Family Case Study 1,2,3

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.
LEARNING MODULE
NCM 104
Community Health Nursing (Clinical RLE)
TITLE: Family Health Nursing Process
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 (NCM 104 Laboratory)
Presented by:
Maxene Dhale P. Pabalan

BSN 2-1
PRESENTED TO
Mrs. Hasna Pascual, RN, MAN
Clinical Instructors
September 2021
TABLE OF CONTENTS
I. INTRODUCTION ---------------------------------------------------------------------1-2
II. OBJECTIVES ----------------------------------------------------------------------------3
III. INITIAL DATA BASE -----------------------------------------------------------------4-
7
a. Family Structure, Characteristics, and Dynamics------------------------------3
b. Genogram
-------------------------------------------------------------------------------4
c. Socio – Economic and Cultural Characteristics-------------------------------5-
6
d. Home Environment ----------------------------------------------------------------6-7
e. Health Status of Each Family Member --------------------------------------- 8-
33
A. Physical Assessment -------------------------------------------------8-
14
B. 13 Areas of Assessment -------------------------------------------15-33
f. Nutritional Assessment ------------------------------------------------------------34
g. Values, Habits, Practices on Health Promotion --------------------------- 34-
35
IV. FAMILY COPING INDEX -------------------------------------------------------- 36-
38
V. TYPOLOGY OF NURSING PROBLEMS ---------------------------------------- 39
VI. RANKING OF PRIORITIZATION OF
IDENTIFIED HEALTH PROBLEMS ------------------------------------------40-43
VII. FAMILY NURSING CARE PLAN ----------------------------------------------43-48
VIII. SUMMARY, EVALUATION,
AND RECOMMENDATIONS -------------------------------------------------- 48-49
IX. DOCUMENTATION ---------------------------------------------------------------50-52
X. GROUP PROFILE ----------------------------------------------------------------- 53-56
1
I. INTRODUCTION
The traditional definition of "family" entailed one man and one woman who
were married, and their children. A grandparent might live with and be a part of the family,
too, although that practice isn't as popular in recent times. In the 1950s, the ideal family was a
father, a mother, and two offspring. The current definition is somewhat open and inclusive. A
family might be two parents of any gender, married or not. Some people even have a family
with more than three parents. The children may have been born to one of the parents, both
parents, or adopted[ CITATION Ash20 \l 1033 ].
The field of public health aims to protect and improve health by addressing the
structures and systems that define a place—and by supporting the people who live and work
there in making healthy choices. Problems are studied, data is collected, and resources are
gathered to help solve those problems[ CITATION Elm18 \l 1033 ].
Nies and McEwen (2019) defined Public Health Nursing and Community Health
Nursing refers to the field of nursing practice that is applied to promote and preserve the
health of populations. It is population - focused, with the goals of promoting health and
preventing disease and disability for all people. It also refers to the engagement of healthcare
through comprehensive nursing care of families and other groups.
Tarlac is the most multicultural of the Central Luzon provinces. A mixture of four
distinct groups – the Pampangos, Ilocanos, Pangasinenses and Tagalogs – share this province
and living together resulted in offering to the visitors the best cuisine of the places where
their ancestors had come from, namely Bulacan, Nueva Ecija, Zambales, Pangasinan and the
Ilocos Region. Tarlac is also best known for its fine foods and vast sugar and rice plantations.
That it has fine cooking to offer is largely since it is the melting pot of Central Luzon. Its
myriad of historical sites, fine foods, vast sugar and rice plantations, and a beautifully
landscaped golf course plus so many other attractions all make the province of Tarlac one of
the best places to visit in Central Luzon.
The family that was chosen by the student nurse comes from the Lungsod ng
Tarlac of the Philippines—Tarlac City. It is a landlocked province in the Philippines
located in the Central Luzon region, Its capital is the city of Tarlac. It is bounded on
the north by the province of Pangasinan, Nueva Ecija on the east, Zambales on the
west and Pampanga in the south. Tarlac City is the largest city in the province of
Tarlac. It has 76 barangays. Gerona is to its north, Capas to the south, San Jose to the
west and Victoria, Concepcion to the east. According to the 2020 census, it has a
population of 385,398 with 74,429 households Being at the meeting point of
both Kapampangan and Pangasinan languages, cultures, and ethnicities, both
languages are predominantly spoken in the city and environs. Ilocano and Tagalog are
also used by a few city dwellers, especially those
with Ilocano and/or Tagalog ethnicity/ancestry, respectively, with the latter language
also serving as a medium for inter-ethnic communications.
2
II. OBJECTIVE
General:
This study aims to create an environment to help us identify and recognize the
needs of the family which will lead us to develop and understand the health
status of each member of the family. With that, we will be able to formulate
nursing care plans to address the needs of the family, promote care for the
individual and the family, and implement the proper interventions to address
the problems and maintain the health status of the family in the community.
Specific:
1. To establish rapport and build trust between the family and the student nurse.
1. To assess the health status of the chosen family using 13 areas of assessment.
2. To identify problems that can affect the health of the family and the factors
contributing to it.
3. To create a family nursing care plan for achieving optimal health of the family.
4. To perform nursing interventions that will benefit the family and improve their overall
health.
5. To evaluate the family if there are any improvements and changes on the behavioral
aspect towards health using the set objectives as the basis.
Family based:
1. Participate actively in planning
2. Participate actively in interventions given by the group
3. Apply interventions in their daily lives for further improvement of healt
3
III. INITIAL DATA BASE
A. Family Structure, Characteristics, and Dynamics
Family Position in Sex Age Civil Status Education
Member The family attainment
Marlon V. Father M 47y/o Married Undergraduate
Pabalan in College
Zoraida P. Mother F 48y/o Married High School
Pabalan Graduate
Maxene Eldest F 19y/0 Single 2nd Year
Dhale Daughter College
P. Pabalan
Lexter John Middle Son M 18y/o Single 1st Year
P. Collage
Pabalan
Alexa Youngest F 6y/o Single Grade 1
Sophia P. Daughter
Pabalan
Interpretation:
The family structure of the Pabalan family is reckon to be nuclear type of family where they
consist of a mother, a father and three (3) children. Each members of the family have their
own role. Mr. Marlon Pabalan is the head of the family and he has been the provider and
authority figure inside their home while his wife, Zoraida Pabalan has been the caretaker and
responsible for the health and household choirs and also for the emotional side of the family.
Their two Daughter and Son namely Maxene Dhale Pabalan, Lexter John Pabalan, Alexa
Sophia Pabalan are expected to follow the leadership and guidance of their parents they were
being a obedient to their parents and also responsible for their action. For 19 years, they
have been residing at Camella Homes Maliwalo Tarlac City. Both of the parents are working
together to provide for their family’s financial needs. The couple are likely to hold different
positions in the family hierarchy however, both of them are the ones who make the final
decision for the family. When it comes to family’s finances, the family’s income was all
handed to Mrs. Pabalan for the allocation of monthly expenditures of the family
Norms:
Extended family members, especially grandparents, can assist in passing on cultural
teachings and traditions, including language. For example, grandparents can share stories, skills
and teachings during their time with the grandchildren. This is also connected to the children’s
healthy self-esteem[ CITATION Fam19 \l 1033 ].
4
Analysis:
The V Family is considered as an extended family since the family is composed of
grandparents married partners and offspring. Since the mother has already passed away, Mr V is
classified as widowed and is responsible for decision making like in financial and health which is
considered as Patriarchal.
B. Genogram
Marlon V. Pabalan
Zoraida Pabalan,
47
Maxene Dhale P. Lexter John P.

Alexa Sophia P.
Pabalan, 19y/o Pabalan, 18y/o
Pabalan, 6y/o
(asthma)
1. Family history of health and illness/ (pregnancy)
LEGENDS:
- healthy male -female deceased CoD-cause of death
-male with medical complication

-healthy female
-male deceased -female with medical complication

C. Socio- Economic And Cultural Characteristics
5
Family Member Educational Occupation Ethnic Religion
Attainment Background
Marlon V. College Overseas Ilocano Roman
Pabalan Graduate Filipino Worker Catholic
Zoraida P. High School Business Ilocano Roman
Pabalan Graduate Woman Catholic
nd
Maxene Dhale 2 Year College N/A Ilocano Roman
P. Pabalan Catholic
Lexter John P. 1st Year Collage N/A Ilocano Roman
Pabalan Catholic
Alexa Sophia P. Grade 1 N/A Ilocano Roman
Pabalan Catholic
Marlon V. College N/A Ilocano Roman
Pabalan Graduate Catholic
Table 2: Socio-Economic and Cultural Characteristics of Pabalan Family
Interpretation:
Mr. Marlon Pabalan is the breadwinner and a good provider of the family ever since while
his partner, Zoraida Pabalan also helps him in supporting their family financially by working too
and also, responsible for the allocation of their monthly budget even though Mr. Pabalan can
provide the needs in the house his wife wants to have her own money to help her husband to save
more money for the future of their kids. Mrs. Pabalan was a high school graduate while Mr.
Pabalan was a College student. Both of them weren’t able to finish their studies as they chose to
work instead at a young age to help their parents in their family’s expenses. Mr. Pabalan is a
Overseas Filipino Worker in Saudi Arabia while Mrs. Pabalan sells cosmetic at the market near
their barangay. These were all the sources of their family’s income. The whole family are Roman
catholic where they pay visit to the church when they have spare time on their hands. They are a
believer of God and they praise him for all of his glory, blessings, and love for the family.
Expenditures Estimated Monthly Prioritization (1-10)
6
Allotted Budget
Food (Groceries) ₱ 5,000 1
Gas ₱ 1,000 6
Education ₱2,000 3
Medical/Health(e.g.medications ₱500 5
)
Clothing ₱500 8
Household expenses (Bills) ₱7,000 4
Transportation ₱200 10
Vices ₱300 9
Savings ₱5,000 2
Other minimal expenses ₱500 7
TOTAL: ₱22,000
Table 3: Monthly Expenditures of the family
Interpretation:
Mrs. Pabalan, the one who’s in charge of the family’s finances rate the prioritization she
does every time she allocates their whole family’s income every month. Their estimated monthly
income for this year is ₱27,000.00. Every time she dispenses their monthly budget, she always
prioritizes giving bigger portion of their income on their their foods (groceries) followed by
savings (Bank Account). Their least priority in the allocation of their monthly budget is
transportation expenses as they don’t usually go out nor travel in a far distance.
7
Total monthly income of the family
- Marlon →₱ 20,000
- Zoraida →₱ 7,000
Total: ₱27,000
Total Annual/household family income=Total monthly income x 12 months
₱27,000 x 12,000 = ₱324,000
Total annual family income/ number of the members of the family=Total per Capita Income
₱324,000/5= ₱ 64,800
Expenses of each family member → ₱ 64,800
─ Monthly income of the family → ₱27,000
Total ₱ 37,800 [lacking income of the family]
= Estimated monthly income - Estimated total monthly expenditures
=₱ 22,000.00 – ₱27,000
=₱5,000 (not lacking)
As you can notice on the computation above, the family’s income is adequate enough to
suffice the family’s monthly expenditures however, if you will compare the monthly income of
the family to the estimated expenses of each member of the family, it is insufficient to meet each
family member’s needs.
Norms & Standards:

