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Republic of the Philippines

Tarlac State University

College of Science

Department of Nursing

Lucinda Campus, Brgy. Ungot, Tarlac City Philippines 2300

Accredited Level 3 Status by the Accrediting Agency of Chartered Colleges and Universities in
the Philippines (AACUP), Inc.

A Family Case Study presented to the Faculty of the


Tarlac State University
College of Science, Department of Nursing

In Partial Fulfillment of the Requirements of the Subject


Community Health Nursing

PRESENTED BY:
Bato, Carl Jacob Numos
Castro, Jonah Jireh Garcia
Domingo, Tricia Anne
Dueñas, Christine Pauline Deang
Dupitas, Erica Kate Quinto
Fabian, Nicah Lynn Bejamae Cayabyab

Presented to
Mr. Jomer V. Manalang, RN, MAN
Ms. Flora M. Tel-Equen
Mrs. Rowena B. Lamorena
Ms.Marie Jennielyn V. De Ocampo

Presented on
(Date)
I. BACKGROUND OF THE FAMILY

The Mujar family consists of five (5) members. The father and head of the family is Mr.
Anthony Mujar, 43 years old, Ilocano, and born in Victoria, Tarlac. While the mother is Ms.
Michelle Marinay, a 37-year-old woman, Tagalog who is born in Batangas. Although they are
still not yet married, they already have three children; Nathaniel M. Mujar (7 years old), Nathalie
M. Mujar (6 years old), and Nicole M. Mujar (5 years old). For 7 years they have been residing
in Cabuluan, Victoria, Tarlac. Since then, they are a nuclear family as the family only consists of
parents and their children. Ms. Marinay is the one who manages and handles the money of the
family, which falls under a family system of matriarchal. When it comes to family decisions, only
the parents are responsible for the decision-making, since their children are still minors, and
they have a strong marital relationship. In terms of the family’s financial status, the father is the
only one who is working, and he is the one who fulfills their financial needs as a farmer. The
father has a monthly income of 7,000 and their sole expenses come from the daily allowances
of the children, their everyday food, and electricity. On the other hand, the mother is the one
who handles the majority of the household duties, giving care to the children and primarily
supervising the health of the whole family. Approvingly, all of the family members have no vices.
In addition, the parents both received the COVID-19 vaccine, but the children are still not
vaccinated because they are still underage. They also have a strong faith in God, in which they
attend church near their vicinity, while their religion is Born Again Christian.

Based on the collected data from the Mujar family, the floor area is ample for the whole
family and their house has poor ventilation since they only have 4 windows in total. Additionally,
their open drainage poses a threat to the Mujar family's health because it contributes to
mosquito nesting sites. They owned their house but the land is still named under Mr. Anthony’s
parents on the legal document. Also, their house was made of semi-permanent and light
materials which cause it to be prone to accident hazards and risk for disaster. When it comes to
water, the family uses a well pump built by the Barangay as their source of drinking water, and
for their bath water. Unfortunately, they currently do not have electricity because they have not
paid the electricity bill for the past 2 months. Since they use well-pump, they use a pail system
for their excreted waste and use the toilet of their neighborhood which means it is a shared
toilet. For their garbage disposal, they commonly burn or dump their garbage but sometimes
they segregate it properly and then wait for the garbage collector every week. The family does
not own any pets, but rather, their major problem comes from the mosquitoes and cockroaches
present in their environment. Concerning their health, both parents do not have any vices in
smoking, drinking alcohol, etc. But their children usually develop colds and they have poor
personal hygiene. They are lacking in medical sources at home. Fortunately, they do not inherit
a hereditary disease from their ancestor. Lastly, according to the computed Body Mass Index
(BMI), the family is all in a normal range except for the mother and their youngest daughter.
They are lacking in water intake and also have poor nutrition as poverty is their most pressing
problem.
II. INTRODUCTION

The word "community" is understandable. By its core, the word unites us. Community has
a diverse definition. The Latin words "Com" and "Munis," which mean "together" and "servicing,"
respectively, are the root of the word "community”. Both an emotion and a network of
interpersonal connections exist inside communities. Communities are places where people feel
safe, trusted, and cared for by one another. The members understand that they can affect the
environment and one another as a group and as individuals by being a part of it. (Chavis,2015)

According to the American Nursing Asouth-EastANA, 2017), Community Health Nursing


which is also known as Public Health Nursing, is defined as the implementation of enhancing
and maintaining the health status of the individuals of the community holistically by considering
all the dimensions of health using the knowledge acquired from nursing, social, and public
health sciences. Additionally, Community Health Nursing primarily focuses on a systematic
process of promoting and providing health services and nursing care in order to enhance the
general health of the community (WHO, South - East Asia) Furthermore, the goal is “To raise
the level of the citizenry by helping communities and families to cope with the discontinuities in
and threats to health in such a way as to maximize their potential for high-level wellness”
( Nisce, et al).

Family on the other hand, as stated by Thomas et al., (2017) plays a central role in
determining and shaping a person's well-being during the course of their life. Through each
stage of life, family members are connected in significant ways, and these interactions are a
significant source of social influence and connection for people, thus it can have an impact on
well-being through psychological, behavioral, and physiological processes. Over the period of
time, family connections frequently get more complicated as people age, with perhaps
complicated marriage histories, diverse relationships with children, conflicting time pressures,
and care commitments.

The province of Tarlac is located in the Central Luzon region of the Philippines, taking up
most of the island of Luzon. From the north, it is surrounded by Pangasinan, Nueva Ecija,
Pampanga, and Zambales. 3,046.49 square kilometers, or 1,176.26 square miles, make up its
land area. 1,503,456 people were living there as of the 2020 Census. There is one city and 17
municipalities in Tarlac. There are 511 barangays in the province as a whole. The Philippine
province of Tarlac is a landlocked one, and one of its municipalities is called Victoria. It is
situated in the Central Luzon region and had 69,370 residents as of the 2020 Census. It is made
up of 26 barangays, one of which is Barangay Cabuluan, which has 1,498 residents. This
accounted for 2.16% of Victoria's entire population. In the 2015 Census, there were 335
households with a total of 1,339 people living there or an average of 4 people per household.
(PhilAtlas.)

In addition, the family that was chosen by the student nurse comes from the barangay
Cabuluan of Victoria, Tarlac. The Municipality of Victoria is geographically located in the eastern
part of Tarlac Province. It is bounded by the Municipalities of Guimba and Licab, Nueva Ecija in
the East, the City of Tarlac in the West, the municipalities of Gerona and Pura, Tarlac in the
North, and the municipality of La Paz in the South. Today Victoria is a melting pot for
Kapampangans and Ilocanos. The former is mostly found in the western part of the town while
the latter mostly lives in the eastern portion. Despite the two prevailing languages, which are
Ilocano and Tagalog, the latter is the common language. Being an agricultural town; festivals,
fiestas, and practices are directly linked with farming. Food, recipes, and delicacies reflect the
major crops being produced. Cabuluan is a barangay in the municipality of Victoria, in the
province of Tarlac. Its population as determined by the 2020 Census was 1,498. This
represented 2.16% of the total population of Victoria. The household population of Cabuluan in
the 2015 Census was 1,339 broken down into 335 households or an average of 4.00 members
per household. Its land area is 254.16 sq. meters and the percent of the land to the Municipality
of Victoria is 2.14%. Cabuluan is situated at approximately 15.5443, 120.6799, on the island of
Luzon. Elevation at these coordinates is estimated at 31.2 meters or 102.4 feet above mean sea
level. It shares a common border with Barangay Batangbatang, San Jacinto, Cruz, Lalapac, and
Balayang.

The student nurses have selected the Mujar family as their chosen family. They are
residents of the same towns where the family case study respondents are from; Cabuluan,
Victoria, Tarlac. As the student nurses visited this five-person family in their modest home, we
saw a number of health problems. Such as a lack of essential health information, environmental
and surrounding difficulties, and other elements or challenges influencing the family's health. To
address the healthcare needs of this family, various nursing interventions are necessary. Later
on, it is anticipated that nursing services including health promotion, health maintenance,
environmental sanitation, and health awareness would be provided. The family's situation will be
improved with the help of appropriate education, the availability of resources that promote
health, and adequate health awareness.

III. OBJECTIVES
General:

At the end of the student-family relationship, the student nurses will be able to have
complete knowledge and understanding regarding the health condition of the adopted family.
Hence, they will be able to devise an effective nursing care plan and implement the proper
nursing interventions that the family needed for their health and environmental problems.
Meanwhile, the adopted family will be able to perform health teaching pertaining to different
health problems and improve their health status by maintaining their health through all the
interventions and teachings accomplished by the student nurses.

Specific:
1. To build a good relationship and mutual understanding between the student nurse and
the family.
2. To assess the current state of health of the chosen family.
3. Identify health, environmental and other factors that may harm the family.
4. To enhance the knowledge of the family towards health and provide health teachings to
inform them of the risk factors that could affect their health as a whole.
5. To establish nursing interventions by taking into account the resources of the chosen
family, community, and student nurses.
6. To help the chosen family in preserving and protecting its members' health and in
promoting personal care.

Family based:
After the student-nurse family interaction, the family should be able to:
1. Exhibit trust and understanding with the student nurse.
2. Provide relevant and accurate information when conducting assessment and interviews.
3. Determine the present and possible problems that make it difficult for them to maintain
their optimal state of health.
4. Identify the effectiveness of the nursing interventions by applying the predetermined
objectives as a basis.
5. Improve their way of understanding that health should be their primary priority.
6. Evaluate whether there are any changes in the family’s health condition after providing
proper health teaching and nursing intervention.

IV. INITIAL DATABASE


A. Family structure, Characteristics, and Dynamics

Family Member Position Sex Age Civil status Education attainment


in the
family

Anthony Mujar Father M 43y/o Single High School Graduate

Michelle Marinay Mother F 36y/o Single 2nd year High School

Nathaniel M. Mujar Son M 7y/o Single Grade 2

Nathalie M. Mujar Eldest F 6y/o Single Grade 1


Daughter

Nicole M. Mujar Youngest F 5y/o Single N/A


Daughter

Table 1: Family structure, Characteristics, and Dynamics of Mujar Family

Interpretation:
The Mujar family is thought to have a nuclear family structure, with a mother, a father, and
three children. Each member of the family has a certain responsibility. The family's head, Mr.
Anthony Mujar, has served as the family's provider and the household's top authority, the
mother, Ms. Michelle Marinay, has looked after the family's physical needs and been in charge
of its mental well-being. Nathaniel M. Mujar, Nathalie M. Mujar, and Nicole M. Mujar are their
three offspring, and they are expected to obey their parental direction and leadership. They
have lived in Cabuluan, Victoria, Tarlac, for seven years. To meet the financial necessities of
their family, only Mr. Mujar works. Regarding the family's finances, Ms. Marinay received all of
the family's earnings to allocate the family's monthly expenses. Although the couple may have
distinct roles within the family hierarchy, they both have the last say in family matters.

Norms:

A nuclear family is a unit of the family that only consists of a father, a mother, and their
offspring. In this type of family structure, the male is typically the primary provider and the head
of the home, while the female takes on the role of homemaker and operates within a
subordinate role to the husband. Furthermore, there is a widespread perception that the nuclear
family structure is superior to other family structures since intact families are linked to better
child outcomes as well as higher levels of parental participation, routine, and stability, (Bryant,
L,E. 2016).

