish
conjunctiva. When
lids open, no visible
sclera above corneas
and upper and lower
borders of cornea are
slightly covered.
Absence pf edema
and hollowness. No
evidence of
increased tearing.
Pupils constrict when
looking at near
object; pupils dilate
when looking at far
objects.
Ears and Hearing Inspection and Color same as facial Normal
Palpation skin. Symmetrical,
Auricle aligned with
outer canthus of eye.
Mobile, firm not
tender; pinna recoils
after it is folded
Nose and Sinuses Inspection and Symmetrical and Normal
Palpation straight. No
discharge or flaring.
Uniform color. Not
tender; no lesions.
Nasal Septum intact
and in midline.
Mouth and Inspection Moist, smooth, soft, Normal
Oropharynx glistering, and elastic
texture. Teeth are
clean. No sores and
ulcers.
Neck Inspection and Muscles equal in size; Normal
Neck Muscles Palpation head centered.
Coordinated, smooth
 movements with no
discomfort. Head
flexes, hyperextends,
laterally flexes, and
laterally rotates.
Lymph nodes Palpation Not palpable. Normal
Trachea and Thyroid Inspection and Central placement in Normal
gland Palpation midline of neck;
spaces are equal on
both sides. Glands
not visible and
ascends during
swallowing.
Breast Inspection and Generally Normal
Palpation symmetrical breast
and nipple. Absence
of lesions, discharge
and masses.
Chest Inspection Symmetrical Normal
respiratory effort
without the use of
accessory muscles.
Lungs Percussion and Quiet, rhythmic, and Normal
palpation effortless
respirations.
Cardiovascular Inspection No pulsations in Normal
System Palpation and aortic and pulmonic
auscultation areas. Pulsations
visible in apical area.
PULSES RADIAL POPLITEAL DORSALIS PEDIS POSTERIOR
TIBALIS
Right 2+ normal 2+ normal 2+ normal 2+ normal
Left 2+ normal 2+ normal 2+ normal 2+ normal
AREA METHOD FINDINGS INTERPRETATION
Abdominal Inspection, Unblemished skin. Normal
auscultation, Uniform color. No
percussion and signs of stretch
palpation marks. Flat, rounded,
or scrap hold. No
evidence of
enlargement of liver
or spleen. Symmetric
 contour. Symmetric
movements caused
by respiration. No
visible vascular
pattern. Audible
vowel sounds.
Absence of friction
rub. Tympany over
the stomach and gas-
filled bowels,
dullness, especially
over the liver and
spleen, or a full
bladder. No
tenderness; relaxed
abdomen with
smooth, consistent
tension.
Genital / inguinal ____ ____ ____

Rectum, / anus ____ ____ ____

(client refused to
asses on this area)

MUSCULOSKELETAL
Head and neck It appears normal without evident masses,
lesions, foreign bodies or other
abnormalities. No tenderness to palpation.
The neck moves in flexion, extension,
rotation and lateral flexion. Neck and
shoulder are stable. Range of motion and
tone are within normal limits. Strength is 5/5
muscle is functioning normally and is able to
maintain its position even when maximum
resistance is applied.
Left Upper Extremity It appears normal and symmetric with the
Right Upper Extremity. No evident masses,
lesions, foreign bodies or other
abnormalities. Joints are stable. Range of
motion, strength and tone within normal