Filipino families earned Php 313 thousand in 2018, on average. In comparison, their
expenditure for the same year was Php 239 thousand, on average. These figures translate to an
8
average annual savings of Php 75 thousand. The average family income ranged from Php 113
thousand for the first income decile (lowest 10 % income group) to Php 867 thousand for the
tenth decile (highest 10% income group). The average annual income of families in the tenth
decile was about eight (8) times of those in the first decile, while nine (9) times of those in the
first decile in 2015. The national per capita income decile is obtained by ranking the per capita
family income of all sample families from lowest to highest and was compiled into ten groups.
The first tenth, meaning those with the lowest income, is called the first decile, the second tenth,
second decile, and so on. (Family Income and Expenditure Survey, 2018)
Analysis:
As you can notice on the computation above, the family’s income is adequate to suffice the
family’s monthly expenditures however, if you will compare the monthly income of the family
to the estimated expenses of each member of the family, it is insufficient to meet each family
member’s needs
D. Home Environment
Type of house Completed; Owned
Overcrowding Absent
Ventilation Satisfied
Lighting Adequate
Kitchen Type Smokeless
Bathroom Owned
Drainage Improper/Stagnant
Source of drinking local water system and water refilling station
Fuel Used Liquefied Petroleum Gas (LPG)
Disposal of Waste they store their garbage in a sack, then a
garbage collector will collect those
Excreta Disposal Closed pit privy
Vectors present flies, roaches, termites and mosquitoes
Power Source Electricity
Table 4: Environmental Aspect of Pabalan Family
The house of Pabalan family is currently residing in Barangay Maliwalo, Tarlac

City in the province of Tarlac, which considered as an urban type of community. It was
year 2002, when they decided to move to their current home right now. Therefore, they
9
inhabit it for almost 19 years already. The house is mainly made with heavy materials like
Dependable Concrete, Bricks, cements, hollow blocks and such. The title of the land in
which the house was built is currently named to the Mr. Marlon Pabalan, the house itself
was owned by the family. The household was surrounded mostly by houses since it is a
subdivision-type location. Because they live in the subdivision in Camella homes their
environment is clean because they are paying monthly for the garbage collector and the
garbage collectors gets garbage three times a week and their monthly payment includes
for the maintenance of their surroundings. Upon entering the house, you will be greeted by
the Garden first and in the garden there are chairs where guests can sit, and Outside the
garden there is a big trash bin where the family can store their daily garbage. After the
garden there is a screen door and a door to their entrance to prevent the mosquito to enter
over the house. Upon entering the house there is a living room and kitchen, It has a four
(4) sliding window and one (1) door at the back for emergency purposes. The area is quite
wide so more than 10 guests can accommodate the guest capacity in the house. On the
lower ground of the house there is a bedroom and has its own comfort room and also there
is a powder room for guests, There is also a staircase to the second floor with two rooms
and a comfort room as well there is an attic for storage of unused/not using items. Each
room has a aircon and electric fan and the bed are very comfortable. The masters bedroom
is on downstairs and the two bedroom upstairs is for their child. Maxene and Sophia are
roommate while Lexter have his own room.
Their kitchen have exhaust fan and they are cooking on a smokeless one thus, it is
free from smoke generated when they are cooking. Instead of traditional way of cooking,
they use Liquefied Petroleum Gas (LPG) as their fuel for cooking. To supply the household
with water, they have the local water system as their source and for drinking water they
have a supply for mineral water. They usually store drinking water in a water dispenser.
For power source, their main power supply within the household is through electricity. For
the food preparation, they use refrigerator, freezer, a basket, and their cabinet to prevent
any contamination and spoilage of the foods . The family have a one dog on their
household . As the inspection and roaming around there are a some mosquitoes found
inside and outside the house and some flies outside their house . Flies were commonly seen
outside their house where all their garbage were piled up in a sack. Due to the weather
since it’s rainy season today some water are accumulates and mosquitoes live there,
mosquitoes tend to inhabit it. As we observe there is no any presence of termites in the
house because every two months the maintenance are spraying an anti-termites. The
communication tools within the household are cellphones, telephone and television. Their
means of transportation is through their owned car
CROWDING SPACE
STANDARD: (Concepts and Guidelines in COPAR, 1ST Edition, 2005 by Untalan)
10
Formula:
Total Floor Area (TFA)
TFA = length x width of the house
TFA = 7.2m x 5.1m = 36.72 sq. m
Total Space Requirement (TSR)
Standard:
Adults – 3.0 sq. m
Children – 1.5 sq. m
Infant ─ 0
No. of adults in Pabalan family = 3 x 3.0 sq. m = 9 sq. m

No. of children in Pabalan family = 2 x 1.5 sq. m = 3 sq. m
TSR = 12 sq. m
Interpretation:
TFA>TSR = not overcrowded
TSR>TFA = overcrowded TFA (36.72) > TSR (12): NOT OVERCROWDED
VENTILATION
Interpretation:
20% - Satisfactory
18% - 19% - Fair Below
18 % - Poor
TFA = 36.72 sq. m Total

No. of windows: 6
Formula:
Ventilation = TWO / TFA x 100
TWO: total area of windows (L x W)
Computations:
WO (window openings)
W1 = 0.45m x 1.15m = 0.51 sq. m
W2 = 0.85m x 1.15m = 0.98 sq. m
W3 = 0.85m x 1.15m = 0.98 sq. m
W4 = 0.45m x 1.15m = 0.51 sq. m
W5 = 0.55m x 0.60m = 0.33 sq. m
W6 = 0.55m x 0.60m = 0.33 sq. m
Total Window Opening (TWO) = 3.64 sq. m
Ventilation = TWO/TFA x100

= 3.64 sq. m ÷ 36.72 sq. m x 100
= 0.099 sq. m x 100 = 9.91 = POOR VENTILATIO
11
NORMS:
According to Maglaya book 4th edition typical normal family living in a proper
housing is not overcrowded and ventilation must be above 20%. They must have a
good sleeping pattern completing 8 hrs. of required sleep. Free from all presence of
vectors sites that causes diseases in each family members. They should have proper
storage food and water sanitary condition. Need to segregate garbage and put in on
proper trash bags and proper drainage system. (Nursing Practice in the community by
Dra. Araceli S. Maglaya)
ANALYSIS:
Pabalan Family’s house is not overcrowded, which means that it has enough
space to accommodate their family size of five (5). However, it has satisfied
ventilation. The sleeping pattern of each member is normal. The house of the family
has a good accommodation and the kids are very comfortable on their life they have
a place to be with when they want to breath because there are so many plants and
tress on their backyard. They have proper storage for foods and these are all in good
condition. They are able to maintain the cleanliness and good ventilation also of
their drinking water. When it comes to their garbage, they compiled everything in a
sack and routinely collected by the garbage collectors in their subdivision every three
times a week . The drainage system within their area are all open, yet, they are still
clean and free-flowing.
12
A.Health Status of each family member
13 Areas of Assessment
Marlon V. Pabalan
Age: 47y/0
Area of assessment Findings Norms Analysis

Social Status Mr. Pabalan is 47 years old, Children’s status- Mr. Pabalan has a good
born on January 07, 1874, expectations about others relationship with his
He is the foundation of the were unrelated to beliefs workmates and neighbor,
family and also a good about their own status, friends, and his family.
provider of their family. suggesting children more When in times of stress,
He’s working as a Overseas readily apply category- his family and friends help
Filipino Worker in Saudi based status beliefs to him to cope up.
Arabia for 15 years. Based others than to themselves.
on his statement, He’s Children’s use of race and
having a vacation for one gender as cues to social
month in the Philippines status. Rhodes M (2020)
every year and he stated that
when he is in the Philippines
his only focus is his family.
As well he is socially active
since he has a lot of friends
particularly with his
workmates. He had a good
relationship with his wife
and children.
Mental Status The patient should

appear relaxed with the
> General During the initial visit, his appropriate amount of He still has a good
Appearance and clothes are all in good concern for the educational background.
Behavior condition. Upon checking assessment. The patient However, there were
his appearance, it is should exhibit erect limitations on the
noticeable that his hair is posture, smooth gait and questions being asked. It
newly cut, skin is not dry, symmetrical body shows that he he is good in
fingernails are clean but the movement. The patient communication. As for his
toenails looks quite dirty, should be clean and well- general appearance, he is
and he has no facial hair. As groomed and should wear properly groomed at the
stated by Mr. Pabalan, he appropriate clothing for time of the visit
was a undergraduate in age, weather, and
college, he can still read and socioeconomic status.
write. He’s very cooperative Facial expressions should
during the whole interview be appropriate to the
13
session. There are some content of the conversation
questions. In the interview and should be symmetrical
he is good in communication (Jensen, 2019)
skills.
The message's The client is well-oriented

>Level of content should correspond to time and place during
consciousness and He was coherent, well- to the patient's level of the assessment. Some
orientation oriented and cooperative education. The patient explanations coming from
during the whole interview should be able to answer him are well verbalized.
session. He was able to questions accurately and He responds to the
respond to each question identify all of the objects questions aptly thus, his
thrown at him aptly but there as instructed. Denial and mental capabilities is
are times where he seeks poor eye contact are functioning well, but some
clarifications. However, he common reactions during questions are repeated
was able to respond the first conversation, especially if they are not
accurately and quickly when which may be attributed to familiar with the words
asked about his name, their anxiety over meeting a being asked.
address, his line of work, his stranger or an attempt to
children, his wife and other screen or dismiss
vital question concerning his unwanted truths by
self and most importantly, refusing to acknowledge
his family. them. (Jensen, 2019)
>SPEECH The patient should He has good

be able to produce communication skills but
His way of delivering speech spontaneous, coherent still needs some
is audible to ear but some speech (Jensen, 2019) improvements especially
words are not clearly said. for the clarity of words
He was still able to deliver being said.
concrete messages when
being asked.
Emotional Status Mr. Pabalan stated that he During adulthood, The client shows a normal
does not get bother by fear, here is some support for emotional status . His
anxiety, and grief, but he the view that people do support system during
stated that sometimes he’s undertake a sort of time of stress is his family
feeling emotional and lonely emotional audit, reevaluate and they were able to help
when he is in Saudi because their priorities, and emerge him to feel at ease.
he express felt that he with a slightly different
misses so many years orientation to emotional
without his family. He regulation and personal
shows no sign of tremors, interaction in this time
uncertainty, irritability, period (Lumen, 2017).
panic, and tension. His
support system is his family
14
and they always help him in
coping with stress.
Sensory Perception
Normal vision is
Sense of sight Based on observation, his considered 20/20. A visual He has a normal sense of
eyes are color brown without acuity of 20/50 indicates sight as well as external
any lesions, swelling or that the patient can read appearance of the eyes.
discharge. His pupils are from 20 ft what a person The data gathered shows
equal, round and with normal acuity (20/20 that he has normal visual
symmetrical. It constricts vision) can read from 50 ft acuity, extraocular muscle
and equally move to cross (Shultz et.al., 2016). movements, pupillary
when pen light was slowly response and the client is
move closer to his nose and not color blind.
when shine the light in from
the side in each eye. His A person usually
sclera is white and shiny not identifies the taste of
jaundice. His conjunctiva is bitter, sweet, sour, and
pink and not red and salty. By the use of our
swollen. While performing sense of taste, we can fix
near visual test, the student or adjust the taste of our
nurse asked him to read the food based on our capacity
words on the paper that was (Blue, 2018).
14 inches away from the
client’s eyes. He was able to
read the words on the paper
clearly.
Sense of Taste Auditory acuity: The The sense of taste of the

