OLIVAREZ COLLEGE TAGAYTAY

E. Aguinaldo Highway, San Jose, Tagaytay

College of Nursing and Health Related Sciences

Family Case Study

Submitted by:

Mata, Allan Jr.

Magtang, Irish

Melo, Josaine Harsey

Mendoza, Patricia Cathlyn

Morales, Erhanne Joie

Paciente, Carlo Jayron

Ramos, John Khymer

Submitted to:

Ms. Ann Margarette T. Morales, RN, LPT

Date Submitted:

2022
 TABLE OF CONTENTS

I. Introduction
II. Demographic data
III. Family Data
IV. Family members chart
V. Monthly family income source and total
VI. Family characteristics
VII. Type of family structure
VIII. General family relationship/dynamics
IX. Ecogram
X. Home and environment
XI. Awareness of community organization
XII. Health status of each family members
A. Medical and nursing history
B. Family health status/health history (genogram)
C. Review of symptoms of systems
D. Functional assessment
E. Physical assessment of each member of the family
F. Laboratory and diagnostic findings supportive to assessment findings
XIII. Data Analysis
XIV. Family Nursing Health Condition
A. Prioritizing health condition
XV. Family Nursing Care Plan
XVI. Drug Study
XVII. Summary
XVIII. Conclusion
INTRODUCTION

Community health nursing serves as a link between healthcare organizations and

communities, working together to promote a healthy lifestyle and raise community
awareness about their health status. Every community faces unique challenges and as
student nurses, community health nursing teaches us the appropriate solution for health
problems within a specific group by combining and expanding our knowledge and skills.
In this case study, we focus on different families, as family and community are two of
the most crucial social institutions in the development and daily lives of
individuals. Together, they guide who we are, embody values in us, define what we
consider appropriate and inappropriate, and teach us about what is and is not possible.
Our families and communities help us navigate the world by printing the numerous inner
maps we carry. Although family and community are frequently studied separately, they
are inextricably and reciprocally related. The family's viability as a social institution has
always been dependent on the support of the local community, and vibrant communities
are defined by active and engaged families.
Sanitation is a major concern in communities where people are constantly
exposed to polluted environments. Improvements in disposal practices are critical to
improving public health. A number of studies suggest that a lack of sanitation facilities
causes health problems, particularly among the urban poor who live in overcrowded
informal settlements. The poor are invariably the ones who suffer the most from a lack
of safe water and sanitation, as they lack not only the resources to provide such
services but also the knowledge of how to mitigate the negative effects of living in
unsanitary conditions. As a result, the detrimental effects of unsanitary living conditions
reduce the productive potential of those who can least afford them. Therefore, proper
collection, transportation, treatment, and disposal of garbage are critical to community
health and environmental improvement. Malnutrition, on the other hand, needs to be
addressed as well, as it is one of the most impactful social and health problems
affecting young children today, whether they live in a developed city or a less developed
rural area. In order to ensure that the general public is informed about healthy habits
and the effects of malnutrition, especially in young children, it is the responsibility of the
government to implement nutritional education through relevant agencies' and
departments' involvement in a national education strategy. In addition, in this generation,
it is also important to be vigilant, especially mothers, as their children may experience
bullying when they are not around them. Bullying is a serious problem in the public
health sector. This is based on the effects it has on victimized children, as they may
develop low self-esteem, become physically weak, and have poor social skills until
adulthood. Thus, it must be addressed by all stakeholders, including the parents and
teachers of the children. The fact that bullying affects children's psychology emphasizes
the importance of this issue in public health. It is a vice that has affected children,
particularly those of school age, and most commonly occurs in schools, where children
are bullied by peers who may be stronger than them. The victims may find it difficult to
relate to other children, as they may have difficulty standing up for themselves. In most
cases, this is a problem that is likely to cause children to drop out of school. Given the
effects of bullying on children, it is critical to develop comprehensive policies to address
the issue. Anti-bullying policies should be developed and implemented in all areas
where children are bullied, particularly schools.
 Family Name: Pagal Family
Address: Purok 1, Barangay Iba Ibaba Silang, Cavite

I. Demographic data:
Household number: 040 Brgy. House number:

II. Family Data:

Length of residency: 34 years
Place of origin: Masbate
Family size: 6(six)
Religion: Roman Catholic
Husband: Roman Catholic
Wife: Roman Catholic
Family Member’s Chart:

Family Age Sex Civil Position Relationship Educational

Member’s (yrs./mo.) (M/F) Status in to family head Attainment Occupation
Name Family

Elna Pagal 34years old F Married Mother Wife 2nd year high school N/A

Mark Lenard 31 years M Married Father Head of the Elementary Fish

Pagal old family graduate vendor

Mark Joseph 11 M Single 1st born Son Grade 2 N/A

Pagal

Angela Pagal 7 F Single 2nd born Daughter Grade 1 N/A

Angelo Pagal 7 M Single 2nd born Son Grade 1 N/A

Baby Shell Pagal 4 F Single 3rd born Daughter N/A N/A

Monthly Family Income Source:

A. Husband: Estimated 12,000Php
B. Wife: N/A
C. Others:N/A
 Monthly Family Income Sources Total: (check bracket)

〇 Below Php 5,000.00

〇 Above Php 5000.00 – 9,999.99
〇 Above Php 10,000.00 – 14,999.99
〇 Above Php 15,000.00 – 19,999.99
〇 Above Php 20000.00 – 29.999,99
〇 Above Php 30000.00 – 39999.99
〇 Above Php 4000.00 – 49,999.99
〇 More than 50,000.00

III. Family Characteristics:

Type of family structures:
〇 Nuclear
〇 Extended
〇 Patriarchal
〇 Matriarchal
〇 Patrilocal
〇 Matrilocal
〇 Bilocal
〇 Others, specify:

Dominant family member: Husband

General family relationship/dynamics:
A. Observations conflicts between family members: Third party/ Adultery
B. Characteristics of communication: Direct communication
C. Interaction pattern among members: They talk to each other with respect.
Family traditions, events, or practices that may affect members’ health or family
functioning: whom do you consult for health-related problems?

〇 Doctor
 〇 Nurse
〇 Midwife
〇 Barangay health workers
〇 Health center
〇 Albularyo
〇 Manghihilot
〇 Others, specify:

For problems other than health, whom do you consult?

〇 Family members
〇 Relatives
〇 Friends
〇 Priest
〇 Brgy. Officials
〇 Others, specify:
Others:
Ecogram (relationship of the family to larger community)

Health Iba,
Center Elementary
jjj (RHU) School

Pagal
Family

Silang
Market
IV. Home and environment
A. Is your lot owned?
. yes . ✓ no
B. Is your house owned?
. ✓ yes . no
C. Type of housing materials
. ✓ Wood . Makeshift
. Concrete . others, specify:
D. Is the living space adequate?
. ✓ yes . no
E. Number of rooms used for sleeping 1 .
F. Type of lighting facilities:
. ✓ electricity (Jumper) . candle
. kerosene . others, specify:
G. What are the appliances owned by the family?
1. Refrigerator
2. Television
3. DVD
4. Speaker
H. Type of water supply:
. owned . ✓ bought (Nawasa)
I. Drinking water storage:
. ✓ covered . refrigerated
. uncovered . others, specify:
J. Containers used
. pitchers . jars or clay pots
. bottles . ✓ others, specify: Water gallon
K. Food storage/cooking facilities:
. ✓ covered . ✓ stove (electric/gas)
. uncovered . firewoods/charcoal
. ✓ refrigerator . others, specify:
L. Type of garbage disposal
. collected . burial in pit
. segregation . hog feeding
. ✓ open dumping . composting
. ✓ open burning . others, specify:
M. Type of waste disposal
. flush type . balot system (wrap and
throw)
. water-sealed latrine . pail system
 . pit privy . ✓ others, specify: Chamber pots
N. Type of drainage system?
. ✓ open . closed
O. Pets/animals kept in the yard/home
1. Dog ( not vaccinated)
2. Cat
P. Common household pests found at home:
1. Cockroaches
2. Snake
3.Mosquito
4. Rat
Q. Are there breeding sites of insects, rodents, etc present?
. ✓ yes . no
R. Are there any accident hazards present?
. ✓ yes . no
S. Kind of Neighborhood: Joyful, “Marites”