Analysis:

The Mujars are classified as a nuclear family. Because their family consists of only their
parents. (Father and Mother) They also have three children. Typically, the father meets the
majority of the family's financial needs. The mother is in charge of the children and the house
the majority of the time. And when it comes to power, both are responsible for making critical
decisions for the sake of their children and the entire family.
B. Genogram
C. Socio-Economic and Cultural Characteristics

Family member Educational Occupation Ethnic Background Religion


Attainment

Anthony Mujar High School Farmer Ilocano Born Again


Graduate Christian

Michelle Marinay 2nd year High N/A Tagalog Born Again


School Christian

Nathaniel M. Mujar Grade 2 N/A Ilocano Born Again


Christian

Nathalie M. Mujar Grade 1 N/A Ilocano Born Again


Christian

Nicole M. Mujar Not Attending N/A Ilocano Born Again


School Christian

Table 2: Socio-Economic and Cultural Characteristics of Mujar Family

Interpretation:

Mr. Anthony Mujar is the one working for the family as a farmer, and her partner Ms.
Michelle Marinay is the one tasked with managing their finances. Mr. Anthony was a high school
graduate while Ms. Michelle is a high school undergraduate; their eldest Son Nathaniel is in
second grade, Nathalie their second born is a first grader, while their youngest daughter Nicole
is not attending school at this time, nonetheless, she will enroll next year for kindergarten. The
whole family considered themselves as Ilocano based on their ethnic origin, other than Ms.
Michelle who was born and raised in Batangas and classified themselves as Tagalog. Also, the
whole family's religion is Born Again Christian they attend church near their house, and from
time to time they attend bible study.

Monthly Expenses of the family:

Expenditures Estimated Monthly Allotted Prioritization (1-5)


Budget

Food Php. 3,700.00 2

Electricity Php. 60.00 3

Daily Allowance of Children Php. 1,000.00 1

Transportation Php. 0.00 4

Vices Php. 0.00 5

Total: Php. 4,760.00

Table 3: Monthly Expenditures of the family

Interpretation:

The family’s main provider, Mr. Mujar, is in charge of the family's finances. He earns an
estimated monthly salary of Php.7,000.00. Ms. Marinay (mother) is in charge of handling their
finances, however. She claimed that they put a monthly budget allocation of 1,000.00 for the
children's daily allowances, followed by Php. 3,700.00 total for food with Php.1,700.00 for rice
and Php. 2,000.00 for viands. Since their electricity bill only costs 60 pesos, it is one of their
least priority. The family just typically walks; they do not have any expenses for transportation.
None of them have any vices.

Total monthly income of the family

Anthony Mujar - Php. 7,000.00


Michelle Marinay - Php. 0.00

Total: Php. 7,000.00

Total monthly income x 12 months = Total Annual/household family income

Php. 7,000 x 12 months = 84,000

Total annual family income/ number of the members of the family = Total per Capita
Income
Php. 84,000/5 = 16,800
Expenses of each family member Php. 16,800
─ Monthly income of the family. Php. 7,000
Total = Php.9,800 [lacking income of the family]

= Estimated monthly income - Estimated total monthly expenditures

= Php. 7,000 ─ Php. 4,760

= Php. 2,240 (not lacking)

Norms:

From January to December 2021, Filipino households' average annual income was
expected to be PhP 307,19,000. This was -2.0 percent less than the average household income
of PhP 313.35k during the same time period in 2018. The average family expenditure in the
Philippines was PhP 228.80 thousand in 2021, down -4.1 percent from the average family
expenditure of PhP 238.64 thousand from January to December 2018. (Philippine Statistics
Authority, 2021)

Analysis:
The Mujar family makes Php. 7,000 per month and they earn Php. 84,000 annually. Their
earnings fall short of the specified quota as the average yearly income of Filipino households is
307,19,000. The family's monthly income of Php 7,000 is not enough to cover each member's
needs when compared to the expected costs of Php 16,800 for each family member. On the
other hand, their monthly income is sufficient to cover their expenses because there is still Php.
2,240 extra.

D. Home Environment

Type of house Owned

Type of Dwelling (House materials) Semi-permanent (combination of permanent


and temporary materials)

Overcrowding Absent

Ventilation Poor

Lighting Adequate

Kitchen Type Dirty Kitchen

Bathroom Shared

Bedroom Shared

Drainage Open but poorly maintained

Source of drinking Local deep well/water pump

Disposal of Waste Burning and Open Dumping

Vectors present Mosquitoes, Termites, and Flies

Power Source N/A

Backyard Garden Fair (Minimal dirt visible)

Acdidents Hazard Present

General Cleanliness Fair (Minimal dirt visible in and outside of


household)

Table 4: Environmental Aspect of Romano Family

Interpretation:

The family Mujar resides in Cabuluan, Victoria, Tarlac. They have been living there for
years. The house itself is a semi-permanent type of house having a combination of permanent
and temporary materials with locally crude materials such as bamboo, wooden planks, and iron
sheets. The overall structure is made from hollow blocks, bamboo, and cement. Some termites
house the woods and bamboo. The structure of the house poses a risk if a disaster occurs.

The deep wells in the neighborhood serve as the family's water source. They usually
keep it in a jug because this is their main source of drinking water. Additionally, they utilize it as
their water for laundry, dishwashing, and bathing.

The dirty kitchen of the Mujar family has wood-burning stoves that are separated from the
main home which is beside it. The reason for separating the kitchen includes
fire prevention, preventing the smoke and coal odor out of the household, and maintaining
charcoal particles and oil grease out of the house. However, they also have a dining room in
their kitchen. This means that the family can inhale toxic gasses from the charcoal when
someone is cooking. Flies surrounded the exposed leftovers. Which means that their kitchen is
unsanitary.

The bedroom is shared by the family. Clothes that have been folded were scattered
across the bed and there is no door. They have a bamboo-stick bed with a cushion, a few
pillows, and blankets. Their sleeping arrangements are somewhat cramped, leaving little room
for movement. Their unprotected water storage was right next to the window of their bedroom,
making it a potential mosquito breeding place. As a result, the family uses a mosquito coil
“kulambo” constantly to keep insects away from the house during the night.
With their neighbors, the household shares a bathroom and a comfort room. One of their
regular tasks was to make sure the shared bathroom/comfort room was clean. The family
mentions that they maintain their bathroom and comfort room clean so that other people can
use it. Their comfort room and the bathroom had a dry floor that wasn't covered in urine, didn't
smell, didn't have flies, or had any excreta on the floor. However, there is no permanent door,
and they just have a cover made of bamboo sticks that have been wrapped in a blanket.

The family's drainage system is an open one in which the drainage is continuous and
flows in all directions. Their wastes are burned and dumped as disposal methods. Although
there are several animals from their neighbors, the family does not have any pets or farm
animals of their own. In the vicinity of the house and in front of the house, numerous plants have
been planted, mosquitoes and other vector insects can therefore survive in their outside
environment. Additionally, because their house is on the same level as the land, flooding is a
threat.

They only have Ms. Mujar's (mother's) cell phone for communication; no additional
equipment or gadgets are available. They only have one television, but their electricity is
currently out. They also do not have internet access. Their phone is being charged with the
assistance of their neighbors.

The family does not own any transportation vehicle. When they need to get somewhere
in the community, they take a kuliglig. When they go outside of Victoria or the city proper, they
usually rent a tricycle. However, they normally walk, especially to school and work.

CROWDING SPACE STANDARD: (Concepts and Guidelines in COPAR, 1ST Edition, 2005
by Untalan) Formula:

TOTAL WINDOW OPENING = 4


Formula:
Ventilation =2/TFAx100

TOTAL FLOOR AREA (TFA)


TFA = length x width of the house
TFA=9.017m x5.1024m=46 sq.m

TOTAL SPACE REQUIREMENT (TSR)

Standard:
Adults – 3.0 sq. m
Children – 1.5 sq. m
Infant ─ 0

No. of adults in Mujar family = 2 x 3.0 sq. m = 6 sq. m


No. of children in Mujar family = 3 x 1.5 sq. m = 4.5 sq. m

TSR = 10.5 sq. m

Interpretation:

TFA>TSR = not overcrowded


TSR>TFA = overcrowded
TFA (46 sq.m ) > TSR (10.5 sq.m): NOT OVERCROWDED

Norms:

Household crowding is a condition where the number of occupants exceeds the capacity of
the dwelling space available, whether measured as rooms, bedrooms, or floor area, resulting in
adverse physical and mental health outcomes. Crowding is a result of a mismatch between the
dwelling and the household. In order to establish clear guidance on minimizing the health risks
associated with crowding, a systematic review of the evidence was commissioned. Accessible
housing should consider other factors related to healthy housing in addition to usability for
occupants. If providing a household with an accessible dwelling entails people moving to
another location, it could potentially remove them from social networks, child care support, and
work or educational opportunities, affecting health and earning opportunities. Each Member
State should choose an appropriate way to measure the amount of crowding in a household,
including a threshold that can be used to define a household as “crowded”. Implementing
agencies can draw on a range of existing measures of crowding to determine a measure
appropriate to their context. (Geneva: World Health Organization, 2018)

Analysis:

Mujar Family’s house is not overcrowded since their Total Floor Area (TFA) is greater
than Total Space Requirements (TSR), this indicates that their house has sufficient space for
their family of five (5)

VENTILATION (V)

Interpretation:
20% - Satisfactory
18% - 19% - Fair
Below 18 % - Poor
TFA = 46 sq.m
Total No. of windows: 4
Formula:
Ventilation = TWO / TSR x 100
TWO: total area of windows (L x W)

Computations:
WO (window openings)
W1 = 1.60m x 1.22m = 1.952
W2 = 1.05m x 0.30m = 0.315
W3 = 1.07m x 1.05m = 1.124risk for their three children to acquire asthma and allergies, as well
as respiratory and lung
W4 = 1.07m x 1.05m = 1.124
Total Window Opening (TWO) = 4.515 sq. m
Ventilation = TWO/TSR x100
= 4.515 sq. m ÷ 10 sq. m x 100
= 0.4515 sq. m x 100
= 45.15% = SATISFACTORY VENTILATION

Norms:

The air flow in buildings and houses that results from the air pressure difference at the
openings is known as natural ventilation this includes doors, windows, and corridors. Thus, in
order to maintain a normal climate and fresh, clean air in the room, the exchange of indoor and
outside air flow can lower the room's temperature and remove moisture as stated by Geng-
Yang et al., (2022). Furthermore, there is a recent study in Finland that shows 58% of
classrooms suffer from insufficient ventilation, also teachers' respiratory symptoms are
significantly associated with classroom ventilation. They discovered that paint odors, mold, and
moldy odors, and reported dust and dust reservoirs are associated with one or more perceived
symptoms. Sick building syndrome (SBS) symptoms have been linked to sensations of stuffy
air, dry air, and electricity Winqvist, et al., (2018)

Analysis:

With the computations above, it has been shown that the Marinay – Mujar family’s house
has Satisfactory ventilation, hence there is enough fresh air coming from the outside. With this,
there is enough ventilation to keep and maintain fresh, and clean air in the room.
A. Health Status of each family member

13 Areas of Assessment

Name: Anthony Mujar


Age: 43 years old

Area of assessment Findings Norms Analysis

● Social Status
Mr. Anthony Mujar does not always Social standing is referred
Allthough Mr. Mujar does not always
interact with other people other than to as the honor
interact
or with other people, his
those he works with in the farm where distinction associated
attitude
with towards his family and co-
he spend most of his time, according one's place in society.
worker
As a represent good relationship.
to him; he go straight home from the son or daughter, playmate,
farm wherein he got to spend time with student, etc., it can also
his family, and on some occasion he refer to a status or position
drop by at school to pick up his one holds within a group.
children. Also, he attends bible study (Libretexts, 2021)
every Friday with Ms. Marinay near
their house.
Mental Status Looks comfortable or
Mr. Mujar came home from the The client presents himself in
uncomfortable built; physical
farm earlier than his usual time a clean and appropriate
> General Appearance appearance (approximate
schedule, the student nurse manner. He was cooperative
and height, weight, and
were able to meet him and do throughout the assessment
Behavior appearance); physical health;
the initial assessment. During hence the student nurse was
grooming; hygiene; self-care;
the initial assessment, Mr. able to obtain data needed
dressing (sufficient,
Mujar clothes are clean, his for the study from the client.
acceptable); facial
toenails and fingernails are
expressions (non-verbal ‘
newly cut however there is
expression of mood)).
visible dirt present. His skin is
(Manuel, 2021)
dry, hair is long, and has facial
hair. Throughout the
assessment Mr. Mujar is
cooperative and comfortable in Being alert means you can
answering questions, and his react correctly to the The client’s level of
answers are consistent upon situations and things around consciousness and
verifying. you. Knowing who you are, orientation is normal based
where you are, where you on the findings.
live, and what time it is

>Level of Mr. Mujar is cooperative, means that you are oriented


consciousness responds quickly, to place and time. Your
and orientation communicates very well and is capacity to be awake,

well oriented to where he is, aware, and oriented is

the date and of compromised


time when

assessment. Also, when asked consciousness is

about his personal data he was diminished. (Lights, 2019)


able to answer them and there
Whether speech is present or
are times wherein he asks
not, the rate and volume of
questions in relation to the
speech (mutism). Determine
topic.
whether it is spontaneous if it
is. Either productivity rises or
falls. Rapid or slow rate.
Speaking under pressure or
poorly. b. Speech has
changed in volume and pitch. Mr. Mujar, communicate
(Manuel, 2021) clearly and the student nurse
was able to understand him
throughout the assessment.