clarity or clearness of client is normal which
hearing, a measure of how indicates that his taste
After asking Mr. Pabalan to well a person hears. buds were functioning
cover both his eyes, he was Auditory acuity is well.
asked to differentiate measured in order to
different food tastes in determine a person's need
which the student nurse used for a hearing aid (Stoppler,
sugar for sweet, coffee for 2021).
bitter, salt for salty taste, and
droplets of calamansi juice
Sense of Smell for sour. The client was able
to differentiate each taste A person usually The client was able to
identifies the taste of recognize what aromatic is
Patency of nostrils was bitter, sweet, sour, and being asked. Therefore, he
noted. Tenderness, salty. By the use of our has a normal sense of
discharge, trauma, bleeding, sense of taste, we can fix smell as well as external
lesions, masses, swelling or adjust the taste of our appearance of the nose
and asymmetry were not food based on our capacity
15
observed. His internal nose (Blue, 2018)
was clean. Smell test was
used and he was able to
differentiate the odor of
coffee and the smell of Touch consists of
perfume. several distinct sensations
communicated to the brain
through specialized
neurons in the skin.
Pressure, temperature,
light touch, vibration, pain
and other sensations are all
part of the touch sense and
are all attributed to
Tactile different receptors in the
skin (Bradford, 2017). The sensory transmission
of the client is functioning
well.
The client was asked to

close his eyes and then the
student nurse asked him to
hold things like paper and
cloth. He was able to
differentiate the two based
on its texture. The SN also
used a test tube with hot or
cold water and then pat it on
the skin of client. He was
able to identify if it is cold
or hot
Motor Stability During the assessment, the Stability skills are The gait and balance of
student nurse observed that a type of gross motor skill Mr. Pabalan are well
Mr. Pabalan is able to stand involving balance and coordinated. He has no
on his own and has good weight transfer. To master difficulty in moving his
balance. While walking, he these skills, children must body parts and can
shows no sign of difficulty be able to maintain various perform ROM.
in moving from one place to body positions, as well as
another. The Range of adjust them, without
Motion (ROM) was also falling. It takes muscle
assessed through rotating or strength and body
bending of shoulders and awareness (or
elbows, flexing of knees, proprioception) to be able
ankles, and feet. He was able to gain balance and hold it
to move the different parts while moving around, or
of the body being asked. even staying still. (H.
16
Catherine, 2020)
st
Body Temperature 1 day of Assessment: Normal axillary The recorded temperatures
37.2 ⁰C temperature is within 36.4 from all the day of
to 37.4 degrees Celsius. A assessment are within the
single temperature reading normal range.
2nd day of Assessment: does not always indicate a
37.1 ⁰C fever (Potter, et al, 2021)
3rd day of Assessment:

36.9⁰C
Respiratory Status 1st day of Assessment: Respiration rates The respiratory rate of Mr.
18 bpm may increase with Pabalan is within the
exercise, fever, illness, and normal range. No
2nd day of Assessment: with other medical abnormal signs in
17bpm conditions. When checking breathing but the
respiration, it's important respiratory might get
3rd day of Assessment: to also note whether you affected soon if he will
17bpm have any trouble continuously smoke
breathing. Normal cigarettes.
respiration rates for an
Shoulders were at the same adult person at rest range
level as he inhaled and from 12 to 20 breaths per
exhaled. No increased minute (URMCR, 2021).
respiratory effort was noted.
Breathing is fine and
respirations are regular and
in rhythm. But the client
often uses cigarettes
Circulatory Status 1st day of Assessment: The normal cardiac During the 1st day of
PR: 102 bpm rate for an adult is 60-100 assessment, the cardiac
BP: 116/74 mmHg beats per minute while for rate of the client exceeds
a normal reading of blood within normal range. This
2nd day of Assessment: pressure, it needs to show might be due to his vice of
PR: 89 bpm a top number (systolic frequently smoking
BP: 112/78 mmHg pressure) that’s between cigarette. The cardiac rate
90 and less than 120 and a on the following days
3rd day of Assessment: bottom number (diastolic were normal. His blood
PR: 90 bpm pressure) that’s between pressure is normal on all
BP: 120/72 mmHg 60 and less than 80. days of assessment
(Kozier, 2017).
Nutritional Status According to the client, he Adequate food The food diet of Mr.
usually eats 3 times a day. intake consists of a Pabalan is considered
His diet includes a wide balance of nutrients such normal since it includes
range of foods such as meat as water, carbohydrates, different types of food.
(fish, pork, and chicken), proteins, fats, vitamins, But his vices can interfere
17
green and leafy vegetables, and minerals. The normal in him having a good
fruits, and rice. He usually eating pattern of a person nutritional status.
prefers eating vegetables is a minimum of three
during meals than meat. He times per day depending
drinks 8 glasses of water upon the metabolic
each day. He has vices demand and needs of the
which includes smoking patient. Most of the
cigarettes and drinking school-age slum children
alcohol. in our study had a poor
nutritional status.
Interventions such as
skills-based nutrition
education, fortification of
food items, effective
infection control, training
of public healthcare
workers and delivery of
integrated programs are
recommended. (Kozier &
Erb's, 2018 and Potter, et
al, 2021)
Elimination Status As stated by the client, he Normal urinary The elimination status of
usually defecates one times a output of a person is 2 Mr. Pabalan is normal
day. As for his urination, he liters per day and should since the frequency in
usually voids 3 times a day typically defecate from defecation and voiding is
and described the color as once a day to every 3 to 5 within the normal and
clear to yellowish brown days. Feces are normally usual range.
with no strong odor. brown in color and soft but
formed. (Kozier & Erb's,
2018)
Reproductive The client stated that he had Menarche usually His reproductive status is
Status been circumcised at the age begins between the ages of normal. As indicated on
of 12. He and his wife 9–15, about two years the number of children, he
already have 3 children. No after the onset of puberty. and his wife are sexually
recorded sexually The average age of active.
transmitted disease. menarche is 12–13, but it
can be normal for it to
happen earlier or later.
(Yermachenko, 2018).
Sleep-rest Pattern He stated that his usual Getting enough The total sleeping hours of
sleeping pattern starts from sleep is essential for the client is usually about
around 10:00 pm in the helping a person maintain 8 hours of sleep each day.
evening until 6:00 am in the optimal health and well- As compared to the norms,
morning. He usually wakes being. When it comes to Mr. Pabalan still has a
up 6:00am in the morning to their health, sleep is as normal number of sleeping
prepare for the his work. vital as regular exercise hours and was able to rest
18
After a long day in work, he and eating a balanced diet despite bunch of works.
usually rest for a while as he (Fletcher, 2019).
arrives home.
State of Skin As the student nurse The skin He has a normal condition
Appendages assessed the client, it was appendages are epidermal of skin appendages. No
observed that the client has and dermal-derived abnormalities were found
fair complexion of skin that components of the skin during the assessment
was warm to touch and not that include hair, nails,
tender. No localized or sweat glands, and
systemic edema and sebaceous glands. Each
tenderness observed.There component has a unique
are no IV sites on the hands structure, function, and
of the client and no presence histology. This article
of phlebitis. The describes the unique
conjunctivae of the client are characteristics of each of
pinkish on both side and not these components and
dry. The nails on both provides insight into tissue
fingers and toes of the client preparation for
are trimmed and only the microscopic evaluation
fingernails looked clean. The and the clinical
skin looks smooth and not significance of these
dry. The hair of the client is structures (Yousef, Miao,
color black with slightly et al. 2021).
heavy even-distributed hair
strands. The scalp of the
client has dandruff.
19
Zoraida P. Pabalan
Age: 48 y/o
Social Status Mrs. Pabalan is 48 years old, Social status is the Mrs. Pabalan maintains a
born on 12nd day of January position one hold's in a good relationship with her
1975. She is currently group or community. It is family, friends, neighbors
residing in Camella Homes, social support that builds and even on her
Maliwalo,Tarlac City people up during times of customers. During stress,
together with her kids . She stress and often gives she’s able to manage it
currently has a small business them the strength to carry through the help of her
with her sister and works as a on and even thrive support system which is
cosmetic product in the (Cherry, 2020) her family.
market near their barangay.
Since she is a seller in a
market, she has time to
socialize with others
particularly on her customers.
Within their home, she is
strict with her children but
she is still able to interact
with them. Sometimes when
she got home and his husband
is drunk he create a argument
but the client stated that they
were in the good term it’s that
he is just being concern on
her husband health. In their
neighborhood, she is able to
interact with her neighbors
every day. Her support
system is her family, friends,
and her mother.
Mental Status
> General Upon interviewing Mrs. Appearance is described On her educational

Appearance and Pabalan, it is noticeable that as background, it is on a
Behavior her clothes are all clean. Her wellgroomed/disheveled, normal state. Even though
hair was neat . Both of her how they are dressed, she was not able to finish
fingernails and toenails are demeanor in interview, her studies, she’s still able
clean and trimmed. As she level of eye contact. In to read, write and
stated, she was only able to males - shaving. As understand the things
graduate with high school appropriate, physical being said to her. She
degree. She said that she can behavior such as looked presentable during
read and write. She restlessness, motor the assessment
cooperates well and even Activity (retardation/over
20
accompanied the student activation) Level of co-
nurse all throughout the operation, any evidence
assessment days. of aggression or hostility.
Overfamiliarity, for
instance touching
interviewer
inappropriately (MSE,
n.d)
>Level of She was coherent, well- She is well oriented to

consciousness and oriented and cooperative The normal state of time and place that she is
orientation during the whole interview consciousness comprises in. She was able to answer
session. She was able to either the state of well during each
respond to each question wakefulness, awareness, assessment and cooperates
thrown at her aptly. She was or alertness in which well with the student
able to respond accurately most human beings nurse.
and quickly when asked function (Tindall, 1990).
about her name, their address, Being oriented to place
her line of work, her children, and time means that you
her husband and other vital know who you are,
question concerning herself where you are, where
and most importantly, her you live, and what time it
family. is. When consciousness
is decreased, your ability
to remain awake, aware,
and oriented is impaired
(Lights, 2019)
>SPEECH
She is very articulate and she Rate ranges from Her way of
doesn't exert too much effort "poverty of speech" with communication through
in talking and explaining few utterances to verbal manner is normal
things. Her way of talking "pressure of speech", and can easily be
was loud and clear and spontaneity with little or understood.
understandable no spontaneous
utterances to
circumstantiality with
overinclusion of detail,
volume: from low to
high, rhythm:
monotonous, without
variation or inflection;
staccato, with frequent
pauses between fluent
speech and normal., tone:
ranges from low to high
21
(MSE, n.d)
Emotional Status After asking for her During adulthood, here is e support for the view that
condition, she said that she is some support for the people do undertake a sort
feeling well. The student view that people do of emotional audit,
nurse asked if there is undertake a sort of reevaluate their priorities,
something that bothers her emotional audit, and emerge with a slightly
like fear of something, reevaluate their priorities, different orientation to
anxiety, or grief. And she and emerge with a emotional regulation and
stated that there is nothing slightly different personal interaction in this
specifically that bothers her. orientation to emotional time period (Lumen, n.d).
Her support system in case of regulation and personal Her emotional status is
stress is mainly her Child. interaction in this time normal since there is
She also stated that she is an period (Lumen, n.d). nothing that bothers her.
optimistic type of person. She has a good support
system to help her cope up
during stress
Sensory Perception
Sense of sight For the near visual acuity test, Normal vision is The client has a normal
Mrs. Pabalan was asked to considered 20/20. A vision as indicated in the
read the words on a paper visual acuity of 20/50 near visual test. The
with a distance of about 14 indicates that the patient extraocular muscle
inches. She was able to read can read from 20 ft what movements are normal as
the different words written on a person with normal well as the pupillary
that paper. When a light was acuity (20/20 vision) can response of both eyes. The
pointed towards the pupil of read from 50 ft (Shultz client is not color blind.
client using a penlight, both et.al., 2016)
pupils were able to constrict.
Upon checking the
appearance of the eyes, it was
noted that both eyes are
symmetrical. The sclera is
color white. The eyes are
moving symmetrically while
performing the extraocular
muscle movement test. The
client is able to state the right
names of color that was
presented to her. There are no
lesions or swelling on both
eyes
Sense of Taste The client’s sense of taste
A person usually is normal.
The student nurse used identifies the taste of
different types of food for bitter, sweet, sour, and
assessing the sense of taste. salty. By the use of our
22
These include sugar for sense of taste, we can fix
sweet, coffee for bitter, salt or adjust the taste of our
for salty taste and calamansi food based on our
juice for sour. The client’s capacity (Blue, 2018).
eyes were covered during the
assessment. She was able to
differentiate each taste
Sense of hearing The hearing acuity of Mrs.