Right Upper Extremity
Spine
Right Lower Extremity
Left Lower Extremity
Family Member: Janniyah Bandal
Date of Birth: January 8, 2012
Age: 8 years old
Gender: Female
limits. Strength is 5/5 means muscle is
functioning normally and is able to maintain
its position even when maximum resistance
is applied.
It appears normal and symmetric with the
Left Upper Extremity. No evident masses,
lesions, foreign bodies or other
abnormalities. Joints are stable. Range of
motion, strength and tone within normal
limits. Strength is 5/5 means muscle is
functioning normally and is able to maintain
its position even when maximum resistance
is applied.
It appears normal and aligned. No
deformities; No tenderness or swelling
It appears normal and symmetric with the
Left Lower Extremity. No evident masses,
lesions, foreign Right Lower Extremity bodies
or any abnormalities. No tenderness to
palpation. Strength is 5/5 means muscle is
functioning normally and is able to maintain
its position even when maximum resistance
is applied.
It appears regular and symmetric with the
Right Lower Extremity. No evident masses,
lesions, foreign bodies or any abnormalities.
No tenderness to palpation. Range of motion
and tone are within normal limits. Strength is
5/5 means muscle is functioning normally
and is able
 HISTORY
Ms. Janniyah Bandal is an 8-year-old elementary school student with no major illness.
She has never experienced her menarche yet.

In the past, she may have fever, cough, and cold, but never became severe or serious
because of proper medication.
She’s very active because she likes playing around. She eats healthy food like meats,
fish, fruits and vegetables. She drinks 8 glasses of water a day. She sleeps 8 hours or more a day
with enough rest.

Family Member: Janniyah Bandal

Date of Birth: January 8, 2012

Age: 8 years old
Gender: Female

GORDON’S 11 FUNCTIONAL HEALTH PATTERNS

 Health Perception and Health Management
Nutrition and Metabolism
Elimination Pattern
Activity and Exercise Pattern
Cognition and Perception
Sleep and Rest Pattern
Self- Perception and Self- Concept
Roles and Relationship
Sexuality and reproduction
Coping and Stress Tolerance
Values and Belief Religion
DATA BASE: PHYSICAL EXAMINATION
(Head-to-Toe Assessment)
Family Member: Janniyah Bandal
Date of Birth: January 8, 2012
When feeling sick, she goes to a private
doctor to have a check-up
Eats her meal three times a day with snack in
between, most of the times she eats meats,
fish, fruits and vegetables. Drink 8 glasses of
water a day.
She has 5 to 7 times of urination. She has at
least 1 bowel movement every day. Pale
yellow color of urine.
She’s very active because she likes playing
around; she is also busy with her online
classes.
Speak well and clear, doesn’t have any
sensory deficit.
She sleeps 8 hours or more a day; has enough
rest.
She follows her mother’s command; she’s
starting to have self-confidence.
She has a good and strong relationship with
her mother, sisters, aunt and cousin.
She has never got pregnant and no menarche
yet.
She likes playing and she enjoys watching
television.
Religion: Roman Catholic, believes in God and
goes to church (before), but now attends
online mass with her family.
Age: 8 years old
Gender: Female
Vital Signs

• Temperature: 36.9 °C
• Pulse Rate: 75 beats per minute
• Respiratory Rate: 19 beats per minute
• Blood Pressure: 110/70 mm Hg