He was able to communicate


properly even though tagalog is
not his first language, his
words are clear to understand,
>SPEECH he delivers his words correctly
and has a good construction of
words and sentences, and is
loud enough to ear.

Emotional Status The intricate process of


He is not agitated to fear, and anxiety, During the assessment patient’s
emotional development starts
also during assessment the client is emotional status, how he interacts,
in infancy and lasts into
not showing any signs of tremors due and reacts with the questions is
maturity. Joy, rage, sadness,
to nervousness. On the other hand, within normal based on norms. On
and fear are some of the
stress due to financial difficulties the other hand, the client verbalize
earliest feelings that infants
causes him to stay awake at night as feelings of stress hence it keeps him
can detect. More complex
well as fatigue in relation to his work. awake at night.
feelings including shyness,
surprise, elation,
embarrassment, shame,
remorse, pride, and empathy
emerge as children's sense
of self grows..(Beyou, 2021)

Sensory Perception
The client eyes does not have A 20-foot distance Snellen
The client eye, eye sight, structure,
any visible signs of lesions, eye chart is used
color,toand peripheral view is within
Sense of sight
and they move in a smooth, measure visual acuity
normal
or
coordinated manner. Sclera is vision. If you have 20/20
transparent as well as the vision, you can see what a
cornea and it is smooth and "normal" person can see at
moist, iris and pupil is round, 20 feet while you are 20
equal, and uniform in color, feet away from the chart.
also pupil converges and (Atlantis Eyecare, 2021)
constrict. Mr. Mujar was tested
for visual acuity; he was able to
read the presented papers with
letters 14 inches away without
any difficulty. Also, for his
peripheral vision he was able
Your tongue contains taste
to see objects and movement
Mr. Mujar, was able to identify if the
buds, which are sensory
outside the direct line of vision.
organs that let food is sweet, sour, salty, and bitter
you
hence,
Mr Mujar was assessed for experience the flavors of client’s taste is normal.
Sense of Taste his sense of taste, sugar was sweet, salty, sour, and
used for sweet, cooked bitter. (kidshealth, 2021)
ampalaya for bitter, vinegar for
sour, and salt for salty. He was
able to identify different tastes The temporal bone
without any problem occurred. completely encloses the

inner ear. The cochlea,


Client’s
which controls hearing, and ear structure, color,

the temperature
vestibule and and hearing is within

semicircular canals, normal,


which no lesions and presence of
Ears are equal in size, skin is control balance anyandabnormalities.
smooth and there are no equilibrium, are its three
Sense of hearing nodules present, non-tender or distinct areas. The
pain when palpated, it is warm, vestibulocochlear nerve,
and intact. For gross hearing, cranial nerve VIII, is the
the patient was assessed using conduit through which the
a voice test, wherein words neural impulses from the
were whispered 1 to 2 feet inner ear regions are
away from the client where he transmitted to the
was able to repeat every word brainstem. (Lumen
from both ears. Learning)

Olfactory system, the bodily


organs responsible for
smell. The system is made
up of the nose and nasal
cavities, which support the
olfactory mucous
membrane for Thesmell
client’s nose in outer and inner
perception in theirstructure
top is normal, as well as for his
sections and servesenseas of smell he was able to
respiratory (Brittanica,
identify different smell during the
2019) assessment.

Nose was symmetrical in


appearance, no nodules,
masses, and the client did not Our skin has tactile

report any pain during receptors, which recognize


Sense of Smell
palpation. Mucosa is pink, the experience of touch.
uniform in color, and no Our mouth and hands, for
presence of upon example, have more touch
lesions
inspection. Client was able to receptors than other parts
identify the smell of perfume, of our skin. Identification of
alcohol, ointment, and food. touch, pressure, pain,
temperature, and texture
The client was able to identify the
depends on the tactile
difference between rough and
senses. (Middletown
smooth, he was also able to feel
Autism 2021) warm feeling on both hands when it
was directed to sunlight, thus tactile
is normal.

Mr Mujar was directed to close


his eyes, he was assessed for
tactile by using tissue paper for
soft texture and a rough wall
surface for rough texture. He
was able to identify the
Tactile difference on both textures

Motor Stability
The student nurse observed Not only are standing
Theandclient has a normal motor
Mr. Mujar during the sitting generally stability,
fixed was able to do full range of
assessment and remarked that positions, but also moving
motion when asked, can stand
he can stand by himself with the head, torso, orstraight
limbs with good balance.
good balance, and without any need a steady platform,
apparent difficulties. Also, which balance offers.
range of motion (ROM) was (Adolph, K.)
measured, along with the
flexion of the knees, ankles,
and feet, rotation or flexion of
the shoulders, and elbows. He
was able to move all of the
necessary body components.

Body Temperature 1st day of Assessment: 36.9 °c Normal body temperature


Although the client’s temperature on
varies by person, age,
activity, and time of day. The
assessment is low considering
2nd day of Assessment: 35.6 average normal body
that the client just finished taking a
°c temperature is generally
bath after temperature was obtained,
accepted as 98.6°F (37°C).
hence body temperature is normal
3rd day of Assessment: Some studies have shown
according to baseline data.
that the "normal" body
temperature can have a wide
range, from 97°F (36.1°C) to
99°F (37.2°C) (MedicinePlus,
2021)

Respiratory Status 1st day of Assessment: 19bpm


The amount of breaths
Theyou
client’s respiratory status is
take each minute is referred
normal, he has a 18, and 19 breaths
2nd day of Assessment:
to as your respiratory
perrate.
minute during 1st and 2nd
18bpm
Adults typically breathe
assessment
12 and the normal
to 20 times per minute
respiratory
while rate is 12 – 20 hence it is
3rd day of Assessment:
at rest. While resting,
withinannormal range.
abnormal respiration rate is
one that is less than 12 or
greater than 25 breaths per
minute. (ClevelandClinic,
2021)

Circulatory Status 1st day of Assessment: A blood pressure reading of


Mr. Mujar’s pulse rate per minute is
120/80 is considered normal.
PR: 94bpm within normal range, on the other
Heart rate, also called pulse,
hand there is inconsistency to the
BP: 110/80 mmHg is the number of times your
client’s blood pressure, there is only
heart beats per minute. Heart
two available data, thus further
rate can change based on
2nd day of Assessment: assessment of blood pressure is
activity level, age,
needed although assessment phase
medication, and other factors
PR: 84bpm has ended.
throughout life. For most
adults, a resting heart rate of
50 to 100 beats per minute is
BP: 150/100 mmHg
considered normal. People
who exercise regularly often
have lower resting heart

3rd day of Assessment: rates. (Oklahoma Heart


Hospital, 2017)

Nutritional Status
According to Mr. Mujar, he eats three Nutritional status hasSince
been the client does not eat junk
times per day; most of the time each defined as an individual's
foods, only contain and eat nutritious
meal includes fish and vegetables, health condition asfood,
it isand body max index is within
however, he rarely eats chicken, pork, influenced by the normal
intake based on client’s height and
beef and fruits. The client drinks 2 and utilization of nutrients
weight, with that nutritional status is
liters of water every day, he does not (Todhunter, 1970).normal,
In on the other hand the client
have any vices or he does not drink theory, optimal nutritional
is encourage to eat pork, meat, and
alcohol and use cigarettes. He weighs status should be attained
chicken once in a while to have a
54.7 kg height is 171 cm and his body by consuming sufficient,
balance
but diet.
mass index is 18.71 not excessive, sources of
energy, essential nutrients,
and other food components
(such as dietary fiber) not
containing toxins or
contaminants.(National
Research Council (US)
Committee on Diet and
Health.Washington)

Elimination Status The client urinate 5 times a day


There is no “normal”
Client’s elimination status is normal.
the color is clear to yellowish,
number of bowel
and according to Mr. Mujar no
movements. Many
presence of bad odor, also he
healthcare providers agree
defecate once a day but there
that healthy bowel
are times that he defecate
once every other day.
movement frequency can
range from three times a
day to three times a week.
However, your 'normal'
pattern may be different
from these numbers. To
say that a person’s bowel
movements have become
more frequent is based on
an increase in that person’s
usual pattern, not on a
standard definition that
applies to everyone.
(Cleveland Clinic)

Reproductive Status Human reproductive system,


According to the client at aged 11 he The client does not have sexually
organ system by which
was circumcised, he has no history or transmitted disease, provided that
humans reproduce and bear
current presence of Sexually he has already 3 children hence
live offspring. Provided all
transmitted disease. They have 3 reproductive status is normal
organs are present, normally
children all of whom were born alive.
constructed, and functioning
properly, the essential
features of human
reproduction are liberation of
an ovum, or egg, at a specific
time in the reproductive
cycle, internal fertilization of
the ovum by spermatozoa, or
sperm cells, transport of the
fertilized ovum to the uterus,
or womb (Harrison, 2021)
Sleep-rest Pattern
The client usually sleeps at 7:00 pm, Getting a healthy amount
Clientofhas a steady sleep pattern, he
there are times that he was awaken at sleep is a key partwas
of able
a to sleep 9 hours every day,
night by mosquitos but after a minute good sleep pattern.withThethat being said sleep-rest
or so he will go back to sleep. He National Sleep Foundation
pattern is normal
wakes up 4:00 am the next day. First recommends that most
thing he do in the morning is to drink adults get between 7 and 9
coffee and cook meal for the family, hours of sleep each night
after that he will go to the farm where and that older adults over
he works. 65 years of age get
between 7 and 8 hours.
The rapid growth and
development of youth
means that children need
additional hours of sleep,
with specific
recommendations varying
by age. Babies might need
up to 17 hours per night,
while the range for teens is
8 to 10 hours. (Fry, 2021)

State of Skin
The student nurse assessed Skin: The client’s skin is The Client skin shows no
Appendages
Mr Mujar for skin appendages; uniform in color, visible signs of cyanosis,
upon inspection his skin is dry unblemished and no pallor, or jaundice, with
but uniform in color no signs of presence of any foul odor. hair, no signs of
jaundice, pallor, or cyanosis, He has a good skin turgor kwashiorkor, alopecia, and
no visible lesions and edema and skin’s temperature is hirsutism. However, skin is
upon palpation. within normal limits. dry, hair has visible lesions
on scalp, and nails show
Hair: The hair of the client is
signs of koilonychia. Other
thick, silky hair is evenly
than this stated problem,
distributed and has a skin appendages are
variable amount of body normal.
His hair is black in color, evenly
hair. There are also no
distributed, no dandruff present
signs of infection and
upon inspection however there
infestation observed.
are some lesions in some
areas. Hair texture is not dry, Nails: The client has light
no presence of kwashiorkor, brown nails and has the
alopecia, and hirsutism. shape of a convex curve. It is
smooth and is intact with the
epidermis. When nails are
pressed between the fingers
(Blanch Test), the nails
The student nurse assessed return to usual color in less
client’s nail, nail plate shape is than 4 seconds. (Vera, 2020)
half-moon, texture is smooth at
fingernails but rough on
toenails, fingernail bed is about
160° however client’s toenail is
showing signs of Koilonychia
as evidence by concave nails.