Pabalan is normal and no
The appearance of her An adult is classified as signs of abnormalities are
external ears are clean, free having normal hearing recorded
from tenderness, swelling, ability if their responses
thickening, lesions, and they indicate they heard
are symmetrical in size. For noises between 0 and 25
auditory sense, a noninvasive dB across the frequency
test was used such as the range (Mroz, 2020). For
voice test (whisper test). She auditory acuity, the
was asked to repeat all the patient should be able to
words whispered by the repeat the words
student nurse on each ear. whispered from a
After the nurse whispered, the distance of two feet.
client was able to repeat all (Estes, 2014)
the words and she stated that
she heard those words clearly.
Sense of Smell Client was able to

recognize each smell
which indicates that the
Patency of nostrils was noted. To determine the olfactory sense is normal.
Tenderness, discharge, presence of smell, have
trauma, bleeding, lesions, the patient close both
masses, swelling and eyes and describe or
asymmetry were not identify a particular scent
observed. Her internal nose that you wave under the
was clean. Aromatics like nose. The scent should be
coffee and perfume were used one that the patient is
for olfactory test. Both of her familiar with and able to
eyes were covered first before identify under normal
assessing. Mrs. Pabalan was circumstances (Shultz
able to identify the aromatics et.al., 2016). Nose must
being asked. be symmetrical and along
of the face. Each nostril
must be patent and
recognize the smell of an
Tactile object (Estes, 2014) The sensory signals were
23
transmitted immediately
along the sensory
pathways which indicates
After covering both eyes, the Tactile receptors identify a normal state of the
student nurse used paper and the sensation of touch client’s sense of touch.
cloth for the test. She was and are all over our
asked to hold the items and bodies in our skin. Some
differentiate or identify each areas of our skin have
based on the texture. A test more tactile receptors
tube with hot/cold water was than other areas e.g.
also used and was placed on mouth and hands. The
the skin of the client. The tactile senses are
client was able to identify important for identifying
whether the test tube contains touch, pressure, pain,
hot or cold water. temperature and texture
(Sensory Processing
Resource, 2021)
Motor Stability While the client is standing, it Balance is not only The gait and balance of the
was observed that she can important for relatively client are well coordinated
stand on her own and has a stationary positions such and normal. She shows no
good balance. Her walking as sitting and standing, sign of difficulty in
ability shows no sign of but also it provides the moving his body parts and
difficulty as she moves from necessary stable base to no discomfort felt during
one place to another. The support movements of ROM exercise. No signs
Range of Motion (ROM) was the head, torso, or limbs of abnormal body
also assessed through rotating (Adolph, 2003). There formation was found.
or bending of shoulders and should be absence of
elbows, flexing of knees, discomfort during range
ankles, and feet. Mrs. Pabalan of motion exercise.
can move the body parts (Estes, 2006)
being asked in a normal range
of motion.
Body Temperature 1st day of Assessment: Normal body The axillary temperature
36.9 ⁰C temperature varies by of the client on all days of
person, age, activity, and assessment is normal.
2nd day of Assessment: time of day. The average
36.8 ⁰C normal body temperature
is generally accepted as
rd
3 day of Assessment: 98.6°F (37°C). Some
37.1 ⁰C 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). (MedlinePlus,
2021)
24
Respiratory Status 1st day of Assessment: Respiration rates may The respiratory rate is
17 bpm increase with exercise, considered normal on all
fever, illness, and with days of assessment. No
2nd day of Assessment: other medical conditions. abnormal conditions were
20 bpm When checking noted.
respiration, it's important
3rd day of Assessment: to also note whether you
19 bpm have any trouble
breathing. Normal
respiration rates for an
Shoulders were at the same adult person at rest range
level as she inhaled and from 12 to 20 breaths
exhaled. No increased
respirations are regular and in
rhythm.
Circulatory Status 1st day of Assessment: The normal cardiac rate The cardiac rate of the
PR: 88 bpm for an adult is 60-100 client on the 1st, 2nd and
BP: 118/74 mmHg beats per minute while 3rd day of assessment is
for a normal reading of normal as well as her
2nd day of Assessment: blood pressure, it needs blood pressure
PR: 92 bpm to show a top number
BP: 120/76 mmHg (systolic pressure) that’s
between 90 and less than
3rd day of Assessment: 120 and a bottom number
PR: 86 bpm (diastolic pressure) that’s
BP: 118/70 mmHg between 60 and less than
80. (Kozier, 2017)
Nutritional Status As stated by the client, she Nutritional status is a The nutritional status of
eats 3 times a day and drinks requirement of health of the client is considered
up to 10 glasses of water each a person convinced by normal since she usually
day. She does not have the diet, the levels of eats all types of food that
history of condition that nutrients containing in supplies her body with
affects her diet. She had a the body and normal enough nutrients. Her
regular diet which consists metabolic integrity. status is not affected by
mainly of vegetables, meats Normal nutritional status any vices and bad habits
such as fish, chicken and is managed by balance
pork, fruits, rice, and dairy food consumption and
products like milk and normal utilization of
cheese. As per her also, she nutrients (NSRA, 2021).
has no bad habits in diet and Normal eating pattern is
no vices. considered to be at least
three times a day
depending on the
metabolic demands and
25
needs of the patient.
Fluid intake should be 8-
10 glasses per day
(Monahan, 2017
Elimination Status Mrs. Pabalan usually defecate Normal bowel movement The elimination status of
once a day and voids up to 4 of a person must be 1 to Mrs. Romano is normal
times a day. She described 2 times a day and voiding since she has enough urine
her stool with brown color in 3 to 4 times a day with output and her stool is
and not watery in consistency an output of 1200 to normal. The frequency of
while her urine is light yellow 1500mL a day. A normal elimination is in normal
in color; she has no difficulty stool is brown in color range.
in voiding or defecating. and well formed, urine is
clear to yellowish in
color. (Kozier, 2017)
Reproductive She stated that her first It occurs approximately The onset of her menarche
Status menstruation occurred when every 28 days, with a occurred within the normal
she was on her first year in range from every 21 to age. Her reproductive
high school, around 13 years every 45 days. The status is considered as
of age. She has an OB score average age of onset of normal.
of G4T4P0A0L4. No history menarche is 12.4 years
of sexually transmitted (Lacroix, 2020).
disease.
Sleep-rest Pattern The client stated that she is Sleep refers to altered The sleeping pattern of
already asleep at 9:00 pm in consciousness with Mrs. Pabalan is considered
the evening and wakes up at general slowing of as normal since it did she
5:00 am in the morning to physiological process meet the normal range of
prepare before going into the while rest refers to sleeping hours.
market for her business. relaxation and calmness,
Since she is usually tired after both mental and physical.
work, she regains energy by A typical sleeper will
getting some sleep in the pass through 7 to 9 hours
afternoon for about 30 of sleep and take a rest
minutes to 1 hour. using some relaxation
activities such as reading,
telling stories and others
(Daniels, 2015)
State of Skin During assessment, it was During assessment, it The texture and color of
Appendages noticed that the skin was noticed that the skin her skin is normal. There
complexion of the client is complexion of the client is a localized tenderness
warm to touch. There are no is warm to touch. There on the wound on her left
sites for IV injections and no are no sites for IV foot.
phlebitis observed. Both injections and no
conjunctivae of the eyes are phlebitis observed. Both
pinkish and not dry. The nails conjunctivae of the eyes
of the client are trimmed and are pinkish and not dry.
clean. Her skin is not dry. Her The nails of the client are
26
hair is black in color and has trimmed and clean. Her
even distribution of hair skin is not dry. Her hair
strands. The scalp has limited is black in color and has
dandruff found. She has small even distribution of hair
wound in her left leg. strands. The scalp has
limited dandruff found.
She has small wound in
her left leg.
27
Maxene Dhale P. Pabalan
Age: 19y/o

Social Status Maxene Dhale is 19 years old, Social status is the She gets along with
born on July 23, 2002. She is position one hold's in a his family, colleagues,
currently living together with group or community. It and classmates well.
his parents and two siblings. is social support that
She is now in 2nd year college builds people up during
and able to communicate with times of stress and often
her classmates using online gives them the strength
tools. As she stated, she has an to carry on and even
interactive relationship with thrive (Cherry, 2020).
her siblings, they sometime
play and have fun through
mobile gaming. When it
comes to her parents, she is
more close to the father than
the mother but they still able
to interact with each other
without hesitation. She has a
lot of friends in their neighbor
and they always play together
using their phones.
Mental Status
> General During the initial assessment, Appearance is described The general
Appearance and Her hair is newly cut and neat; as appearance of John
Behavior skin is smooth and not dry; wellgroomed/disheveled, Lloyd is normal and
and both of her fingernails and how they are dressed, he’s properly
toenails are cleaned and demeanor in interview, groomed. His answers
trimmed. She is currently in level of eye contact. In to the questions was
college and was able to read males - shaving. As matched on his
and write. She was able to appropriate, physical educational level.
respond on questions being behavior such as
asked but there are some restlessness, motor
questions that she needs to Activity
consult her parents first before (retardation/over
answering activation) Level of co-
operation, any evidence
of aggression or
hostility.
instance touching
interviewer
28
n.d)
>Level of During interview, she was able She was able to