T. Social and health facilities available: Center (RHU)

U. Communication facilities: Cellphone

V. Transportation facilities: Tricycle

V. Awareness of community organization

A. Are you aware of existing organizations in the community?
. yes . ✓ no
B. List/name all organizations you know
N/A
C. Are you a member of any of these organizations?
. yes . ✓ no
D. Are you aware of its activities and projects?
. yes . ✓ no
E. How are you involved in its activities? N/A
. attend meeting . planning
. give donation . implementation
. give advice . others, specify:
F. Name five(5) leaders (formal and non-formal of the community whom you think
can lead the people.
1. Maam Jona
VI. Health status of each family member
A. Medical and nursing history
Present health history (symptoms analysis (PQRST) for a sick member of
the family)
Past Health History

Common illness encountered for the past six (6) months and the
treatment applied

Common illness Treatment

Fever Paracetamol
Cough Ambroxol and Solmux
Common colds Neozep
Wound Amoxicillin
Diarrhea Loperamide

Immunization status of the family members

Name of child Immunization received Date received​

Mark Joseph Pagal Not vaccinated
Angela Pagal Not vaccinated
Angelo Paga Not vaccinated
Baby Shell Not vaccinated
 B. Family health status/Health history (genogram)

Marlene Joseph Leni

Junion Pagal Garcia Garcia
Pagal
60yrs old 56 yrs old

v
Marvin Alvin Miche
Mark Joan Joan Mariss Elna Elmar Wendy
Pagal Pagal Pagal a al
Lenard Pagal Garcia Pagal Garcia Garcia
28yrs 26 yrs 23yrs 20 yrs 35 yrs Garcia 27 yrs
31yrs old 34 yrs 32 yrs
old old old old old 30 yrs old
old old
old

Mark Joseph Angela Baby Shell

Angelo Pagal
Pagal Pagal 4 yrs old
11 yrs old
7 yrs old
7 yrs old
 C. Review symptoms of systems for each family member includes 1) past and
present health, 2) checks significant data omitted under present illness
(for sick member), 3)evaluates health promotion (HP)

Father Mother Child 1 Child 2

1hr 1hr 8-10hrs 8-10hrs
SKIN: (HP sun exposure)
Lice Lice Lice
hair

head
Yellowish
Eyes (HP-glasses/contacts)

Ears (HP hearing loss, aids, exposure to noise)

Common
Nose and sinuses Colds
Missing tooth in canine Missing Missing
Mouth and throat (HP dental care) part molar incisors
above

neck

Breast (HP BSE)

axilla
Dyspnea
Respiratory system (HP-chest x-ray)

Cardiovascular (HP-WCG/heart tests)

Peripheral vascular (HP-sitting/standing-support

hose)
Diarrhea Diarrhea
Gastrointestinal: (HP-antacids, laxatives,diet history)

Urinary
Urinary system (HP-prevention of urinary tract tract
infection) infection
(UTI)
Genitals:

female (HP-GYNE exam,pap smear)

sexual health

Musculoskeletal system (HP-interpersonal

relationships, coping)

Neurological system (HP-interpersonal relationships,

coping)

Hematologic

Endocrine

D. Functional Assessment
COMPONENTS Father Mother Child 1 Child 2

SELF CARE ABILITIES `

ADL’S

PERSONAL HABITS:

Alcohol use:
✓

Tobacco use: ✓
Medications:

(use of illegal drugs)

NUTRITION AND METABOLIC PATTERN

Usual food intake Rice, Fish,

Rice, Fish, Vegetables Rice, Fish, Rice, Fish,
Breakfast Vegetables
Vegetables Vegetables
Lunch

Dinner

Preferences

usual fluid intake 2 glasses of 2 glasses of 2 glasses of

water 2 glasses
Any problem with the ability to eat water water of water

Any supplements (Vitamin, feeding) Celin Celin

ELIMINATION PATTERN
3 2 1 1
Bladder
2 2 2 2
Bowel

ACTIVITY EXERCISE PATTERN N/A N/A N/A N/A

Usual daily/weekly activities:

Any limitations of physical ability:

✓
history of dyspnea or fatigue

SLEEP REST PATTERN

Usual sleep pattern

9 pm 7 pm 7 pm 7 pm
No. of pillows 2 4 1 1

Sleep routines

Any problems regarding sleep

COGNITIVE PERCEPTUAL PATTERN

Any deficits in sensory perception (hearing, sight, touch) None

Ability to read and write. Any difficulty in learning? None

None
Any complaints? (e.g. pain)

SELF PERCEPTION PATTERN: Health goals: Effect of

present illness on the self (for sick member)

Never get sick

How does the client see/feel about self?