Name: Michelle Marinay


Age: 36 years old
Area of assessment Findings Norms Analysis

Social Status Ms. Marinay was born on Ms. Marinay typically


Social standing is
January 24, 1986, and is 36 remains at home. She
referred to as the
years old. Together with her has time to establish a
honor or distinction
family, she is presently positive rapport with the
associated with
residing in Cabuluan, Victoria, community.
one's place in
Tarlac. Because her husband
society. As a son or
does not want her to work and
daughter, playmate,
instead focuses only on caring
student, etc., it can
for their three children, she is
also refer to a status
presently a housewife. She
or position one
has time to interact with others
holds within a group.
because she is a housewife,
(Libretexts, 2021)
especially with her neighbors
when she is doing outdoor
domestic duties in the
morning. She is strict with her
kids at home, yet she is still
able to communicate with
them. Conflicts are easily
resolved and she does not
argue with his husband. Her
mother, her family, and her
friends make up her support
network.

Mental Status Looks comfortable or Throughout the


uncomfortable built; interview. The client was
> General Appearance and She was sweeping outdoors physical appearance attentive and capable of
Behavior when we first met her, so her (approximate height, responding to all of the
clothing is not decent, but her weight, and questions. She didn't
finger and toe nails are clean. I appearance); physical have decent grooming,
felt that her skin was a little bit health; grooming; and she didn't look bad
dry and that she had some lice hygiene; self-care; overall.
in her hair. She only made it dressing (sufficient,
through the second year of acceptable); facial
high school, according to Ms. expressions (non-
Marinay, but she can still read verbal expression of
and write. The entire interview mood)). (Manuel,
process is very cooperative 2021)
from her.
During the interview, Ms.
>Level of consciousness To every inquiry that was Marinay was able to
Being alert means
and orientation asked to her, she had an respond to the query
you can react
answer. She was able to clearly. She was also
correctly to the
answer questions regarding attentive and well-
situations and things
her name, her residence, her focused throughout the
around you.
husband, her children and visit.
Knowing who you
other critical questions about
are, where you are,
herself and, most importantly,
where you live, and
her family, precisely and fast.
what time it is means
She spoke well and
that you are oriented
>SPEECH She speaks in a way that can could be heard.
to place and time.
be heard by others. Additionally, she was
Your capacity to be
Nevertheless, when able to speak with the
awake, aware, and
questioned, she was still able visitor.
oriented is
to convey clear answers.
compromised when
consciousness is
diminished. (Lights,
2019)

Whether speech is
present or not, the
rate and volume of
speech (mutism).
Determine whether it
is spontaneous if it is.
Either productivity
rises or falls. Rapid or
slow rate. Speaking
under pressure or
poorly. b. Speech has
changed in volume
and pitch. (Manuel,
2021)

Emotional Status She stated that she is feeling The intricate process The emotional state of
good when I inquired about her of emotional Ms. Marinay may be
condition. If there is anything development starts in described as normal.
bothering her, such as a dread infancy and lasts into She has an innate ability
of something, worry, or maturity. Joy, rage, to feel and express
sadness, the student nurse sadness, and fear are emotions.
asked. She said that she is a some of the earliest
positive kind of person. feelings that infants
Furthermore, she said that she can detect. More
was not bothered by anything complex feelings
in particular. Her primary including shyness,
source of support during surprise, elation,
stressful times is her husband. embarrassment,
shame, remorse,
pride, and empathy
emerge as children's
sense of self grows..
(Beyou, 2021)

Sensory Perception Both her perception of


A 20-foot distance
sight and how her eyes
Snellen eye chart is
Sense of sight Ms. Marinay was instructed to seem on the outside are
used to measure
read the words on a piece of normal. According to the
visual acuity or
paper from a distance of information acquired, the
vision. If you have
approximately 14 inches for client is not color blind
20/20 vision, you
the near visual acuity test. The and has normal
can see what a
eyes' appearance was extraocular muscle
"normal" person can
examined, and it was observed movements, pupillary
see at 20 feet while
that both are symmetrical. The response, and visual
you are 20 feet
sclera is white. The various acuity.
away from the chart.
words that were written on that
(Atlantis Eyecare,
piece of paper were all
2021)
readable to her. Both pupils of
the client were able to constrict
when a light was directed at
them using a penlight. The
client can accurately state the
names of the colors that were
shown to her. Both eyes are Your tongue
free of lesions or edema. contains taste buds,
When doing the extraocular which are sensory
muscle movement test, the organs that let you
eyes move symmetrically. experience the Since the client's sense
flavors of sweet, of taste is normal, it is
Ms. Marinay was requested to salty, sour, and safe to assume that his
Sense of Taste close both of her eyes before bitter. (kidshealth, taste buds were in good
being asked to identify various 2021) shape.
food flavors, and the student
nurse used sugar for sweet,
coffee for bitter, salt for salty
The temporal bone
taste, and vinegar for sour.
completely encloses
Each taste was distinguishable
the inner ear. The
by her. Auditory acuity for the
cochlea, which
client is normal. No
controls hearing,
Sense of hearing The client was able to repeat indications of an ear
and the vestibule
all the phrases after the nurse infection were found.
and semicircular
whispered them, and she said
canals, which
that she could clearly hear
control balance and
them. She was instructed to
equilibrium, are its
repeat all the words whispered
three distinct areas.
in each ear during a non-
The
invasive exam for her auditory
vestibulocochlear
sense called the voice test
nerve, cranial nerve
(whisper test). Her external
VIII, is the conduit
ears are clean-looking, without
through which the
lesions, discomfort, swelling,
neural impulses
and they are both of equal
from the inner ear
size. The asked-for odor and
regions are
fragrance were
transmitted to the
Sense of Smell For the sensory test, aromas recognized by the client.
brainstem. (Lumen
like perfume were used. She She was able to
Learning)
closed both of her eyes before distinguish smells, as
assessing. Ms. Marinay was indicated by that.
able to recognize the
aromatics being inquired Olfactory system,
about. Nostril integrity was the bodily organs
observed. There were no signs responsible for
of tenderness, discharge, smell. The system is
trauma, bleeding, lesions, made up of the nose
tumors, edema, or asymmetry. and nasal cavities,
Her inside nose was intact. which support the
olfactory mucous The client understood
membrane for smell the question being
Tactile She was instructed to hold the perception in their posed to be aromatic.
objects and classify or top sections and He therefore has a
distinguish each one based on serve as respiratory typical sense of smell
texture. (Brittanica, 2019) and a normal-looking
nose on the outside.
Our skin has tactile
receptors, which
recognize the
experience of touch.
Our mouth and
hands, for example,
have more touch
receptors than other
parts of our skin.
Identification of
touch, pressure,
pain, temperature,
and texture depends
on the tactile
senses. (Middletown
Autism 2021)

Motor Stability Ms. Marinay can stand by Ms. Marinay is well


Not only are
herself and has balance. She coordinated and has a
standing and sitting
does not appear to be having good sense of balance
generally fixed
any trouble getting from one
positions, but also
area to another as she walks.
moving the head,
Additionally, the range of
torso, or limbs need
motion (ROM) was measured
a steady platform,
by flexing the knees, ankles,
which balance
and feet as well as rotating or
offers. (Adolph, K.)
bending the shoulders and
elbows.

Body Temperature 1st day of Assessment: Normal body Ms. Marinay is well
36.9 temperature varies by coordinated and has a
person, age, activity, good sense of balance
2nd day of Assessment: and time of day. The
37.0 average normal body
temperature is
3rd day of Assessment: generally accepted as
36.9 98.6°F (37°C). Some
studies have shown
that the "normal" body
temperature can have
a wide range, from
97°F (36.1°C) to 99°F
(37.2°C)
(MedicinePlus, 2021)

Respiratory Status 1st day of Assessment: All assessment days are


The amount of
19 bpm regarded as having a
breaths you take
normal respiratory rate.
each minute is
2nd day of Assessment: No unusual
referred to as your
18 bpm circumstances were
respiratory rate.
found.
Adults typically
3rd day of Assessment:
breathe 12 to 20
20 bpm
times per minute
while at rest. While
resting, an abnormal
respiration rate is
one that is less than
12 or greater than 25
breaths per minute.
(ClevelandClinic,
2021)

Circulatory Status 1st day of Assessment: A blood pressure The client's blood
115/80 mmHg reading of 120/80 is pressure was normal on
considered normal. the first, second, and
2nd day of Assessment: Heart rate, also called third assessment days.
120/80 mmHg pulse, is the number
of times your heart
3rd day of Assessment: beats per minute.
110/80 mmHg Heart rate can change
based on activity
level, age,
medication, and other
factors throughout life.
For most adults, a
resting heart rate of
50 to 100 beats per
minute is considered
normal. People who
exercise regularly
often have lower
resting heart rates.
(Oklahoma Heart
Hospital, 2017)

Nutritional Status She eats three times daily, Ms. Marinay is lacking
Nutritional status
according to the client, when it comes water
has been defined as
however, she consumes only intake and his diet is
an individual's
3-4 glasses of water daily. She normal.
health condition as it
has no medical history that
is influenced by the
might cause her diet to
intake and utilization
change. She followed a normal
of nutrients
diet that mostly consists of
(Todhunter, 1970).
vegetables and occasionally
In theory, optimal
includes meats like fish,
nutritional status
chicken, and pig. She does not
should be attained
have any terrible diet or
by consuming
newbie habits, according to
sufficient, but not
her as well.
excessive, sources
of energy, essential
nutrients, and other
food components
(such as dietary
fiber) not containing
toxins or
contaminants.
(National Research
Council (US)
Committee on Diet
and
Health.Washington)

Elimination Status Ms. Marinay can empty up to Ms. Marinay defecate


There is no “normal”
two times daily and typically four times a day and
number of bowel
defecates once. She has no urinates 3 up to 3 times
movements. Many
trouble urinating or defecating. a day which can be
healthcare providers
considered normal
agree that healthy
bowel movement
frequency can range
from three times a
day to three times a
week. However,
your 'normal' pattern
may be different
from these numbers.
To say that a
person’s bowel
movements have
become more
frequent is based on
an increase in that
person’s usual
pattern, not on a
standard definition
that applies to
everyone.
(Cleveland Clinic)

Reproductive Status She claimed that her first Human reproductive According to the data
period started when she was in system, organ system gathered. Her
the sixth grade of elementary by which humans reproductive status is
school, or around the age of reproduce and bear normal as evidence by
twelve. She received a live offspring. there were no history of
G3T3P0A0L3 on the OB scale. Provided all organs sexually transmitted
Absence of any sexually are present, normally disease and the by the
transmitted diseases in the constructed, and number of his children.
past. functioning properly, She and her husband
the essential features were sexually active
of human
reproduction are
liberation of an ovum,
or egg, at a specific
time in the
reproductive cycle,
internal fertilization of
the ovum by
spermatozoa, or
sperm cells, transport
of the fertilized ovum
to the uterus, or
womb (Harrison,
2021)

Sleep-rest Pattern According to the client, she


Getting a healthy
goes to bed at 10:00 p.m. and The sleeping pattern of
amount of sleep is a
wakes up at 5:00 a.m. to get the client can be
key part of a good
her kids ready for school. She considered normal as
sleep pattern. The
often takes a 30-minute evidence by their
National Sleep
afternoon sleep as she is only sleeping hours being 8
Foundation
at home. hours per day
recommends that
most adults get
between 7 and 9
hours of sleep each
night and that older
adults over 65 years
of age get between
7 and 8 hours. The
rapid growth and
development of
youth means that
children need
additional hours of
sleep, with specific
recommendations
varying by age.
Babies might need
up to 17 hours per
night, while the
range for teens is 8
to 10 hours. (Fry,
2021)
State of Skin Appendages During the evaluation, it was
Skin: The client’s According to the
noted that the client's skin tone
skin is uniform in findings. The state of
seems warm to the touch. The
color, unblemished skin appendages of the
client's nails are neatly cut and
and no presence of client is normal.
manicured. She has somewhat
any foul odor. He
dry skin but no presence of
has a good skin
wounds. The conjunctivae of
turgor and skin’s
the eyes are both rosy and
temperature is within
moist. Her hair is evenly
normal limits.
distributed throughout and is a
deep shade of black. There Hair: The hair of the
isn't much dandruff on the client is thick, silky
scalp. hair is evenly
distributed and has a
variable amount of
body hair. There are
also no signs of
infection and
infestation observed.