consciousness and to communicate and can The normal state of answer all the
orientation answer most of the questions consciousness comprises questions including
such as her name, their either the state of the time, date, and
address, her parents, and other wakefulness, awareness, place correctly. She is
vital question concerning or alertness in which aware of her
herself and most importantly, most human beings surroundings and able
her family. It is noticeable that function (Tindall, 1990). to respond
he is alert when the student Being oriented to place immediately when
nurse asks questions. and time means that you asked
know who you are,
where you are, where
you live, and what time
it is. When
consciousness is
decreased, your ability
>SPEECH (Lights, 2019).
Her way of talking to the
student nurse when being Rate ranges from She has good
asked was clear and "poverty of speech" with communication skill
understandable. She was able few utterances to toward other people.
to elaborate his answers "pressure of speech", He was able to deliver
appropriately spontaneity with little or the message of what
no spontaneous he wanted to say
utterances to
volume: from low to
high, rhythm:
monotonous, without
speech, and normal.,
tone: ranges from low to
high (MSE, n.d)
Emotional Status She was asked on what She During adulthood, here The emotional status
feels at the moment. As what is some support for the of the client is normal.
She stated, there is nothing view that people do She has good stress
that bothers her at the time of undertake a sort of coping mechanism
29
the assessment and insisted emotional audit,
that she is okay and feeling reevaluate their
well. The presence of fear, priorities, and emerge
anxiety, grief, tremors, with a slightly different
uncertainty, irritability, panic, orientation to emotional
and tension were all negative. regulation and personal
At the time of stress, she was interaction in this time
able to manage it by himself or period (Lumen, n.d).
sometimes she asks her family
for guidance.
Sensory Perception
Sense of sight The student nurse performed a Normal vision is She has normal vision
near visual test. The client was considered 20/20. A as shown in the near
asked to read the words visual acuity of 20/50 visual test. She also
written on a paper with a indicates that the patient has normal
distance of 14 inches and she can read from 20 ft what extraocular muscle
was able to read them a person with normal movements and
correctly. The iris of his eyes acuity (20/20 vision) can pupillary response to
is black in color, both his eyes read from 50 ft (Shultz light. The client is
are symmetrical in shape and et.al., 2016) also not considered as
is round, has white sclera, and color blind
no lesions and tenderness were
noted. The extraocular muscle
movement test shows that her
eyes are moving symmetrical
with each other. The student
nurse also used color cards to
ask the patient on what color is
being presented. The client
was able to answer all the
colors correctly. Upon striking
a light into the pupils of the
client, it was able to constrict
as it reacts to the light.
Sense of Taste A person usually
The client was asked to identifies the taste of The gustatory sense of
identify the taste of the food bitter, sweet, sour, and the client is normal
given to her while her eyes salty. By the use of our and able to
were covered. The student sense of taste, we can fix differentiate the taste
nurse prepared sugar for or adjust the taste of our of the foods given to
sweet, coffee for bitter, salt for food based on our him which indicates a
salty taste, and calamansi juice capacity (Blue, 2018) normal functioning of
for sour. She was able to her taste buds.
determine and differentiate
what is what because of their
30
contrasting taste.
To determine the
Sense of hearing presence of smell, have
Patency of nostrils was noted. the patient close both The olfactory sense of
Tenderness, discharge, trauma, eyes and describe or the client is normal
bleeding, lesions, masses, identify a particular and able to recognize
swelling and asymmetry were scent that you wave an object through its
not observed. Her internal under the nose. The smell.
nose was clean. The student scent should be one that
nurse used different aromatics the patient is familiar
like coffee and perfume. The with and able to identify
client was asked to cover his under normal
eyes and determine the item he circumstances (Shultz
smells. He was able to identify et.al., 2016). Nose must
which of those is the coffee or be symmetrical and
perfume. along of the face.
Sense of Smell To determine the

presence of smell, have
Patency of nostrils was noted. the patient close both The olfactory sense of
Tenderness, discharge, trauma, eyes and describe or the client is normal
bleeding, lesions, masses, identify a particular and able to recognize
swelling and asymmetry were scent that you wave an object through its
not observed. Her internal under the nose. The smell
nose was clean. The student scent should be one that
nurse used different aromatics the patient is familiar
like coffee and perfume. The with and able to identify
client was asked to cover his under normal
eyes and determine the item he circumstances (Shultz
smells. He was able to identify et.al., 2016). Nose must
which of those is the coffee or be symmetrical and
perfume. along of the face. Each
nostril must be patent
and recognize the smell
of an object (Estes,
2014)
Tactile
Tactile receptors identify

She was asked to close both the sensation of touch The sensory
his eyes and hold the item that and are all over our transmission functions
the student nurse will give to bodies in our skin. Some of the client are
him. The items include paper areas of our skin have normal.
31
and cloth. John Lloyd was able more tactile receptors
to identify what are those he is than other areas e.g.
currently holding. The next mouth and hands. The
test was for differentiating tactile senses are
what is cold and what is hot. important for identifying
Test tube with hot/cold water touch, pressure, pain,
was used for assessment and temperature and texture
then patted it on the skin of the (Sensory Processing
client. He was asked on what Resource, 2021).
he feels and answered
correctly on which of the test
tube has hot or cold content.
Motor Stability She stands on his own without Balance is not only Her gait and balance
the help of any support. She important for relatively is normal and
was able to move from one stationary positions such wellcoordinated.
point to another without any as sitting and standing, There is no sign of
hassle or complaint. Her but also it provides the difficulty during range
Range of Motion (ROM) was necessary stable base to of motion exercise.
assessed through rotating or support movements of
bending of shoulders and the head, torso, or limbs
elbows, flexing of knees, (Adolph, 2003). There
ankles, and feet. she was able should be absence of
to move without complaining discomfort during range
for discomforts of motion exercise.
(Estes, 2006)
Body Temperature 1st day of Assessment: Normal body The axillary
36.8 ⁰C temperature varies by temperature of the
person, age, activity, and client on all days of
2nd day of Assessment: time of day. The average assessment is normal.
36.7 ⁰C normal body
temperature is generally
3rd day of Assessment: accepted as 98.6°F
37.1 ⁰C (37°C). Some studies
have shown that the
"normal" body
(36.1°C) to 99°F
2021)
Respiratory Status 1st day of Assessment: Respiration rates may The respiratory rate is
19bpm increase with exercise, considered normal on
fever, illness, and with all days of
2nd day of Assessment: other medical assessment. No
20 bpm conditions. When abnormal conditions
checking respiration, it's were noted.
32
3rd day of Assessment: important to also note
19 bpm whether you have any
trouble breathing.
Normal respiration rates
Shoulders were at the same for an adult person at
level as she inhaled and rest range from 12 to 20
exhaled. No increased breaths
respirations are regular and in
rhythm.
Circulatory Status 1st day of Assessment: The normal cardiac rate The cardiac rate of the
PR: 87 bpm for an adult is 60-100 client on the 1st, 2nd
BP: 118/74 mmHg beats per minute while and 3rd day of
for a normal reading of assessment is normal
2nd day of Assessment: blood pressure, it needs as well as her blood
PR: 92 bpm to show a top number pressure
BP: 120/76 mmHg (systolic pressure) that’s
3rd day of Assessment: 120 and a bottom
PR: 86 bpm number (diastolic
BP: 118/70 mmHg pressure) that’s between
60 and less than 80.
(Kozier, 2017)
Nutritional Status According to her and her Nutritional status is a The food diet in their
parents, the usual diet that they requirement of health of family is normal since
have in their home includes a person convinced by it gives them adequate
variety of vegetables, fruits, the diet, the levels of nutrients for their
pork, chicken, fish, dairy nutrients containing in everyday lives. There
products, and rice. He does not the body and normal are no factors, coming
have any vices. He was able to metabolic integrity. from vices, than may
consume 7-9 glasses of water Normal nutritional status affect his health.
every day. is managed by balance
food consumption and
normal utilization of
nutrients (NSRA, 2021).
Normal eating pattern is
considered to be at least
three times a day
depending on the
10 glasses per day
(Monahan, 2017)
Elimination Status The client defecates at least Normal bowel Based on the
33
once a day, usually after lunch. movement of a person assessment, the
He urinates about 4 times a must be 1 to 2 times a elimination status of
day and his urine do not have day and voiding in 3 to 4 the client is
strong, foul odor and is times a day with an considered normal.
yellowish in color output of 1200 to
1500mL a day. A normal
stool is brown in color
and well formed, urine is
clear to yellowish in
color. (Kozier, 2017)
Reproductive She stated that her first It occurs approximately The onset of her
Status menstruation occurred when every 28 days, with a menarche occurred
she was on her first year in range from every 21 to within the normal age.
high school, around 13 years every 45 days. The Her reproductive
of age. No history of sexually average age of onset of status is considered as
transmitted disease. menarche is 12.4 years normal.
(Lacroix, 2020).
Sleep- Rest Pattern The client usually asleep at Sleep refers to altered The total sleeping
12:00 am and wakes up at 9:00 consciousness with hours of Maxene is
am in the morning. He was general slowing of usually 9 hours each
able to rest some time of the physiological process day which is in the
day while he plays with his while rest refers to normal range of hours
phone. He is awake until relaxation and calmness, of sleep. But the
midnight due to his excessive both mental and sleeping time is not
usage of mobile phone. physical. A typical normal due to
sleeper will pass through excessive use of
7 to 9 hours of sleep and gadgets. adequate
take a rest using some amount of hours for
relaxation activities such rest.
as reading, telling stories
and others (Daniels,
2015).
State of skin As the student nurse assessed Skin surfaces should not The condition of his
appendages and palpate her skin it was be tender, and the skin is skin appendages is
noticed that her skin is fair in dry with a minimum of considered normal.
color, no tenderness and it is perspiration. Skin No abnormalities
smooth, and has no presence temperature should be were found.
of any edema. There are no IV warm and equal
sites on both hands. The bilaterally, hands and
conjunctivae of the client are feet maybe slightly
both pinkish and not dry. cooler than the rest of
Toenails and fingernails the body. Skin should
looked clean and were normally feel smooth.
trimmed. The hair was neat The skin turgor should
and has evenly distributed hair return within 2-3
strands. The scalp has limited seconds and edema
34
amount of dandruff. should not normally
present. The skin should
be free from lesions and
inflammation (Estes,
2014)
Lexter John P. Pabalan

Age: 18 y/o
Social Status Patient is 18 years old resident Social status is the Mr. Lexter has a
of B7 L7 P3, Camella Homes, position one hold's in a good relationship with
Maliwalo, Tarlac City group or community. It his family and friends.
verbalized that he is in 1st year is social support that
college student and he is builds people up during
taking up a Bachelor of times of stress and often
Science and information in gives them the strength
technology,He is currently to carry on and even
living together with his parents thrive (Cherry, 2020).
and two siblings As she stated,
he has an interactive
relationship with her siblings,
they sometime play and have
fun through mobile gaming.
When it comes to her parents,
she is more close to the father
than the mother but they still
able to interact with each other
without hesitation. He has a
lot of friends in their school
but since it is online class he
easily got bored and play
games on his phone
Mental Status The client’s cloth is The patient should He looks
presentable and clean. His hair appear relaxed with the properly groomed at
> General was not trimmed. His teeth are appropriate amount of the time of the visit.
Appearance and not complete and has some concern for the he had no excessive
Behavior dental carries. His fingernails assessment. The patient movement, and no
and toenails were not trimmed should exhibit erect discomfort was felt
properly and there’s a slight posture, smooth gait and during the
presence of dirt in them. He symmetrical body assessment. He
cooperates well with the movement. The patient exhibits erect posture,
35
students of all the days of should be clean and and symmetrical body
assessment. wellgroomed and movement, and
should wear appropriate smooth gait.
clothing for age,
weather, and
socioeconomic status.
Facial expressions
should be appropriate to
the content of the
conversation and should
be symmetrical (Jensen,
2019) He was able to
answer all the
questions that we ask
correctly. He
responds normally
He was very cooperative and The message's content and appropriately to
>Level of well-oriented during the should correspond to the topics discussed. In
consciousness and interview. He was able to patient's level of addition, he is well-
orientation respond to the questions education. The patient oriented to time and
correctly regarding on the should be able to answer place during the
information that we need for questions accurately and assessment. This
this assessment. He knows identify all of the objects indicates that his level
what to say if asked for her as instructed. Denial and of consciousness and
name, their address, her line of poor eye contact are orientation is normal.
work, her children, and other common reactions
vital question concerning during the first
herself and most importantly, conversation, which may
her family. be attributed to anxiety
over meeting a stranger
or an attempt to screen
or dismiss unwanted
truths by refusing to
acknowledge them. He was able to
(Jensen, 2019) communicate verbally
and clear during the
interview. It is also
consistent and there
>SPEECH During the interview, he stays The patient should be are only minimal
calm while talking. His voice able to produce pauses in his answers
is not too loud but clear and he spontaneous, coherent on the questions. It is
can accurately say the things speech (Jensen, 2019) also observed that he
he wanted to say. In addition, is not nervous and
he was able to elaborate his remained calm during
answers to the question the interview.
properly.
36
Emotional Status The client stated that if they During adulthood, here His support
have misunderstanding at is some support for the system during time of
home, especially with her view that people do stress is his family
older sisters, they often talk undertake a sort of and they were able to
about it for settlement. He also emotional audit, help him to feel at
said that currently, there are no reevaluate their ease.
kinds of things that is priorities, and emerge in addition, he can
bothering him except for his with a slightly different control her emotions
modules that he needs to orientation to emotional that indicates normal
accomplish by the end of regulation and personal emotional status.
every week. The presence of interaction in this time
fear, anxiety, grief, tremors, period (Lumen, 2017).
uncertainty, irritability, panic,
and tension were all negative.
Sensory Perception Normal vision is
His eyes are brown and considered 20/20. A He has a
Sense of sight have a normal vision. There visual acuity of 20/50 normal visual ability.
are no lesions or swelling of indicates that the patient The extraocular
the eyes noted. Both eyes can read from 20 ft what muscle movements
move symmetrically in each 6 a person with normal are normal as well as
cardinal movements. Using a acuity (20/20 vision) can the pupillary response
penlight, the pupils were read from 50 ft (Shultz of both eyes.
observed as dark brown in et.al., 2016).
color, equally round and
reactive to light.
The client was able to