AREA METHOD FINDINGS INTERPRETATION

Integumentary Inspection and Skin complexion is Normal
Skin Palpation fair.
Has an equally warm
temperature on both
arms and legs. Skin
feels so smooth,
glows, and firm.
Hair Inspection Hair color is brown, Normal
bouncy, and shiny.
Evenly distributed
Thick and silky hair
Absence of hirsutism.
Nails Inspection Smooth texture Normal
Intact epidermis
Prompt return of
pink or usual color
when nails press.
Head Inspection and Symmetric features; Normal
Skull and Face Palpation palpebral fissures
equal in size. No sign
of edema. Symmetric
facial movement.
Eyes and Vision Inspection Has 20-20 vision, Normal
eyebrows are
symmetrically
aligned, equal
movement, free of
scaling, and pinkish
conjunctiva. When
lids open, no visible
sclera above corneas
and upper and lower
 borders of cornea are
slightly covered.
Absence pf edema
and hollowness. No
evidence of
increased tearing.
Pupils constrict when
looking at near
object; pupils dilate
when looking at far
objects.
Ears and Hearing Inspection and Color same as facial Normal
Palpation skin. Symmetrical,
Auricle aligned with
outer canthus of eye.
Mobile, firm not
tender; pinna recoils
after it is folded
Nose and Sinuses Inspection and Symmetrical and Normal
Palpation straight. No
discharge or flaring.
Uniform color. Not
tender; no lesions.
Nasal Septum intact
and in midline.
Mouth and Inspection Moist, smooth, soft, Normal
Oropharynx glistering, and elastic
texture. Teeth are
clean. No sores and
ulcers.
Neck Inspection and Muscles equal in size; Normal
Neck Muscles Palpation head centered.
Coordinated, smooth
movements with no
discomfort. Head
flexes, hyperextends,
laterally flexes, and
laterally rotates.
Lymph nodes Palpation Not palpable. Normal
Trachea and Thyroid Inspection and Central placement in Normal
gland Palpation midline of neck;
spaces are equal on
both sides. Glands
 not visible and
ascends during
swallowing.
Breast Inspection and Generally Normal
Palpation symmetrical breast
and nipple. Absence
of lesions, discharge
and masses.
Chest Inspection Symmetrical Normal
respiratory effort
without the use of
accessory muscles.
Lungs Percussion and Quiet, rhythmic, and Normal
palpation effortless
respirations.
Cardiovascular Inspection No pulsations in Normal
System Palpation and aortic and pulmonic
auscultation areas. Pulsations
visible in apical area.
PULSES RADIAL POPLITEAL DORSALIS PEDIS POSTERIOR
TIBALIS
Right 2+ normal 2+ normal 2+ normal 2+ normal
Left 2+ normal 2+ normal 2+ normal 2+ normal
AREA METHOD FINDINGS INTERPRETATION
Abdominal Inspection, Unblemished skin. Normal
auscultation, Uniform color. No
percussion and signs of stretch
palpation marks. Flat, rounded,
or scrap hold. No
evidence of
enlargement of liver
or spleen. Symmetric
contour. Symmetric
movements caused
by respiration. No
visible vascular
pattern. Audible
vowel sounds.
Absence of friction
rub. Tympany over
the stomach and gas-
filled bowels,

Genital / inguinal ____
Rectum, / anus ____
(client refused to
asses on this area)
MUSCULOSKELETAL
Head and neck
Left Upper Extremity
Right Upper Extremity
dullness, especially
over the liver and
spleen, or a full
bladder. No
tenderness; relaxed
abdomen with
smooth, consistent
tension.
____ ____
____ ____
It appears normal without evident masses,
lesions, foreign bodies or other
abnormalities. No tenderness to palpation.
The neck moves in flexion, extension,
rotation and lateral flexion. Neck and
shoulder are stable. Range of motion and
tone are within normal limits. Strength is 5/5
muscle is functioning normally and is able to
maintain its position even when maximum
resistance is applied.
It appears normal and symmetric with the
Right Upper Extremity. No evident masses,
lesions, foreign bodies or other
abnormalities. Joints are stable. Range of
motion, strength and tone within normal
limits. Strength is 5/5 means muscle is
functioning normally and is able to maintain
its position even when maximum resistance
is applied.
It appears normal and symmetric with the
Left Upper Extremity. No evident masses,
lesions, foreign bodies or other
abnormalities. Joints are stable. Range of
motion, strength and tone within normal
limits. Strength is 5/5 means muscle is
functioning normally and is able to maintain
 its position even when maximum resistance
is applied.
Spine It appears normal and aligned. No
deformities; No tenderness or swelling
Right Lower Extremity It appears normal and symmetric with the
Left Lower Extremity. No evident masses,
lesions, foreign Right Lower Extremity bodies
or any abnormalities. No tenderness to
palpation. Strength is 5/5 means muscle is
functioning normally and is able to maintain
its position even when maximum resistance
is applied.
Left Lower Extremity It appears regular and symmetric with the
Right Lower Extremity. No evident masses,
lesions, foreign bodies or any abnormalities.
No tenderness to palpation. Range of motion
and tone are within normal limits. Strength is
5/5 means muscle is functioning normally
and is able