Nails: The client has


light brown nails and
has the shape of a
convex curve. It is
smooth and is intact
with the epidermis.
When nails are
pressed between the
fingers (Blanch Test),
the nails return to
usual color in less
than 4 seconds.
(Vera, 2020)
B. Cephalocaudal Assessment

Name: Nathaniel Mujar


Age: 7 years old

Area of assessment Findings Norms Analysis

>Skin His skin has a presence of Based on the normal


Skin color is even,
- Inspection rashes but not that many, findings, the skin of
with pigmentation
-Palpation and he has scars, mostly Nathaniel is normal but
appropriate to
from his lower extremities. because they were
genetic background
The color of his skin is always exposed to the
and no obvious
brown. When pinched, the sunlight, his skin is
lesions or color
skin springs back to the slightly darker than the
variations. Normal
previous color. Overall, his child’s race color. Also,
skin color varies
skin is smooth in texture the scars were the result
from pink, yellow,
and oily. of often playing
olive green, brown to
outdoors.
dark brown or black,
depending on the
child’s race. It is
essential to know the
child’s normal skin
color to assess for
color or pigment
changes accurately.
(Nursing Health
Assessment by
Sharon Jensen)

>Hair & Nails His hair color is black, and Based on the normal
Hair is smooth, thick,
there is no presence of findings, his hair and
and evenly
-Inspection dandruff. When it comes to nails are normal, but
distribution, his hair are only lacking when it
distributed. Nails are
evenly distributed. Also, comes to hygiene
smooth, translucent,
his hair is smooth and no considering their family
and consistent in
lice. Nails are intact with status.
color and thickness.
no convex surface, firm
Longitudinal ridging
and pinkish. But when it
is common in aging
comes to hygiene, his nails
patients.
has dirt inside.
Longitudinal
pigmentation in dark-
skinned patients is a
normal variant.
(Nursing Health
Assessment by
Sharon Jensen)

>Head His head is symmterical, The head is centered, Based on the normal
-Inspection there is no lice, dandruff proportional to the findings, the findings are
-Palpation and any lesion present. body (1/7), erect, and normal.
without tremors, tics,
or unusual
movements. The skull
is round without
obvious deformities.
The neck muscles are
symmetric. Nails are
smooth, nontender,
and firmly adherent to
the nail bed. Lateral
and proximal folds are
nontender and non-
swollen. Normally no
clubbing is present.
(Nursing Health
Assessment by
Sharon Jensen)

>Eyes The right eye is slightly Eyes are in parallel Based on the normal
-Inspection smaller than the left eye, alignment. Eyebrows findings, both eyes are
but they both dilate and show no unexplained normal but their shape is
contrict during the hair loss. Lashes asymmetrical.
asssessment. Also, his curve outward away
eyebrows and eyelashes from the eyes and are
are evenly distributed both distributed evenly
side. along the lid margins.
Eyelids open and
close completely, with
spontaneous blinking
every few seconds.
Eye shape varies
from round to almond
but is symmetrical.
(Nursing Health
Assessment by
Sharon Jensen)

>Ears His ears are big but they Ears are symmetrical, Based on the normal
-Inspection are symmetrical in size, equal size, and fully findings, both ears are
- Palpation and the color is the same formed. Facial tone is normal, but earwax is
as the face. But when it uniform with ears. present considering their
comes to hygiene, earwax Skin is intact. Ears family status and
is present on both ears. are firm without inadequate cleaning
Also, there is no discharge, lumps, lymph tissue is tools resulting from poor
and presence of redness not palpable, ears are hygiene.
and swelling. nontender, and no
pain is elicited with
palpation of the
auricle or mastoid
process. (Nursing
Health Assessment
by Sharon Jensen)

>Nose The nose has the same Based on the normal


It is symmetrical,
-Inspection color as the face, they are findings, the findings are
midline, and
-Palpation symmetric, no discharge, normal.
proportional to face.
and most importantly they
Skin surface is
are patent.
smooth without
lesions; color is
consistent with facial
complexion. There is
no pain, tenderness,
or break in contour.
Septum is midline;
mucosa is pink and
moist; and no
prominent blood
vessels or crusts.
Drainage is clear.
Airflow is adequate.
(Nursing Health
Assessment by
Sharon Jensen)

>Mouth His lips are pink, slightly Based on the normal


Lips are pink and
-Inspection dry, symmetric, and no findings, his teeth are
moist with no
presence of lesions. Gums not well aligned, and has
lesions. Buccal
and tongue are also evidence of decay. Poor
mucosa and soft and
pinkish, intact, no lesions hygiene is noted.
hard palates are pink
but his teeth has cavities
with no lesions.
and some them has dental
Gingiva is pink and
caries.
moist without
inflammation. Breath
has no foul odor.
Tongue is smooth
and midline. Teeth
are well aligned with
no evidence of
decay. Uvula rises
symmetrically with
“ah.” Ducts are
smooth without
inflammation.
Tonsils are absent.
(Nursing Health
Assessment by
Sharon Jensen)

>Thorax, Lungs, and Abdomen His breathing is stable, Findings are normal.
Skin color is
-Inspection quiet, and effortless. The
appropriate tone for
-Auscultation chest wall is intact and no
race. Expiration is
-Palpation tenderness. His abdomen
twice as long as
-Percussion has uniform color, and no
inspiration.
lesion. During palpation,
Diaphragm and
Nathaniel verbalized no
external intercostals
pain all through out the
do most of the work.
assessment. His
The patient denies
respiratory rate is within
chest pain or
normal range, and there is
discomfort, dyspnea,
no presence of abnormal
orthopnea,
lung sounds.
paroxysmal
nocturnal dyspnea,
cough, mucus,
wheezing or
tightness in chest,
and decrease in
functional ability.
Breathing, posture,
and facial
expression are
relaxed.
Respirations are 16
breaths/min without
accessory muscle
use or retractions.
Skin is pink without
cyanosis or pallor.
Symmetrical chest
shape without
kyphosis or
scoliosis. Vesicular
breath sounds over
lung fi elds. The
patient denies chest
pain or tenderness.
No crackles or
wheezes. (Nursing
Health Assessment
by Sharon Jensen)

>Extremities His extremities are all Based on the normal


Arms and hands are
-Inspection complete and equal in findings, the findings are
warm and equal in
-Palpation size. But the right leg has normal.
temperature. Patient
presence of scars. They
denies upper or
both can perform complete
lower extremity pain;
range of motion. The color
of the extremities are
no claudication,
slightly darker, but upon
coldness,
palpation Nathaniel
numbness, pallor,
verbalized no pain.
hair loss, or nail
changes in the
extremity; no color
changes related to
cold temperatures,
swelling, or redness
in fingers or toes.
Arms and legs are
symmetrical with full
joint movement.
Arms and legs pink
and smooth with no
ecchymosis or
lesions. Skin warm
and dry; good turgor.
Capillary refill in 2
seconds. Radial and
posterior tibial
pulses +3/4
bilaterally. No
edema. No
tenderness or pain.
(Nursing Health
Assessment by
Sharon Jensen)

Name: Nathalie M. Mujar


Age: 6 years old
Area of assessment Findings Norms Analysis

>Skin Inspection reveals that the Skin color is even, As the findings states,
- Inspection skin's complexion is brown with pigmentation the findings are normal.
-Palpation and shows minor scars appropriate to genetic
from wounds acquired background and no
while playing, as she obvious lesions or
stated. The skin is smooth, color variations.
firm, and adequately Normal skin color
moisturized when varies from pink,
palpating. Since there is yellow, olive green,
elasticity once the skin is brown to dark brown
pinched, the skin's turgor is or black, depending
normal. on the child’s race. It
is essential to know
the child’s normal skin
color to assess for
color or pigment
changes accurately.
(Nursing Health
Assessment by
Sharon Jensen)

>Hair & Nails Her hair is black, evenly Hair is smooth, thick, Based on the findings,
distributed, and has no and evenly the hair is dry and has
-Inspection dandruffs, but it is also distributed. Nails are presence of lice. And the
fairly dry and inhabited by smooth, translucent, nails are normal.
lice. On the other hand, and consistent in
her nails are slightly pale, color and thickness.
and a blanch test of Longitudinal ridging is
capillary refill indicated that common in aging
it took 1-2 seconds for the patients. Longitudinal
capillaries to refill. The pigmentation in dark-
nails have a firm texture skinned patients is a
and a convex shape. normal variant.
(Nursing Health
Assessment by
Sharon Jensen)

>Head Her head is symmetrical The head is centered, According to the data
-Inspection and firm. There are no proportional to the gathered. The head is
-Palpation presence of lesions on her body (1/7), erect, and normal.
scalp, but it is overall dry. without tremors, tics,
There are little amount of or unusual
dandruffs evident as well. movements. The skull
is round without
obvious deformities.
The neck muscles are
symmetric. Nails are
smooth, nontender,
and firmly adherent to
the nail bed. Lateral
and proximal folds are
nontender and non-
swollen. Normally no
clubbing is present.
(Nursing Health
Assessment by
Sharon Jensen)

>Eyes According to the PERRLA Eyes are in parallel Upon assessment, the
-Inspection (Pupils Equal, Round, alignment. Eyebrows finding indicates that
Reactive to Light and show no unexplained Nathalie’s eyes are
Accommodation) test, her hair loss. Lashes normal.
pupils are normal. The curve outward away
conjunctiva is normal, and from the eyes and are
there is no cloudiness in distributed evenly
the cornea. Her peripheral along the lid margins.
vision and eye movements Eyelids open and
are normal. Her eyebrows close completely, with
and eyelashes are also spontaneous blinking
evenly distributed. every few seconds.
Eye shape varies
from round to almond
but is symmetrical.
(Nursing Health
Assessment by
Sharon Jensen)

>Ears Her ears are symmetrical Ears are symmetrical, Based on the data
-Inspection in size. The ears have the equal size, and fully gathered, the findings
- Palpation same tone as her face. formed. Facial tone is are normal even though
Ears are firm and non- uniform with ears. there are presence of
tender but there is a Skin is intact. Ears ear wax.
presence of ear war. There are firm without
is also no difficulty in her lumps, lymph tissue is
hearing. not palpable, ears are
nontender, and no
pain is elicited with
palpation of the
auricle or mastoid
process. (Nursing
Health Assessment
by Sharon Jensen)

>Nose Her nose is symmetrical It is symmetrical, Nathalie’s nose is


-Inspection and proportional to her midline, and normal as the findings
-Palpation face. The facial tone is proportional to face. indicates.
uniform with the nose. The Skin surface is
airflow is quite inadequate smooth without
due to nasal drainage. lesions; color is
consistent with facial
complexion. There is
no pain, tenderness,
or break in contour.
Septum is midline;
mucosa is pink and
moist; and no
prominent blood
vessels or crusts.
Drainage is clear.
Airflow is adequate.
(Nursing Health
Assessment by
Sharon Jensen)

>Mouth Her lips are pink, smooth, Lips are pink and There are no abnormal
-Inspection and moist. Her gums as moist with no lesions. findings based on the
well are pinkish in color, Buccal mucosa and assessment. Therefore,
moist, and have no soft and hard palates her mouth is normal.
presence of any lesions. are pink with no
The tongue is smooth and lesions. Gingiva is
moist. Teeth are well pink and moist without
aligned and free of decay inflammation. Breath
and cavities. has no foul odor.
Tongue is smooth and
midline. Teeth are
well aligned with no
evidence of decay.
Uvula rises
symmetrically with
“ah.” Ducts are
smooth without
inflammation. Tonsils
are absent. (Nursing
Health Assessment
by Sharon Jensen)