recognize what
aromatic is being
asked. Therefore, he
has a normal sense of
smell as well as
external appearance
of the nose.
The client’s nose is in the A person usually

midline of the face, and it is identifies the taste of
Sense of Taste symmetrical. He was able to bitter, sweet, sour, and
determine and identify salty. By the use of our
different kinds of odors that sense of taste, we can fix His auditory accuracy
was placed near his nose with or adjust the taste of our is normal. No signs of
his eyes closed. The presence food based on our abnormalities were
of any swelling, lesions, capacity (Blue, 2018). observed.
edema or masses was not
37
observed
His taste buds

are functioning well.
Sense of hearing The client has a good hearing Auditory acuity: The No signs of
ability. There is also no clarity or clearness of abnormalities were
redness or swelling in his ear hearing, a measure of observed.
and no tenderness or redness how well a person hears.
upon the assessment. Whisper Auditory acuity is
test was performed in both his measured in order to
ears, and he was able to repeat determine a person's
all the words that was said to need for a hearing aid
him. (Stoppler, 2021).
His sense of
touch is also
functioning well. The
sensory signals were
transmitted
immediately along the
sensory pathways.
Sense of Smell The client has no problem with A person usually

regards to his sense of taste. identifies the taste of
He was able to determine and bitter, sweet, sour, and
identify the food that was salty. By the use of our
given to him with his eyes sense of taste, we can fix
closed. Whether it is sweet, or adjust the taste of our
salty, bitter or sour kind of food based on our
foods. capacity (Blue, 2018)
Sense of Touch The client was asked to hold The skin contains
various things while his eyes receptors for pain,
are close and he was able to pressure, temperature.
identify the things we gave Sensory signals are
him such as paper, pen, and transmitted along rapid
cellphone. He can easily sensory pathways, and
respond to pain and touch. In less distinct signals such
addition, he can also as pressure of localized
differentiate between hot touch are sent via slower
objects and the cold ones. sensory pathways.
(Estes, 2014)
Motor Stability Upon assessment, the Stability skills He has a good
client does not have any are a type of gross motor and normal motor
38
problem when it comes to her skill involving balance stability as he is still
movement such as when and weight transfer. To young. In addition,
running, jumping, sitting, master these skills, He completely uses
walking, and standing. He can children must be able to all the parts of his
move in her own and shows no maintain various body lower extremities
difficulty in doing the things positions, as well as while walking and
she is asked to. According to adjust them, without sitting while showing
the patient, he does not falling. It takes muscle no signs of difficulty.
experience any kinds of pain strength and body
from moving any part of his awareness (or
body and his balance is proprioception) to be
normal. able to gain balance and
hold it while moving
around, or even staying
still. (H. Catherine,
2020)
Body Temperature 1st day of assessment Normal axillary The body
T = 37.0 °C temperature is within temperature is
36.4 to 37.4 degrees considered normal on
2nd day of assessment Celsius. A single the 1st,2nd, and 3rd day
T = 37.2 °C temperature reading of assessment. No
does not always indicate abnormal conditions
3rd day of assessment a fever (Potter, et al, were noted.
T = 36.9 °C 2021)
Respiratory Status 1st day of assessment Respiration rates The
RR = 20 cpm may increase with respiratory is
exercise, fever, illness, considered normal on
2nd day of assessment and with other medical the 1st,2nd, and 3rd day
RR = 18 cpm conditions. When of assessment. No
checking respiration, it's abnormal conditions
3rd day of assessment important to also note were noted.
RR = 18 cpm whether you have any
trouble breathing.
for an adult person at
rest range from 12 to 20
breaths per minute
(URMCR, 2021).
Circulatory Status 1st day of assessment The normal The cardiac
PR = 90 bpm cardiac rate for an adult rate and blood
BP = 110/70 mmHg is 60-100 beats per pressure is considered
minute while for a normal on the 1st,2nd,
2nd day of assessment normal reading of blood and 3rd day of
PR = 92 bpm pressure, it needs to assessment. No
BP = 120/80 mmHg show a top number abnormal conditions
(systolic pressure) that’s were noted.
39
3rd day of assessment between 90 and less than
PR = 96 bpm 120 and a bottom
BP = 120/80 mmHg number (diastolic
pressure) that’s between
(Kozier, 2017)
Nutritional Status The client stated that Adequate food The nutritional
he eats up to 5 times a day intake consists of a status of the client is
which is 3 meals and 2 set of balance of nutrients such considered normal
snacks. He has no culture or as water, carbohydrates, since he has a balance
religious dietary restrictions. proteins, fats, vitamins, diet. She usually eats
His regular diet consists and minerals. The meats with
mainly meats, which is his normal eating pattern of vegetables. But it is
favorite, and usually avoids a person is a minimum recommended that he
vegetable dishes if it is present of three times per day should not avoid
in the table. Though he eats depending upon the fruits and vegetables
fruits and vegetables, it is only metabolic demand and as they are vital as
in minimal amount. In needs of the patient. source of nutrients in
addition, he drinks Most of the school-age our body. His
approximately 8 glasses of slum children in our nutritional status is
water daily. study had a poor not affected by any
nutritional status. vices and bad habits.
Interventions such as
skills-based nutrition
education, fortification
of food items, effective
infection control,
training of public
healthcare workers and
delivery of integrated
programs are
recommended. (Kozier
& Erb's, 2018 and
Potter, et al, 2021)
Elimination Status The client stated that Normal urinary His
he had regular bowel output of a person is 2 elimination status is
movements which she liters per day and should normal and there are
defecates once a day and typically defecate from no abnormalities. His
urinates 4 times daily. He does once a day to every 3 to stool and urine is
not have any difficulty in 5 days. Feces are considered as normal.
eliminating wastes. The color normally brown in color His number of times
of her pee ranges from clear to and soft but formed. urinating, and
yellowish. He described her (Kozier & Erb's, 2018) defecating is also
stool as brown in color and not within the normal
watery. range. No problem in
characteristics of the
40
stool and urine found.
Reproductive Client was still Puberty is the His
Status uncircumcised and there are stage during which reproductive status is
some presences of pubic hair. people reach full normal based on the
The penis has no lesions and reproductive ability and interview. Since the
urethral discharge. Testes develop the adult client is still
normal size without masses or features of their sex. In uncircumcised there
tenderness. No scrotal masses boys, puberty usually was a slight presence
and hernia. In addition, there is occurs between the ages of smegma in the
no history of sexually of 10 and 14 years. penis foreskin.
transmitted disease. However, it is not
unusual for puberty to
begin as early as age 9
or to continue until age
16. (Potter, et al, 2021)
Sleep- Rest Pattern The client usually Getting enough The amount of
sleeps at around 2-3 am in the sleep is essential for time the client sleeps
morning after playing mobile helping a person is 7 hours a day which
games, specifically mobile maintain optimal health within the normal
legends and watching random and well-being. When it range of hours of
videos on social media. He comes to their health, sleep an individual
usually wakes up at around 10 sleep is as vital as need. Even though the
am in the morning. He is able regular exercise and amount of time is
to sleep for at least 7 hours a eating a balanced diet normal, the time of
day and reported no difficulty (Fletcher, 2019). the day he sleeps is
in sleeping. not normal, which is
around 2-3 am due to
the consistent usage
of his gadget in
playing online games.
State of skin It is observed that the The skin appendages are The state of
appendages client’s skin has a fair epidermal and dermal- her skin appendages
complexion and there is no derived components of is normal based on the
presence of neither skin the skin that include observation during
discoloration nor edema. hair, nails, sweat glands, interview. No
In addition, there was no and sebaceous glands. significant
presence of wound, skin Each component has a abnormalities
irritation and lesions were unique structure, were found.
noted. No rashes to be seen function, and histology.
and has normal capillary refill This article describes the
which goes back 2-3 seconds. unique characteristics of
There is no hair loss, and his each of these
nails were short and slightly components and
pinkish in color. No pallor, provides insight into
jaundice, or cyanosis. His hairs tissue preparation for
are dry, evenly distributed, no microscopic evaluation
41
parasite infestations, and and the clinical
well-trimmed. significance of these
structures (Yousef,
Miao, et al. 2021).
Patient is a 32 years old resident of 56 Bayan Park Aurora Hill, Baguio City. Patient
verbalized that he currently provides his basic needs by working as a radio technician.
His wife and relatives are always around helping him in doing his activities of daily
living. Patient is practicing Catholic. He believes that his current condition is due to the
effects of alcohol and believes that he could overcome it.
effects of alcohol and believes that he could overcome it
42
Alexa Sophia P. Pabalan
Age: 6 y/o
Social Status The Client is very talkative at Social status is the The client is very jolly
the age of six Ms. Alexa can position one hold's in a she is the stress
state her age and where she group or community. It reliever in their family
lived and what are the names is social support that and she can socialize
of her family. She is currently builds people up during with anyone
starting her grade school times of stress and often
which she is now a grade one gives them the strength
student. Since she is the to carry on and even
youngest her mother is very thrive (Cherry, 2020).
strict to her when using
gadgets and cellphones
particularly she have many
friends on their neighbors As
the client stated she always
play with her Sister and
brother after she sleep in the
afternoon she stated that her
favorite playmate is her father
43
since it is pandemic she is not
allowed to go outside to play
with her friends. Also she is
not a shy type person and can
entertain the visitors by
singing and dancing
Mental status
> General During the visitation Alexa Appearance is described On the client status
Appearance and Sophia took a bath already and as the client is on the
Behavior she have a neat clothes and wellgroomed/disheveled normal state. Even
hair. Also her nails are been , how they are dressed, though she is still
trimmed. The client can count, demeanor in interview, young and starting
write and read. Since She is level of eye contact. In school she could
still a kid when the student males - shaving. As cooperate very easy
nurse are interviewing her appropriate, physical and understand the
she’s easily distracted but the behavior such as things the being ask.
client could cooperate with the restlessness, motor She is very
student nurse with respect Activity presentable and neat
(retardation/over during the assessment.
activation) Level of co-
operation, any evidence
of aggression or
hostility.
instance touching
interviewer
n.d)
The Client is very cooperative She is well oriented to