ROLE RELATIONSHIP PATTERN

Language spoken Tagalog Tagalog Tagalog Tagalog

Manner of speaking

Significant person to client Parents

Complaints regarding family

Living with (member of the family)

SEXUALITY SEXUAL FUNCTION

anticipated change in sexual relations because of illness

(for ill member)

knowledge of sexual functioning ✓ 2x in a

week
 COPING STRESS MANAGEMENT PATTERN

Decision making ability

any significant stress in the past year 3rd party Bullying Bullying

management of stress “Chismisan”

expectations from nurses None

VALUE BELIEF SYSTEM

God
Source of strength or meaning

E. Development assessment of infants, toddlers, and preschoolers (MMDST)

F. Physical assessment of each member of the family.

AREAS METHOD NORMAN DEVIATIONS ACTUAL ACTUAL Child 1 Child 2

ASSESSED FINDINGS FROM FINDINGS FINDINGS
NORMAL Angela Angelo
Mother

Hair Inspection Hair must be Patchy areas, Scalp is Scalp is Scalp is Scalp is
/scalp moisturized loss hair, symmetrical and symmetrical symmetrical symmetrica
palpation and evenly brittle, dry and no presence of and no and no l and no
distributed no presence of lesions. presence of presence of presence of
parasite lesions. (+) lesions.(+) lesions. (+)
lice lice lice

Scalp must be
symmetrical,
smooth, firm,
and no
presence of
lesions,
Head Inspection Skull is Uneven Skull is Skull is Skull is Skull is
normocephalic, molding, symmetrical. symmetrical symmetrical symmetrica
Palpation symmetrical, asymmetrical l
features masses,
appropriate enlarged head,
for the size, the hydrocephalus,
head may have microcephaly
odd shape due
to the molding
of childbirth

Face and Inspection Shape may be face a bump or Face shape is Face shape Face shape Face shape
cranial oval soft, lumps on asymmetrical;Has is is is
nerves V Palpation or rounded; lesions no involuntary asymmetric asymmetrica asymmetric
and VII the face is observed, movements. al;Has no l;Has no al;Has no
symmetrical: asymmetrical, involuntary involuntary involuntary
no involuntary distorted movements. movements. movements
movements features. .

Nose Inspection Nose is Lesions, Nose has no Nose has no Nose has no (+)
symmetric and asymmetrical, presence of presence of presence of discharge
Palpation straight, there redness, discharge and is discharge discharge and is
is no discharge dryness, or symmetrical. The and is and is symmetrica
present and cracked, color is the same symmetrical symmetrical. l. The color
the color is the tenderness as the face and . The color is The color is is the same
same as the has no lesions. the same as the same as as the
face, no the face and the face and face and
tenderness and has no has no has no
lesions were lesions. lesions. lesions. He
observed and has a nevi
palpated. The
nasal system is
intact and in
the midline. A
red glow is
seen in the
maxillary and
frontal
sinus during
light
illumination.
Eyes and Inspection (+) PERRLA, (-) PERRLA, (+) PERRLA (+) PERRLA (+) PERRLA (+)
Vision the sclera is asymmetrical PERRLA
Palpation white no blink, The sclera is (+)yellowis The sclera is
edema or incomplete white. h. white. The sclera
tearing, closure, rapid is white.
palpebral blinking, The eyes has no The eyes The eyes has
conjunctivae irregular involuntary has no no The eyes
are smooth shape, movements and involuntary involuntary has no
and pinkish inconsistent are symmetrical movements movements involuntary
red, no color, cloudy when blinking. and are and are movements
discharge and lens, jerky eye symmetrical symmetrical and are
tenderness movements. when when symmetrica
noted upon blinking. blinking. l when
palpation of blinking.
the lacrimal
sac, the cornea
is transparent,
shiny smooth
and blinks
when it is
touched.