>Thorax, Lungs, and Abdomen No abnormalities were Skin color is Upon assessment of the
-Inspection seen, and the chest is appropriate tone for Thorax, Lungs, and
-Auscultation symmetrical in shape. The race. Expiration is Abdomen, the findings
-Palpation abdomen is normal in size twice as long as indicates that these are
-Percussion with no evidence of lesion. inspiration. normal.
She has normal heart Diaphragm and
rhythm and depth as external intercostals
evidenced by effortless do most of the work.
breathing. No crackles, The patient denies
stridors, or wheezes were chest pain or
heard upon auscultation. discomfort, dyspnea,
She also denies any orthopnea,
difficulty in breathing. paroxysmal nocturnal
dyspnea, cough,
mucus, wheezing or
tightness in chest,
and decrease in
functional ability.
Breathing, posture,
and facial expression
are relaxed.
Respirations are 16
breaths/min without
accessory muscle use
or retractions. Skin is
pink without cyanosis
or pallor. Symmetrical
chest shape without
kyphosis or scoliosis.
Vesicular breath
sounds over lung fi
elds. The patient
denies chest pain or
tenderness. No
crackles or wheezes.
(Nursing Health
Assessment by
Sharon Jensen)

>Extremities The extremities were Arms and hands are Based on the findings,
-Inspection complete and warm to the warm and equal in the extremities are
-Palpation touch. Her arms and legs temperature. Patient normal.
are symmetrical with full denies upper or lower
joint movement. Palms are extremity pain; no
normal in color and claudication,
texture. There are no coldness, numbness,
presence of lesions, pallor, hair loss, or
edema, inflammation, or nail changes in the
complains of pain. extremity; no color
changes related to
cold temperatures,
swelling, or redness in
fingers or toes. Arms
and legs are
symmetrical with full
joint movement. Arms
and legs pink and
smooth with no
ecchymosis or
lesions. Skin warm
and dry; good turgor.
Capillary refill in 2
seconds. Radial and
posterior tibial pulses
+3/4 bilaterally. No
edema. No
tenderness or pain.
(Nursing Health
Assessment by
Sharon Jensen)

Name: Nicole Mujar


Age: 5 years old

Area of assessment Findings Norms Analysis

>Skin Her skin has presence of Skin color is even, The skin of nicole is not
- Inspection scars in her legs because with pigmentation normal. There are
-Palpation of dog lice. The overall appropriate to genetic presence of lesion and
texture of her skin is dry background and no her skin is dry.
due to the fact that when it obvious lesions or
is pinched it does not go color variations.
back immediately. Her Normal skin color
overall skin color is brown. varies from pink,
yellow, olive green,
brown to dark brown
or black, depending
on the child’s race. It
is essential to know
the child’s normal skin
color to assess for
color or pigment
changes accurately.
(Nursing Health
Assessment by
Sharon Jensen)

>Hair & Nails Her hair is evenly Hair is smooth, thick, Based on the assemen\
distributed, smooth and and evenly The findings on the hair
-Inspection color black there is no distributed. Nails are is not normal. Hair has
presence of dandruff. smooth, translucent, presence of lice
However, there is and consistent in infestation. Nails are
presence of lice color and thickness. normal.
infestation. Nails are Longitudinal ridging is
pinkish in color, intact, and common in aging
there is no presence of patients. Longitudinal
inflammation. pigmentation in dark-
skinned patients is a
normal variant.
(Nursing Health
Assessment by
Sharon Jensen)

>Head The face is seen to be The head is centered, Based on the


-Inspection symmetrical. Presence of proportional to the assessment, her head is
-Palpation scars from lice bites is body (1/7), erect, and not normal. Head has
optically visible. There are without tremors, tics, presence of scars from
no presence of dandruff. or unusual lice bites.
movements. The skull
is round without
obvious deformities.
The neck muscles are
symmetric. Nails are
smooth, nontender,
and firmly adherent to
the nail bed. Lateral
and proximal folds are
nontender and non-
swollen. Normally no
clubbing is present.
(Nursing Health
Assessment by
Sharon Jensen)

>Eyes The eyes are Eyes are in parallel Based on the


-Inspection symmetrically placed and alignment. Eyebrows assessment, both eyes
aligned. The eyelids open show no unexplained are normal.
and close with ease, and hair loss. Lashes
the eyelashes point curve outward away
outward. The pupil is round from the eyes and are
and black. The conjunctiva distributed evenly
that covers the sclera, the along the lid margins.
white portion of the eye, is Eyelids open and
neither red nor irritated. close completely, with
spontaneous blinking
every few seconds.
Eye shape varies
from round to almond
but is symmetrical.
(Nursing Health
Assessment by
Sharon Jensen)

>Ears The ears are fully Ears are symmetrical, Based on the assement,
-Inspection developed, symmetrical, equal size, and fully both ears are normal.
- Palpation and of equal size. Small formed. Facial tone is
hairs cover the skin- uniform with ears.
colored canal that Skin is intact. Ears
contains yellowish-brown are firm without
ear wax. No indications of lumps, lymph tissue is
ear discomfort, discharge, not palpable, ears are
lumps, or foreign objects nontender, and no
are present. pain is elicited with
palpation of the
auricle or mastoid
process. (Nursing
Health Assessment
by Sharon Jensen)

>Nose No swelling, discoloration, It is symmetrical, Based on the


-Inspection or abnormalities are midline, and assessment, her nose is
-Palpation present on the nose's proportional to face. normal.
exterior. Drainage is clear. Skin surface is
Airflow is adequate.The smooth without
nasal mucosa is pinkish lesions; color is
red and free of any consistent with facial
swelling, abnormalities, complexion. There is
foreign materials, no pain, tenderness,
discharge, or bleeding. or break in contour.
There is no pain or Septum is midline;
tenderness felt when mucosa is pink and
palpating. moist; and no
prominent blood
vessels or crusts.
Drainage is clear.
Airflow is adequate.
(Nursing Health
Assessment by
Sharon Jensen)

>Mouth She has symmetrical, pink, Lips are pink and Even though there is a
-Inspection smooth, and plump lips. moist with no lesions. cavity on her teeth the
There are no signs of any Buccal mucosa and overall finding is normal.
lumps, growths, or tissue soft and hard palates
discolouration. The buccal are pink with no
mucosa, as well as the soft lesions. Gingiva is
and hard palates, are pink pink and moist without
and no lesions. The inflammation. Breath
gingiva is pink, wet, and has no foul odor.
uninflamed. Breath has no Tongue is smooth and
foul smell. Tounge is s midline. Teeth are
mooth and in the middle. well aligned with no
No indications of painful, evidence of decay.
swollen, retracted, or Uvula rises
bleeding gums are symmetrically with
present. She has oral “ah.” Ducts are
cavity. smooth without
inflammation. Tonsils
are absent. (Nursing
Health Assessment
by Sharon Jensen)

>Thorax, Lungs, and Abdomen In inspecting she has a Skin color is Based on the
-Inspection relaxed posture and appropriate tone for assessment, the findings
-Auscultation facial expression, with race. Expiration is are normal.
-Palpation normal musculature twice as long as
-Percussion . She has a rate of 18 inspiration.
breaths per minute Diaphragm and
. There are no signs of external intercostals
cyanosis or pallor. She do most of the work.
denies chest pain or The patient denies
discomfort chest pain or
. The anteroposterior discomfort, dyspnea,
diameter less than orthopnea,
transverse diameter. In paroxysmal nocturnal
palpating, she has a dyspnea, cough,
symmetric chest expansion mucus, wheezing or
, tactile fremitus present tightness in chest,
and equal bilaterally. In and decrease in
percussion, it is resonant. functional ability.
In auscultating, there are Breathing, posture,
no adventitious sounds. and facial expression
are relaxed.
. Respirations are 16
breaths/min without
accessory muscle use
or retractions. Skin is
pink without cyanosis
or pallor. Symmetrical
chest shape without
kyphosis or scoliosis.
Vesicular breath
sounds over lung fi
elds. The patient
denies chest pain or
tenderness. No
crackles or wheezes.
(Nursing Health
Assessment by
Sharon Jensen)

>Extremities No lesions, bruises, or Arms and hands are Based on the


-Inspection rashes are visible. Her warm and equal in assessment, the findings
-Palpation skin's temperature, temperature. Patient are normal.
moisture level, and texture denies upper or lower
are all normal. extremity pain; no
Extremities are no signs of claudication,
soreness or deformity. coldness, numbness,
Extremities are free of pallor, hair loss, or
erythema and edema. All nail changes in the
joints have full range of extremity; no color
motion. changes related to
cold temperatures,
swelling, or redness in
fingers or toes. Arms
and legs are
symmetrical with full
joint movement. Arms
and legs pink and
smooth with no
ecchymosis or
lesions. Skin warm
and dry; good turgor.
Capillary refill in 2
seconds. Radial and
posterior tibial pulses
+3/4 bilaterally. No
edema. No
tenderness or pain.
(Nursing Health
Assessment by
Sharon Jensen)

B. Nutritional Assessment

Interpretation:
Family members only take medications as necessary; none of them have a condition that
requires a maintenance dose of medication. The other family members do not take any dietary
supplements and primarily rely on their diets for their nutrient intakes, while Mr. Mujar takes
vitamin C every night. The household has access to enough food and clean water to consume
three times a day. Filipino cuisine is the most common type of meal that Ms. Marinay (her
mother) prepares. They typically consume a range of foods, including meat, green and leafy
vegetables, fruits, and rice, which is their main source of carbohydrates. Ms. Marinay (mother)
and Nicole are both underweight, while Mr. Mujar, Nathaniel and Nathalie have normal weight.
Family member Height Weight BMI

Anthony Mujar 171 cm 54.7 kg 18.71 (Normal)

Michelle Marinay 152 cm 39 kg 16.88 (Underweight)

Nathaniel Mujar 124 cm 21.7 kg 14.11 (Normal)

Nathalie Mujar 109 cm 16.45 kg 13.85 (Normal)

Nicole Mujar 105 cm 14 kg 12.69 (Underweight)

Table 5: Body Mass Index (BMI) of each member of the Family

Norms:

The systematic process of gathering and analyzing data for the purpose of making
judgments regarding the type and cause of nutrition-related health issues that impact an
individual is known as nutritional assessment. (British Dietetic Association (BDA), 2022).
Through nutritional assessment, healthcare professionals may determine a patient's overall
nutritional state, diagnose malnutrition, identify underlying diseases that cause it, and to improve
clinical decision making using a person centered approach. (Kesari A. et. al., 2022)

Anthropometric measurements, medical history, clinical and biochemical characteristics, dietary


habits, current treatments, and food security situations are all included in the nutrition assessment. A
weight-to-height ratio-based anthropometric indicator is the Body mass index BMI. It is used to identify a
person's malnutrition. A requirement for nutrition is indicated by BMI levels that are below or over the
World Health Organization (WHO) range for normal nutritional status.< 16.0 indicates Severe
malnutrition; ≥ 16.0 to < 17.0 Moderate malnutrition; ≥ 17.0 to < 18.5 Mild malnutrition; ≥ 18.5 to < 25.0
Normal nutritional status; ≥ 25.0 to < 30.0 Overweight; and ≥ 30.0 Obesity. (Nutrition Assessment,
Counseling, and Support (NACS), n.d.)

Analysis:
The majority of the Mujar family members have normal BMIs, according to the findings
provided on the table above, however Nicole Mujar, the youngest, and Ms. Marinay, the mother,
are underweight. Nevertheless, they still continue to consume three meals a day and a variety
of foods. But the mother revealed that she frequently skips breakfast. (Fabian)

BMI ASSESSMENT

40%

60%

Underweight Normal Overweight Obese

Base on your BMI assessment make a percentage of how many have normal weight, overweight
or obese, underweight.

FORMULA:

No. of person affected__ X 100 = % of affected person


Total of family members

Example: Underweight – 40%

__2__ x 100 = 40 %
5
*READ THE NORMS ON BMI
(WATER INTAKE GRAPH) ?

Table 6: Water Intake of each member of the Family everyday

Interpretation
Table 6 illustrates the family's daily water consumption. According to the graph, 60% of
the family drinks 6–8 glasses of water daily, 20% of the family barely drinks 3–4 glasses, and
the remaining 20% consumes 8–16 glasses daily.