>Level of and coherent in the whole The normal state of time and place that
consciousness and interview. She is very consciousness comprises she is in. She was able
orientation responsive into the question either the state of to answer well during
that being ask and aware on wakefulness, awareness, each assessment and
can state her age and where or alertness in which cooperates well with
she lived and what are the most human beings the student nurse.
names of her family. Since she function (Tindall, 1990).
was a kid she have so many Being oriented to place
clarification when we are and time means that you
asking a few question she is know who you are,
very curious about anything where you are, where
but she is very well cooperated you live, and what time
and playful all though out the it is. When
assessment consciousness is
44
decreased, your ability
>SPEECH (Lights, 2019). Her way of
communication
She is very articulate and she Rate ranges from through verbal
doesn't exert too much effort "poverty of speech" with manner is normal and
in talking and explaining few utterances to can easily be
things. Her way of talking was "pressure of speech", understood.
loud and clear and spontaneity with little or
understandable. no spontaneous
utterances to
volume: from low to
high, rhythm:
monotonous, without
speech, and normal.,
tone: ranges from low to
high (MSE, n.d)
Emotional Status After asking for her condition, During adulthood, here Her emotional status
she said that she is feeling is some support for the is normal since there
well. The student nurse asked view that people do is nothing that bothers
if there is something that undertake a sort of her. She has a good
bothers her like fear of emotional audit, support system to help
something, anxiety, or grief. reevaluate their her cope up during
And she stated that there is priorities, and emerge stress.
nothing specifically that with a slightly different
bothers her. Her support orientation to emotional
system in case of stress is regulation and personal
mainly her husband. She also interaction in this time
stated that she is an optimistic period (Lumen, n.d).
type of person
Sensory Perception
She has a normal
Sense of sight Her eyes are brown and have a Normal vision is visual ability. The
normal vision. There are no considered 20/20. A extraocular muscle
lesions or swelling of the eyes visual acuity of 20/50 movements are
noted. Both eyes move indicates that the patient normal as well as the
symmetrically in each 6 can read from 20 ft what pupillary response of
cardinal movements. Using a a person with normal both eyes.
penlight, the pupils were acuity (20/20 vision) can
observed as dark brown in read from 50 ft (Shultz
45
color, equally round and et.al., 2016)
reactive to light.
The client has no problem with A person usually Her taste buds are
Sense of Taste regards to his sense of taste. identifies the taste of functioning well. No
He was able to determine and bitter, sweet, sour, and signs of abnormalities
identify the food that was salty. By the use of our were observed.
given to her with eyes closed. sense of taste, we can fix
Whether it is sweet, salty, or adjust the taste of our
bitter or sour kind of foods. food based on our
capacity (Blue, 2018)
Sense of hearing The client has a good hearing To determine the

ability. There is also no presence of smell, have Her auditory accuracy
redness or swelling in his ear the patient close both is normal. No signs of
and no tenderness or redness eyes and describe or abnormalities were
upon the assessment. Whisper identify a particular observed.
test was performed in both his scent that you wave
ears, and he was able to repeat under the nose. The
all the words that was said to scent should be one that
her the patient is familiar
with and able to identify
under normal
circumstances (Shultz
et.al., 2016). Nose must
be symmetrical and
along of the face.
Sense of Smell The client’s nose is in the To determine the The client was able to
midline of the face, and it is presence of smell, have recognize what
symmetrical. He was able to the patient close both aromatic is being
determine and identify eyes and describe or asked. Therefore, he
different kinds of odors that identify a particular has a normal sense of
was placed near his nose with scent that you wave smell as well as
his eyes closed. The presence under the nose. The external appearance of
of any swelling, lesions, scent should be one that the nose.
edema or masses was not the patient is familiar
observed with and able to identify
under normal
circumstances (Shultz
46
et.al., 2016). Nose must
be symmetrical and
along of the face. Each
nostril must be patent
and recognize the smell
of an object (Estes,
2014)
Motor Stability Upon assessment, the Balance is not only Her motor stability is
client can move in her own important for relatively good and normal. In
and shows no difficulty in stationary positions such addition, she
doing the things she is asked as sitting and standing, completely uses all
to. She does not have any but also it provides the the parts of her lower
problem when it comes to her necessary stable base to extremities while
movement such as when support movements of walking and sitting
sitting, walking, and standing. the head, torso, or limbs while showing no
According to the patient, she (Adolph, 2003). There signs of difficulty.
does not experience any kinds should be absence of
of pain from moving any part discomfort during range
of his body and her balance is of motion exercise.
normal. (Estes, 2006)
Body Temperature 1st day of assessment Normal body The body temperature
T = 36.5 °C temperature varies by is considered normal
person, age, activity, and on the 1st,2nd, and 3rd
2nd day of assessment time of day. The average day of assessment. No
T = 36.7 °C normal body abnormal conditions
temperature is generally were noted.
3rd day of assessment accepted as 98.6°F
T = 36.6 °C (37°C). Some studies
have shown that the
"normal" body
(36.1°C) to 99°F
2021)
Respiratory Status 1st day of assessment Respiration rates may The respiratory rate is
RR = 18 increase with exercise, considered normal on
fever, illness, and with the 1st,2nd, and 3rd day
2nd day of assessment other medical of assessment. No
RR = 17 conditions. When abnormal conditions
checking respiration, it's were noted.
3rd day of assessment important to also note
RR = 18 whether you have any
trouble breathing.
47
for an adult person at
rest range from 12 to 20
breaths
Circulatory Status 1st day of assessment The normal cardiac rate The cardiac rate and
PR = 76 bpm for an adult is 60-100 blood pressure is
BP = 110/70 mmHg beats per minute while considered normal on
for a normal reading of the 1st,2nd, and 3rd day
2nd day of assessment blood pressure, it needs of assessment. No
PR = 79 bpm to show a top number abnormal conditions
BP = 100/70 mmHg (systolic pressure) that’s were noted.
3rd day of assessment 120 and a bottom
PR = 83 bpm number (diastolic
BP = 110/80 mmHg pressure) that’s between
(Kozier, 2017)
Nutritional Status The client stated that Nutritional status is a The nutritional status
she eats up to 7 times a day requirement of health of of the client is
which is 3 meals and 4 set of a person convinced by considered normal
snacks. She has no culture or the diet, the levels of since she has a
religious dietary restrictions. nutrients containing in balance diet. She
Her regular diet consists the body and normal usually eats healthy
mainly of balanced meals such metabolic integrity. foods high in nutrients
as healthy foods such as fruits Normal nutritional status and avoids unhealthy
and vegetables together with is managed by balance foods. Her nutritional
high protein foods. She food consumption and status is not affected
observes her diet regularly and normal utilization of by any vices and bad
drinks approximately 8 glasses nutrients (NSRA, 2021). habits.
of water daily. Normal eating pattern is
considered to be at least
three times a day
depending on the
10 glasses per day
(Monahan, 2017)
Elimination Status The client stated that Normal bowel Her stool and urine
she has regular bowel movement of a person are considered as
movements which she must be 1 to 2 times a normal. Her number
defecates once in 2 day and day and voiding in 3 to 4 of times urinating, and
usually urinates at least 3 times a day with an defecating is also
times daily. She does not have output of 1200 to within the normal
any difficulty in eliminating 1500mL a day. A range. No problem in
wastes. The color of her void normal stool is brown in characteristics of the
48
ranges from clear to yellowish. color and well formed, stool and urine found.
She described her stool as urine is clear to
brown in color and soft but not yellowish in color.
formed. (Kozier, 2017)
Reproductive The patient is stil 6 years old It occurs approximately Not yet with a
Status and she didn’t hit puberty yet every 28 days, with a puberty
range from every 21 to
every 45 days. The
average age of onset of
menarche is 12.4 years
(Lacroix, 2020).
Sleep- Rest Pattern The client usually sleeps at Sleep refers to altered She has a normal
around 12 am in the midnight consciousness with sleeping pattern based
after doing school related tasks general slowing of on the norms and able
and activities. She usually physiological process to sleep and rest for at
wakes up at around 7 am in the while rest refers to least 7 hours per day
morning for her online class relaxation and calmness, based on the findings.
which starts around that time. both mental and
In addition, she reported no physical. A typical
difficulty in sleeping and is sleeper will pass through
able to sleep for at least 7 7 to 9 hours of sleep and
hours a day. take a rest using some
relaxation activities such
as reading, telling stories
and others (Daniels,
2015).
State of skin It is observed that the Skin surfaces should not The state of her skin
appendages client’s skin has a fair be tender, and the skin is appendages is normal
complexion and there is no dry with a minimum of based on the
presence of neither skin perspiration. Skin observation during
discoloration nor edema. No temperature should be interview. No
rashes to be seen and has warm and equal significant
normal capillary refill which bilaterally, hands and abnormalities
goes back 2-3 seconds. In feet maybe slightly were found.
addition, there was no cooler than the rest of
presence of wound, skin the body. Skin should
irritation and lesions were normally feel smooth.
noted. No pallor, jaundice, or The skin turgor should
cyanosis. Her hairs are dry, return within 2-3
evenly distributed, no parasite seconds and edema
infestations, and color black. should not normally
There is no hair loss, and her present. The skin should
nails were short and slightly be free from lesions and
pinkish in color. inflammation (Estes,
2014)
49
B. Nutritional Assessment
All the members of the family have no disease that needs an intake of maintenance
medicine, they are only taking medications if needed. No supplements are being taken by anyone
in the family and they mostly based the nutrient intakes in their diet. The family are able to eat 3
times a day and has sufficient source of clean water for drinking. The food that usually prepared
by Mrs. Romano are Filipino dishes. In their overall diet, they are able to eat variety of foods
such as meat like pork, beef, chicken and fish, green and leafy vegetables, variety of dairy
products, fruits, and their main source of carbohydrates is rice. They also have supplies of
biscuits, crackers and candies in their home which they consume whenever they want. No signs
of malnutrition noted within the family.
Family Member Height Weight BMI