Mouth Inspection Lips are moist, Asymmetrical Lips are moist Lips are Lips are Lips are
red and mouth, dry, and smooth, moist and moist and moist and
Palpation smooth, gums pale lips, gums are pink, smooth, smooth, smooth,
are pink, bleeding, white and the tongue is gums are gums are gums are
tongue is at the patches, at the center and pink, and pink, and pink, and
center and broken teeth, moves freely. the tongue the tongue is the tongue
slightly rough dental caries is at the at the center is at the
on top, it ulcers present center and and moves center and
moves freely, presents of moves freely. moves
teeth are not lesions. Note: Cavity on freely. Missing freely.
yet completely the left 2 molar
nd
Missing tooth in Missing
erupting, soft tooth. tooth in molar. tooth in
palate is color canine incisors
pink and hard above.
palate is
lighter in color
and positioned
in the midline.
Pink and
soothing and
no discharge;
Consistency is
even.
Ears and Inspection Ears must be Pinna Ears are equal in Ears are Ears are Ears are
Hearing equal in size positioned size and similar equal in size equal in size equal in
Palpation and similar in below a line in appearance and similar and similar size and
appearance, from a comet and have no in in similar in
auricles have of auricles presence of appearance appearance appearance
the same color have the same discharge. and have no and have no and have
with the facial color with the presence of presence of no
skin. They are facial skin. discharge.. discharge. presence of
symmetrical They are discharge.
and aligned symmetrical
with the outer and aligned
canthus of the with the outer
eye; they are canthus of the
firm and not eye;they are
tender, no firm and not
presence of tender, with no
discharges. presence of
discharges.

Neck Inspection Muscles equal Muscles equal The Head is at the The Head is The Head is The Head is
in size head in size head center. at the at the at the
Palpation centered. centered. center. center. center.
Coordinated
muscle Coordinated Coordinated Coordinate
movement and muscle muscle d muscle
coordinated Coordinated there's no pain movement movement movement
muscle muscle when moving. and there's and there's and there's
movement movement and no pain no pain no pain
and there’s no there’s no pain when when when
pain when when moving moving. moving. moving.
moving.

Lymph nodes
Lymph nodes are not
are not palpable.
palpable.

There is no
tenderness, no
palpable lumps
or masses,
color is the
same as the
face.

UPPER EXTREMITIES

AREAS METHOD NORMAL DEVIATION ACTUAL ACTUAL Child 1 Child 2

ASSESSED FINDINGS FROM FINDINGS FINDINGS
NORMAL Angela Angelo
Mother
Musculoskeleta Inspectio Able to Bone Able to Able to Able to Able to
l structure n perform deformity, perform ROM perform ROM perform ROM perform ROM
ROM muscle exercises. exercises. exercises. exercises.Bone
Palpation exercise, the atrophy, not deformity in
ches is able to right forearm.
symmetric, perform ROM
spine exercises;
vertically limited ROM
aligned asymmetrical
chest wall .
intact, no
tenderness,
no masses.

Number of
fingers per
each hand is
five

Skin Inspectio Uniform in Presence of Skin is Skin is Skin is Skin is uniform

n color, no lesions, uniform in uniform in uniform in in color and
lesion, no deformities color and has color and has color and has has no
Palpation deformities, no presence no presence no presence presence of
same color of lesions and of lesions and of lesions and lesions and (+)
and deformities. deformities. deformities. scars.
temperatur
e as other Same Same Same Same
body parts, temperature. temperature. temperature. temperature.
skin springs
back to
previous

Nails Inspectio Symmetrica Pallor Nails are Nails are Nails are Nails are
n l, equal in cyanotic symmetrical symmetrical symmetrical symmetrical
length, nails: yellow and equal and equal and equal and equal
pinkish in discoloration in length. in length. in length. in length.
color. ;
Capillary Capillary Capillary Capillary Capillary refill
refill; beau lines; refill is refill is refill is is
prompt clubbing; normal.(Turn normal.(Turn normal.(Turn normal.(Turns
return of s to pinkish s to pinkish s to pinkish to pinkish color
pink (less thickened color in less color in less color in less in less than 3
than 3 sec) nails than 3 than 3 than 3 seconds when
seconds seconds seconds pressed)
when when when
pressed) pressed) pressed)