Norms:

The National Academy of Medicine suggests an adequate intake of daily fluids of about
13 cups and 9 cups for healthy men and women, respectively, with 1 cup equaling 8 ounces.
Higher amounts may be needed for those who are physically active or exposed to very warm
climates. Lower amounts may be needed for those with smaller body sizes. It’s important to
note that this amount is not a daily target, but a general guide. In the average person, drinking
less will not necessarily compromise one’s health as each person’s exact fluid needs vary, even
day-to-day. The amount and color of urine can provide a rough estimate of adequate hydration.
Generally, the color of urine darkens the more concentrated it is (meaning that it contains less
water). However, foods, medications, and vitamin supplements can also change urine color.
Smaller volumes of urine may indicate dehydration, especially if also darker in color.

According to Healthdirect Australia, for kids, the suggested daily water intake is: Children
aged 4 to 8: 5 cups, 5 to 6 cups for kids aged 9 to 13, Ages 14 to 18: 6 to 8 cups. In warmer
weather or when exercising, kids need to drink more water. Keep in mind that youngsters
should always drink, even in the winter. Even if they aren't thirsty, they should be encouraged to
drink before, during, and after physical exercise because doing so can help them avoid
dehydration.

Analysis:

The student nurse compared each family member’s daily water intake to the baseline
data above; all of them are within normal range for suggested daily water intake aside from one
family member who only drinks 3-4 cups of water daily. Hence, there is a need to increase water
intake for Ms. Marinay to avoid dehydration.

C. Values, Habits, Practices on health promotion, Maintenance and Disease Prevention

Each member of the family gets between 7 and 9 hours of sleep every night, except of Ms.
Mitch (the mother), who gets only 6 hours. The mother sleeps around 10:00 pm and gets up at
5:00 am to get her children ready for school. The other family members routinely go to bed at
around 6:00–7:00 pm and wake up early at around 4:00–5:00 am. In regards to exercise, they
generally lack a regular exercise routine; the family's physical activities consist of walking and
household chores.

When it comes to the use of herbal medicine, alternatives can be used instead of the
drugs prescribed by the doctor for medication. The family lacks knowledge and has limited
access to information regarding herbal medicines. Instead, both parents are working hard to
care for and provide for their family's needs. But due to a lack of financial resources, when
someone in the family has a sickness, the only time they go to the hospital is when it is the
worst. The family instead encourages their children to study harder, so that when the time has
come that they build their own family, they can sustain and fulfill their children's needs for health
and things they want.

Whenever someone is ill, the family typically avoids going to the closest treatment center
because of fear of hearing bad news, lack of transportation, or the general belief that health
problems will simply get better on their own. Mrs. Mujar (mother) favors self-care for common
diseases like the common cold: "I just believe I will drink a lot of water and it will go away."

Norms:

According to recommendations from the National Sleep Foundation, healthy adults should
get between 7 and 9 hours of sleep every night. To support their growth and development,
babies, young children, and teenagers require significantly more sleep. Additionally, those
above the age of 65 need 7 to 8 hours every night.

The first step is to be aware of the general suggestions for how much sleep you require.
Then, it's critical to consider your own requirements in light of elements like your degree of
exercise and general health. Finally, it goes without saying that following good sleep advice is
essential if you want to achieve the recommended amount of sleep.

A person's environment can have an impact on their physical, mental, emotional, and
spiritual health. This is considered when practicing traditional Filipino medicine. There were
specific healers for each region and population group who passed on their expertise to young
children. Hilot or Ablon, a well-known method also used in other parts of Asia, is frequently
mischaracterized as a sort of massage and provided at spas to draw tourists. Similar to a
shaman, an albularyo is a practitioner who employs a variety of modalities, including herbalism,
prayers, incantations, and mysticism. There are between 10,000 and 14,000 plant species in the
Philippines. Only 120 of them have been verified scientifically, despite 1,500 having potential
medical usefulness. Only 10 medicinal plants can be used in herbal teas, tinctures, fluid
extracts, poultices (vegetable fat combinations), tablets, supplements, powders, lotions, and
essential oils, according to the Philippine Department of Health. The sick individual will either sit
over a coal-heated jar or hover over a steaming pot while participating in the tuob (boiling)
ceremony. The healer massages the hot sufferer with essential oils while reciting a healing
mantra. (Nomoto et al.,2020)

Nomoto, Sandra, et al. “Indigenous Filipino Healing Practices – Cold Tea Collective.” Cold Tea
Collective, 14 Jan. 2020, coldteacollective.com/indigenous-Filipino-healing-practices.

People exercise for one of five reasons: for work, for health, for recreation, for competition,
or for their appearance. The amount of exercise you need depends on your reasons for
exercising, your starting point, and on how quickly you want to achieve your goals. Physical
activity is anything that gets your body moving. Each week adults need 150 minutes of
moderate-intensity physical activity and 2 days of muscle-strengthening activity, according to
the current Physical Activity Guidelines for Americans (2022).

Analysis:

All of the members of the family have a normal sleeping pattern and the number of hours is
normal; based on the suggested normal range a person needed for sleep aside to Ms. Marinay
who only sleeps for 6 hours. They lack a regular exercise routine, however their main physical
activity is going for a walk and doing chores around the house, on the other hand it is suggested
that they do moderate to intensity physical activity to strengthen their body. Also, the student
nurse were able to identify that they lack knowledge to information with regards to herbal
medicines and due to lack of financial resources most of the time they treat themselves when
they are sick at home, hence, the researcher encouraged the family to go to the nearest rural
health unit to sick for advice and medication availability.
IMMUNIZATIONS

Family COVID-19 Booster Measles (2 BCG (1 dose DPT(1 dose OPV HEPA B (3-4
member Vaccine shots dose first at at birth) at 7 years (4 doses) doses)
12- 15 old)
months
then 6
years)

Anthony Complete N/A Complete Complete Complete Complete Complete


Mujar

Michelle Complete N/A Complete Complete Complete Complete Complete


Marinay

Nathaniel M. N/A N/A Complete Complete Complete Complete Complete


Mujar

Nathalie M. N/A N/A Complete Complete Complete Complete Complete


Mujar

Nicole M. N/A N/A Complete Complete Complete Complete Complete


Mujar

Table 6: Immunizations of each member of the family


Interpretation:

The data above clearly demonstrates that every member of the family has received their full
round of vaccines except for covid vaccination, only both parents are vaccinated without any
booster shots. According to the mother, Ms. Marinay, they want to ensure that their children are
protected from illnesses as early as possible because she and her spouse have received all
recommended vaccinations.

Norms:

Children must receive all recommended doses of routine vaccinations from the moment
they are born until the age of one in order for them to be effective. Additionally, they must finish
additional doses during any outbreak or supplemental immunization programs that the
Department of Health may notify.

Getting vaccinated against COVID-19 can help people avoid getting seriously ill from the
acquired virus. As COVID-19 variations continue to arise, COVID-19 vaccines can provide
additional protection for those who have already contracted the virus, including protection
against being hospitalized for a new illness. Getting vaccinated against COVID-19 is a safer and
more reliable way to boost immunity than becoming ill with COVID-19. By generating an
immune response, COVID-19 immunization serves to protect you without requiring you to suffer
from a potentially serious sickness or post-COVID complications. People are most protected
when they receive the recommended number of doses and boosters, when appropriate, just like
with vaccines for other diseases.

Analysis:
The family received their full round of vaccines except for covid 19 vaccines. They
recognize the importance of health, but also develop concern regarding the vaccines that need
to be administered amidst this pandemic. As a result of the side effects of the vaccine after
being given such as pain, swelling, redness on the arm where the shot was given, tiredness,
headache, and feeling sick. Doubt started to plant on their minds, and that resulted from not
having their booster shots for covid 19.
V. FAMILY COPING INDEX
Legend:
1- No competence
2- Moderate Competence
3- Complete Competence

Categories 1 2 3 Justification

1.) Physical Independence: 1st visit:The family was


shocked when we arrived
This category is concerned with the on the first visit, but they
ability to move about to get out of the eventually welcomed us
bed, to take care daily grooming,
walking and other things which
👁 with open arms. Mrs. Mujar
gave us her undivided time,
involves the daily activities. toured us around the
house, addressed all of our
inquiries, and authorized us
to do nursing interventions.
The family enjoys working
together on tasks like
housework but is also
capable of handling their
daily tasks on their own.
2nd visit: On the second
visit of the student nurses,

👁 the family was


presentable and conscious
more

of their odor. They even


took a bath before the said
time of visit. The family
always wakes up according
to their habits and does
their assigned chores
straight away.

3rd visit: On the third visit,

👁 the family maintained their


personal hygiene and
based upon the student
nurse’s re-assessment
there is an improvement.
They manage to perform
minimal physical activity
when they do house
chores.

2.) Therapeutic component: 1st visit : We observe that


the family is unable to keep
This category includes all the an eye on their health
procedures or treatment prescribed for
the care of ill, such as giving
👁 during our visit. Due to a
lack of funds, the family
medication, dressings, exercise and does not prioritize their
relaxation, special diets. health, and only visiting the
hospital when a member of
the family is suffering from
a serious illness.

2nd visit: Based on their


observations on their
second visit, the student

👁
nurses concluded that the
family's ability to manage
their health had not
improved at all. “Hindi kami
pumupunta sa hospital o
clinic kapag may mga sakit
kam i” According to the
mother, even if they are ill,
they still do not want to visit
the nearest clinic or
treatment center.

3rd visit: According to the

👁 family they will try to


consider prioritizing health.

3.) Knowledge of health condition: 1st visit: The family is


unaware of the
This system is concerned with the fundamental concepts and
particular health condition that is the details pertaining to the
occasion of care. illness or disease that runs
in the family. Mrs. Mujar
👁 claimed that because of a
pain on the bottom right
side of her abdomen, she
said she may have a liver
disease. However, the right
side of her abdomen is
where her appendix is.
(Fabian)

2nd visit: The family was


able to reiterate and
👁 comprehend the
information that the student
nurses provided concerning
common diseases that they
might acquire as a result of
their environment.

👁
3rd visit: After providing
informations concerning
about the risk of the
environment to their health,
the family started to clean
and tidy up their
surroundings.

4.) Application of the principles of 1st visit: The family was


the general hygiene: decent as the student
nurses arrived; also they
This is concerned with the family
action in relation to maintaining family 👁 were able to rest well and
have adequate hours of
nutrition, securing adequate rest and sleep every night as stated.
relaxation for family members, carrying
out accepted preventive measures, 2nd visit: Since the house
such of the family is away from
as immunization. the city, they are not
entirely influenced by
technology compared to
others. Their sleeping
👁 pattern is steady, meaning
they always have an
adequate amount of sleep
every day. However, since
finances are their primary
problem. The children lack
enough nutrients in their
food.

3rd visit: The family was


able to maintain good

👁 hygiene; also they were


able to rest well and have
adequate hours of sleep
every night. They still lack
in financial resources, on
the other hand, they are
trying other alternative
nutritious food yet
affordable for their nutrition.

5.) Health attitudes:


👁 1st visit: The
explained that they could
family

This category is concerned with the only visit a doctor when the
way the family feels about health care condition deteriorated or
in general, including preventive required more urgent care.
services, care of illness and public They said that other
health measures. priorities outweighed
health.

2nd visit: Upon reaching


the family about the
significance of health, they
👁 started to be more aware of
their status and interested
in things that they still do
not know about health.
Also, the importance of
regular checkups to avoid
diseases from getting more
severe.

3rd visit: On the third visit,


the mother still does not yet
go to the nearest Rhu for
her checkup because they

👁 do not have a vehicle, and


if walking it will take at least
half an hour. Still, the
student nurses encouraged
her and agreed that she will
have a check-up. So we
expect the mother to have
the result of her checkup on
their next community visit.