Marlon V. Pabalan 160 cm 71 kg 28.6
Zoraida P. Pabalan 170 cm 75 kg 26.7
Maxene Dhale P. 166 cm 56 kg 20.5
Pabalan
Lexter John P. 154 cm 49 kg 20.4
Pabalan
Alexa Sophia P. 140 cm 40 kg 20.5
50
Pabalan
Table 5: Body Mass Index (BMI) of each member of the Family
NORMS:
A healthy body is maintained by good nutrition, regular exercise, avoiding harmful

habits, making informed and responsible decisions about health, and seeking medical assistance
when necessary. (Mankato 2016)
ANALYSIS:
The nutritional intake of the family is considered normal since they are able to eat
wide variety of foods. No medications are altering their body systems. Their lifestyle
when it comes in the diet is normal. Based on the taken height and weight, the BMI was
able to compute. The computed BMI of Mr. and Mrs.Pabalan are both above the normal
range for healthy weight and considered as overweight. All of their children’s BMI are
within the normal range which means that they have healthy weight.
WATER INTAKE EVERYDAY
4-6 glasses a
day
20% 10 glasses
7-9 glasses
4-6 glasses
7-9 glasses a
day
40%
Graph 1 : Water intake of each member of the family in a day
Interpretation
Graph 1 shows the water intake of the family members each day. As you can notice on
the above pie graph, 40% of the family members drink 10 glasses of water and above each day as
51
well as 7-9 glasses. If you will notice on the above graph, there’s 20% or 1 member of the family
that usually drink 4-6 glasses and that is their youngest
Norms:
In May 2018, the Health Assembly approved the 13th General Programme of Work
(GPW13), which will guide the work of WHO in 2019–2023 (19). Reduction of salt/sodium
intake and elimination of industrially-produced trans-fats from the food supply are identified in
GPW13 as part of WHO’s priority actions to achieve the aims of ensuring healthy lives and
promote well-being for all at all ages. To support Member States in taking necessary actions to
eliminate industrially-produced trans-fats, WHO has developed a roadmap for countries (the
REPLACE action package) to help accelerate actions (6).
Analysis:
In comparison to the standards, each family members have adequate water intake each day even
though one of the family member drinks 4-6 glasses, it is still considered normal especially If an
individual is not easily get thirsty since you will still get water in the regular diet. There’s a need for
increase fluid intake if you need to replace fluid loss specially to replenish the lost fluid from sweat.
C.Values, Habits, Practices on health promotion, Maintenance and Disease Prevention
The family still use some herbal plants for medication. These plants include oregano for
cough and calamansi for vitamin C. They also have supply of over-the-counter drugs which
include Paracetamol, Ibuprofen for pain, Loperamide for diarrhea, and Neozep for colds. When it
comes to vaccinations, all of the family members were able to be vaccinated.
Each family member has enough rest and sleep. The members of the family usually have
about 7 to 9 hours of sleep every day. They are all able to have rest during their respective free
time. They usually watch television, listen to music, play with their phones, or asleep during
their resting hours. When it comes to exercising, they usually do not have proper routine of
exercise and the only exercise they stated is walking. The family usually have their respective
scheduled time for cleaning the house.
The parents are both striving to give all the needs of the family. They are also helping and
encouraging their children to strive harder in studies
NORMS:
Personal hygiene is an act of caring your body. This practice includes such as bathing, brushing
teeth, washing your hands, and more. (Kimberly Holland 2018)
52
Immunization programs gives a set of services that provide immunity to vaccine-
preventable diseases, administering immunizations, re-immunizations, documenting evidence of
immunity, and record-keeping (for future purposes) and reporting to state or local immunization
information systems (IIS). (CDC 2019)
Sleep is a vital component of human health and the amount of sleep changes with their
age. A typical sleep is 8 hours. (Lori Smith 2017)
ANALYSIS:
All the members of Pabalan family were able to have complete vaccination except for their
6 years child named Alexa because she is still six year old and the required age in DPT is 7 years
old above . They do not have any member with health problem that is why they do not have any
maintenance medications. They are still able to use traditional medicine like different herbal
plants and they also have adequate supply of over-the-counter drugs which they can use during
ailments. The family understand the importance of health, they usually eat healthy foods also
they used herbal medicine or over the counter medication.
Family Measles (2 BCG (1 dose at DPT (1 dose at OPV (4 doses) HEPA B (3-4
Member dose first at birth) 7 years old) doses)
12-15 moths
then 6 years)
Marlon Complete Complete Complete Complete Complete
Pabalan
Zoraida Complete Complete Complete Complete Complete
Pabalan
Maxene Complete Complete Complete Complete Complete
Pabalan
Lexter Complete Complete Complete Complete Complete
Pabalan
Alexa Sophia Complete Complete N/A Complete Complete
Pabalan
Table 6: Immunizations of each member of the family
ANALYSIS:
In view to the table above, it clearly shows that all the family members have complete
vaccinations except for their 6 years old child name Sophia she’s not yet in the right age to have
DPT vaccine. As claimed by Mrs. Pabalan, since she and her husband have a complete
vaccination, they want to guarantee their children’s early protection from diseases
53
Norms:
Filipino children should grow up healthy and protected from preventable diseases. Health
workers, national and local government officials, civil society, mothers, fathers, and community
members have a role to play to ensure that Filipinos receive the right information on
immunization, families are supported in overcoming barriers, and that children complete their
vaccines (UNICEF, 2018).
Analysis:
The member of the family are able to perform physical activities to improve their health
however, they were able to recognize the importance of health disease prevention as they were
all have a complete vaccination.
IV. FAMILY COPING INDEX

Legend:
1- No Competence
2- Moderate Competence
3- Complete Competence
Categories 1 2 3 Justification
54
1)PHYSICAL INDEPENDENCE 1st Visit: During the first visit, The
student Nurse (NS) observed that
This category is concerned with the the Pabalan Family are able to
ability to move about to get out of the bed, to perform their daily activities and to
take care daily grooming, walking and other maintain the cleanliness of the
things which involves the daily activities. house. They also perform a daily
fitness in their house every 7:00 am
the family had a Zumba fitness in
their house. For the grooming the
SN observe that they are properly
groomed.
2nd Visit: The day after the initial

visit, The family are well manage
and the SN accurately observed the
bonding of the family activities.
After they went to sleep they ensure
that the bed are clean. The SN
asked the family if they did follow
his health teachings or not, and the
family gladly said that they did.
3rd Visit: On the third day, the SN

asked them again about the
information that he gave about the
proper hygiene and guidance in
their daily activities. The family
was able to restate most of the
teachings that the SN said on the
previous days. They are also able to
demonstrate proper hygiene like
hand washing.
2) THERAPEUTIC COMPONENT 1st Visit: During the first visi

the student nurse ask if the cl
This category includes all the they are taking up medicatio
procedures or treatment prescribed for the care they said they are always
of ill, such as giving medication, dressings, Vitamin C and every year they
exercise and relaxation, special diets. a over-all check up to detec
problem that may occur to
Also during the first day the
eating vegetable with meat.
2nd Visit: On the next visit, aft
55
giving health teachings on
preventing major diseases, the
able to cope up with the topic
said that they will be vigilant w
it comes to health problems. T
are able to maintain their healt
diet and some basic exercises
able to demonstrate to them.
3rd Visit: The family member

always prioritize their health.
3) KNOWLEDGE OF HEALTH 1st visit: The family was ask
CONDITION what are the disease that the
encountering or have
This system is concerned with the encountered. Based on
particular health condition that is the occasion statement that they told tha
of care. encountered COVID-19 the
family was been quarantine
statement said that it first
with the father who is in
Arabia and went home in
Philippines to have a vacatio
was been a positive
2nd Visit: On the next day, the

able to understand and verbali
health teachings of the SN wh
about other symptoms and gen
knowledge about this disease.
are also able to understand the
importance of hand washing to
prevent COVID-19
3rd Visit: On the third day Stu

Nurse observe that the implica
of hand washing is being appl
4) APPLICATION OF THE PRINCIPLES 1st Visit: The family’s meals a
OF THE GENERAL HYGIENE well selected. Most of the fam
members are able to have adeq
This is concerned with the family action sleep and rest. They are able to
in relation to maintaining family nutrition, cope up and adapt new preven
securing adequate rest and relaxation for measure particularly for COV
family members, carrying out accepted pandemic. They are able to
preventive measures, such as immunization. complete all the needed vaccin
for immunization from differe
deadly diseases.
2nd Visit: They are able to mai

their routines when it comes to
56
meal, sleep and rest. However
there are still one family mem
with inadequate amount of sle
and rest, but he said that he wi
to improve his sleeping pattern
3rd Visit: The family is able to

maintain and improve their
appropriate hygiene. They wer
also able to restate the teachin
SN.
5) HEALTH ATTITUDES 1st Visit: The family said they
a savings for Health Finance a
This category is concerned with the also they have a Social Securi
way the family feels about health care in Service (SSS) and PHILHEAL
if there is any presence of illne
general, including preventive services, care
that may occur they have a mo
of illness and public health measures to pay the bills.
2nd Visit:Upon teaching the

importance of having a regula
consultation with a doctor, the
said that they will look into th
they will be more vigilant in
observing each of their health
condition
3rd visit: Through the last day

are realizing that saving more
money for Health status is a
investmet.
6) FAMILY LIVING 1st Visit: On the initial visit, t
This category is concerned with the SN noticed that each member
interpersonal or group aspects of the family are respecting each oth
family get along with one another, the and communicate along with t
ways in which they take decisions They are able to interact
accordingly. When it comes to
affecting the family as a whole.
decision making, they are able
share their thoughts with the h
of the family
2nd Visit: hey are able to main

that routine and additional
information are given to them.
Before the end of the visit, the
able to verbalize the informati
they have learned this day.
3rd Visit:They are able to verb
57
the teachings of the SN on the
previous days.
7) PHYSICAL ENVIRONMENT
This is concern with the home, the
community and the work environment as it
affects family health.
V. TYPOLOGY OF NURSING PROBLEM

This Chapter discusses about the problem that were identified during the assessment and interview with
the family. It includes the cues/data, the family nursing problem and the nursing diagnosis. The problems
identified are categorized into presence of wellness state, health deficits, health threats, and foreseeable
crisis and stress points.
58
59

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Republic of the Philippines

Tarlac State University

TITLE: Family Health Nursing Process

A Family Case Study presented to the faculty of the

In Partial Fulfillment of the Requirements of the Subject

Maxene Dhale P. Pabalan

Maxene Dhale P. Lexter John P.

1. Family history of health and illness/ (pregnancy)

- healthy male -female deceased CoD-cause of death

-male with medical complication

-male deceased -female with medical complication

Expenditures Estimated Monthly Prioritization (1-10)

Norms & Standards:

The house of Pabalan family is currently residing in Barangay Maliwalo, Tarlac

No. of adults in Pabalan family = 3 x 3.0 sq. m = 9 sq. m

TFA = 36.72 sq. m Total

Ventilation = TWO/TFA x100

Area of assessment Findings Norms Analysis

Mental Status The patient should

The message's The client is well-oriented

>SPEECH The patient should He has good

Sense of Taste Auditory acuity: The The sense of taste of the

The client was asked to

3rd day of Assessment:

> General Upon interviewing Mrs. Appearance is described On her educational

>Level of She was coherent, well- She is well oriented to

Sense of hearing The hearing acuity of Mrs.

Sense of Smell Client was able to

Area of assessment Findings Norms Analysis

>Level of During interview, she was able She was able to

Sense of Smell To determine the

Tactile receptors identify

Lexter John P. Pabalan

The client was able to

The client’s nose is in the A person usually

His taste buds

Sense of Smell The client has no problem with A person usually

The Client is very cooperative She is well oriented to

Sense of hearing The client has a good hearing To determine the

Family Member Height Weight BMI

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

A healthy body is maintained by good nutrition, regular exercise, avoiding harmful

WATER INTAKE EVERYDAY

Graph 1 : Water intake of each member of the family in a day

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

IV. FAMILY COPING INDEX

2nd Visit: The day after the initial

3rd Visit: On the third day, the SN

2) THERAPEUTIC COMPONENT 1st Visit: During the first visi

2nd Visit: On the next visit, aft

3rd Visit: The family member

2nd Visit: On the next day, the

3rd Visit: On the third day Stu

2nd Visit: They are able to mai

3rd Visit: The family is able to

2nd Visit:Upon teaching the

3rd visit: Through the last day

2nd Visit: hey are able to main

3rd Visit:They are able to verb

V. TYPOLOGY OF NURSING PROBLEM