6.) Family living 1st visit :


The first time they saw the
This category is concerned with the family, the student nurses
interpersonal or group aspects of the saw that everyone
family get along with one another, the respected one another and
ways in which they take decisions interacted with them. They
affecting the family as a whole. 👁 can communicate
appropriately. They have
access to the family
patriarch when making
decisions and can discuss
their ideas with him.
2nd visit: The family's
positive relationships with
one another were able to
remain on this visit. They
value and respect one
👁 another. As the father and
all the children arrived
home, they demonstrated a
decent relationship bond
with one another. In
addition, both the mother
and the father are capable
of communicating their
thoughts to one another
when making decisions.

3rd visit: They were able


to maintain a good
relationship with each
other. As the two children

👁 go home from school they


were asked by their mother
what did they learn and
how was their day going,
hence it shows good and
open communication to
each member of the family.
As for Mr. Mujar, he was
welcome with warm hugs
by his children after he
came home from the farm.
7.) Physical Environment 1st visit :
We saw some construction
This is concern with the home, the debris that may injure the
community and the work environment Mujar family when the
as it affects family health. student nurses were
inspecting the area outside
👁 of their home. Additionally,
there is stagnant water in
the sewage system close
by that might lead to vector-
borne illnesses. They don't
even have a comfort room.
Their open water storage
containers are other
environmental problem
within their home.

2nd visit: After the initial


visit, the family is now more
conscious of the
cleanliness of their

👁
environment and careful
about the things that can
risk their health and that
might be a potential threat
to their health.
Nonetheless, the back of
their house where the sink
is located, needs more
cleaning and organizing.

3rd visit: After giving


health teachings regarding
👁 their environment,
family started to organize
the

their living room, the


kitchen, the bedrooms, as
well as the outside of their
house. Their stock water at
the back of their house was
already covered.

V. TYPOLOGY OF NURSING PROBLEM

This Chapter discusses the problem that was identified during the assessment
and interview with the family. It includes the cues/data, the family nursing problem, and the
nursing diagnosis. The identified issues are categorized into the presence of a wellness state,
health deficits, health threats, and foreseeable crisis and stress points.

Scoring:

1. Decide on a score for each criteria Score Weight

A. Nature of the problem

a. Wellness state 3

b. Health deficit 3 1

c. Health Threat 2

d. Foreseeable Crisis 1

B. Modifiability of the problem

a. Easily Modifiable 2

b. Partially Modifiable 1 2
c. Not Modifiable 0

C. Preventive potential

a. High 3

b. Moderate 2 1

c. Low 1

D. Salience scale

a. A condition needing immediate attention 2

b. A condition needing immediate attention 1 1

c. Not perceive as problem 0

2. Divide the score by the highest possible score and multiply by the weight

3. Sum of the scores for all the criteria. The highest score is 5, equivalent to the total weight

Source: (Nursing Practice in the community Fourth Edition by Arceli S. Maglaya)

VI. RANKING OF PRIORITIZATION OF IDENTIFIED HEALTH PROBLEMS

Problems Scores

1. Presence of breeding sites of vector diseases as a Health Threat. 4.67

2. Poor Personal Hygiene Habits of the family 4.67

3. Improper garbage disposal (Burning and Dumping) as a Health Threat 4.17


4. Lack of medical resources 3.84

5. Malnutrition: Undernourishment (Ms. Michelle Marinay and Nicole Mujar) 3.67

6. Inadequate fluid intake (Ms. Michelle Marinay) 3.67

7. Improper Drainage System as Health Threat 3.34

8. Risk-prone health behavior related to a negative attitude toward healthcare 3.17

9. Presence of accident hazards: Sharp objects as a Health Threat 3

10. Inadequate immunization status as a health threat 3

The family's different health problems are presented in the tables below along with their
prioritization level. The top 10 issues in the family are shown here, with computations and
corresponding justifications.

Presence of breeding sites of vector diseases as a health threat.

CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION

1.) Nature of the 2/3 x 1 0.67 The outside area of


their residence has
problem
stagnant water
because of the
improper drainage
system, and bamboo
stumps, which is
unsafe and poses a
health threat as it
may breed insects
that carry disease.

2.) Modifiability of the 2/2 x 2 2 This part is easily


modifiable by
problem
educating the family
to improve their
drainage system to
lessen stagnant
water and clean other
areas that a vector
may potentially
shelter. Furthermore
is to demonstrate the
proper action that
they could do to
lessen the breeding
sites.

3.) Preventive 3/3 x 1 1 Since the family is


willing to improve
potential
their environment and
keep the area clean
for their overall
health, this problem is
highly preventable.

4.) Salience of the 2/2 x 1 1 This problem needs


immediate action as it
problem
increases the risk for
the family to have or
acquire certain
diseases from having
a poor environment.

Total: 4.67

Poor Personal Hygiene Habits of the family

CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION

1.) Nature of the 2/3 x 1 0.67 Keeping hands clean


is one of the most
problem
important steps to
avoid getting sick and
spreading germs to
others. This is a
health threat as many
diseases and
conditions are spread
by not washing hands
with soap and clean,
running water.

2.) Modifiability of the 2/2 x 2 2.00 It is easily modifiable


as the family shows
problem
signs of willingness to
learn and adjust their
habits to the
teachings provided
by the student
nurses.

3.) Preventive 3/3 x 1 1.00 This is highly


preventable because
potential
handwashing and
other personal
hygiene concerns are
easy to do and clean
water is very much
accessible to
everyone.

4.) Salience of the 2/2 x 1 1.00 The family needs


immediate attention
problem
before it will lead to a
worse situation. Aside
from their children
already having poor
nutrition, the family
cannot spend on
other expenses when
someone in their
family acquires a
certain disease.

Total: 4.67

Improper garbage disposal (Burning and Dumping) as a Health Threat

CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION

1.) Nature of the ⅔x1 0.67 Improper garbage


disposal that includes
problem
Burning and Dumping
is considered a
health threat as it
could affect the
family’s health, and
could result in other
certain problems.

2.) Modifiability of the 2/2 x 2 2 It is Easily modifiable


since the student
problem
nurse will only
provide health
teachings regarding
the proper disposal of
garbage.

3.) Preventive 3/3 x 1 1 There is a High


preventive potential
potential
as it could be done
and accomplished
immediately by the
family, with the help
of the provided health
teachings of the
student nurses.

4.) Salience of the 1/2x1 0.5 There is a need for


immediate attention
problem
as it could lead to
certain health
problems such as
skin irritation.

Total: 4.17

Lack of medical resources

CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION


1.) Nature of the 2/3 x 1 0.67 Having stored
medical resources at
problem
home is a must to
keep the family ready
in terms of
emergency. By taking
medicine we can
prevent possible
sickness.

2.) Modifiability of the 2/2 x 2 2 It is easily modifiable


by educating the
problem
family to provide
medical resources at
home that they might
use for emergencies.

3.) Preventive 2/3 x 0.67 It is moderately


preventable because
potential
they can be educated
to provide but since
they are lacking
financially.

4.) Salience of the 1/2 x 1 0.5 This problem needs


immediate attention
problem
because health
matters the most.
Total: 3.84

Malnutrition: Undernourishment (Ms. Marinay and Nicole Mujar)

CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION

1.) Nature of the 3/3x1 1 The Mujar family is in


a wellness state of
problem
undernourishment.
They are unable to
consume enough
food to meet their
daily basic dietary
needs.

2.) Modifiability of the 1/2x2 1 This problem is


partially modifiable,
problem
considering the
financial status of the
family and the lack of
necessary resources.

3.) Preventive 2/3x1 0.67 Due to financial


constraints, which in
potential
turn cause the family
to consume cheap,
high-energy food
products
carbohydrates and
fats, instead of
nutrient-dense foods,
this problem is
moderately
preventive since the
family is doing their
best to be able to
provide food on their
table.

4.) Salience of the 2/2x1 1 The wellness state of


the family needs
problem
immediate attention.
Since it is a
significant underlying
factor in illness and
death.

Total: 3.67

Lack of water intake (Ms. Michelle Marinay)


CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION

1.) Nature of the 2/3 x 1 0.67 If Ms. Marinay


continues doing it,
problem
the problem can be
viewed as a health
threat. Symptoms
and serious health
issues could result.

2.) Modifiability of the 2/2 x 2 1 It is easily modifiable


as upon the health
problem
teaching of the
student nurse, Ms.
Marinay has shown
willingness and
understanding about
the said problem.

3.) Preventive 3/3 x 1 1 This health threat can


be highly preventive if
potential
Ms. Marininay will
increase her water
intake from 3-4
glasses to 8-10
glasses a day.

4.) Salience of the 2/2 x 1 1 The problem requires


immediate attention.
problem The patient is aware
of the importance of
water and the
adverse affects
dehydration can have
on our health. Taking
into account that the
mother is
undernourished as
well.

Total: 3.67

“Medication is a Last Resort” or Bad Perception on Medications or Negative Perceptions


on Medication

CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION

1.) Nature of the 2/3x 1 0.67 The family treats


medication as a last
problem
resort when someone
is sick. As the Filipino
tradition suggests
that crying is an
indication of the worst
state of sickness. The
family chose to
believe unless they
are not crying due to
the pain, they can still
fight the disease and
not go to the center
or hospital.

2.) Modifiability of the 1/2 x 2 1 It is partially


modifiable because
problem
the family cannot be
easily persuaded to
have an immediate
checkup when they
have a sickness since
they always consider
the money to be
spent

3.) Preventive 3/3 x 1 1 It is highly


preventable as when
potential
an appropriate health
teaching will be given
the family are open to
additional knowledge
about health.

4.) Salience of the ½x1 0.50 This problem does


not need immediate
problem
as the family is very
open to information
about how to
maintain health and
have a healthy
lifestyle.

Total: 3.17

Improper Drainage System as Health Threat

CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION

1.) Nature of the 2/3x1 0.67 Improper drainage


system as a Health
problem
threat; outside the
family’s house there
is an improper
drainage system, the
water that they use,
storm water, and
flood water they were
all together in one
place, this could
results to health
problems such as
bacteria, infection,
and breeding sites of
vectors.

2.) Modifiability of the 1/2x2 1 It is partially


modifiable, the
problem
student nurse could
provide health
education about the
possible effects and
risk of improper
drainage system, on
the other hand it will
be hard for the family
to find materials in
making appropriate
drainage system.

3.) Preventive 2/3x1 0.67 Although it is always


the family’s desire to
potential
have a clean and
healthy environment,
it is a moderate
preventive because
of financial needs in
buying materials.

4.) Salience of the 2/2x1 1 There is an


immediate need for
problem
attention to improper
drainage systems as
it could lead to many
health problems, one
of these is breeding
sites for vectors.

Total: 3.34

Presence of accident hazards: Sharp objects as a Health Threat

CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION

1.) Nature of the ⅓x3 1 The house's


construction poses a
problem
health risk, especially
when paranormal
activity is present. It
should be durable
and made of
concrete.

2.) Modifiability of the 0/2 x 2 0 This problem is not


modifiable because
problem
we are considering
families' capabilities.

3.) Preventive ½x2 1 This is low preventive


since means and
potential
structural changes
are needed.

4.) Salience of the 1/2 x 2 1 There is no


immediate need to
problem
address this issue
because risks can be
readily avoided by
taking alternative
steps, including
evacuating.

Total: 3

Inadequate immunization status as a health threat

CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION

1.) Nature of the ⅓x3 1 It is viewed as a


threat to health since
problem
the possibility of
having inadequate
immunization
exposes the family to
potential health-
related illnesses.
It is partially
2.) Modifiability of the 0/2 x 2 0 modifiable as the
family was frightened
problem about the side effects
of Covid vaccine on
their children’s health.

3.) Preventive ½x2 1 It is low preventable


because the family
potential
itself was not willing
to participate and
they do not usually
visit RHU for any
check-ups.

4.) Salience of the 1/2 x 2 1 The family needs


immediate attention
problem
for this serious
problem since
immunizations help
with regard to their
health and protection
against possible
illnesses.

Total: 3

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