ANTERIOR CHEST

AREAS METHOD NORMAL DEVIATION ACTUAL ACTUAL Child 1 Child 2

ASSESSED FINDINGS FROM FINDINGS FINDINGS
NORMAL Angela Angelo
Mother
Breast Inspection Breast even Gynecomastia, Symmetrical Symmetrical Symmetrical Symmetrical
with chest swelling chest wall. chest wall. chest wall. chest wall.
Palpation wall ulcerations,
symmetrical, irregular hard
color, varies modules.
from light
pink to dark
brown, no
discharge, no
masses, no
modules, no
tenderness

Axilla Inspection No masses, Hair nodules No mass No mass No mass No mass

tenderness, or masses,
Palpation modules tenderness
noted upon
palpation

Precordium Inspection Absence of Murmurs, Absence of Absence of Absence of Absence of

abnormal tachycardia, murmurs murmurs murmurs murmurs
Auscultation heart sounds, bradycardia, and and and and
rhythm, and snap split abnormal abnormal abnormal abnormal
Palpation murmurs sounds, thrills heart sound. heart sound. heart sound. heart sound.
upon
palpation
Point of
maximal
impulse is
taping, 7 cm
lateral to the
midsternal
line in the 5th
intercostal
space

ABDOMEN

AREAS ASSESSED METHOD NORMAL DEVIATION ACTUAL ACTUAL Chold 1 Child 2

FINDINGS FROM NORMAL FINDINGS FINDINGS
Angela Angelo
Mother
Abdomen Inspection Flat, rounded Generalized No scars and the There has No scars No scars
(convex) or abdominal color of the skin a scars of and the and the
Palpation scaphoid distention, is the same. stitch due color of color of
(concave) in asymmetrical to the skin the skin
Percussion shape with organ cesarean is the is the
symmetric enlargement section same. same.
contour, delivery
same color and the
with the color of the
body, no skin is the
scars, good same.
skin turgor,
no masses, no
lumps, no
tenderness

Liver, spleen, Percussion Liver span is Liver span is Liver span is Liver span Liver Liver
kidneys 6 to 12 cm in greater than greater than is greater span is span is
the right 12cm in the 12cm in the than 12cm greater greater
MCL. Liver right MCL with right MCL with in the right than than
span is 4 to 8 enlarged liver. enlarged liver. MCL with 12cm in 12cm in
cm in Dullness Dullness enlarged the right the right
midsternal extends above extends above liver. MCL with MCL with
line: non the 6th rib. the 6th rib. enlarged enlarged
tender, no liver. liver.
masses
Enlarged spleen.
Enlarged spleen. percussed note
percussed note become dull;
Spleen; small become dull; painful upon
area of painful upon palpation,
dullness and palpation, superficial
6th to superficial masses, spleen
10th ribs: masses, spleen enlargement
tympanic on enlargement
inhalation;
not normally
palpable;
nontender

Kidneys: not
normally
palpable,
nontender,
no masses, no
increase in
abdominal
girth, level of
dullness does
not change

POSTERIOR CHEST
AREAS METHOD NORMAL DEVIATION ACTUAL ACTUAL Child 1 Child 2
ASSESSED FINDINGS FROM NORMAL FINDINGS FINDINGS
Angela Angelo
Mother

Musculoskeletal Inspection Skin is intact; Pallor, cyanosis, Skin is Skin is Skin is Skin is
structures spine is bulging intact and intact and intact and intact and
vertically retracting spine is spine is spine is spine is
aligned; intercostals vertically vertically vertically vertically
shoulder and spaces, aligned. aligned. aligned. aligned.
hips are at same asymmetrical;
height depressed or
projecting
sternum; spine
not aligned.

Posterior Palpation Symmetrical, Pain, No No No No

thorax and fair complexion, tenderness deformities deformities deformities deformities
lungs no deformities, asymmetrical, and no and no and no and no
no lesion, skin tactile fremitus lesions. lesions. lesions. lesions.
intact, uniform is increased or
temperature. decreased
Bilateral asymmetrical
symmetrical of expansion
vocal fremitus adventitious
and it is heard sounds
most clearly at
the apex of the
lungs. No
adventitious
sounds.

LOWER EXTREMITIES

AREAS METHOD NORMAL DEVIATION ACTUAL ACTUAL Child 1 Child 2

ASSESSED FINDINGS FROM FINDINGS FINDINGS
NORMAL Angela Angelo
Mother

Musculoskeleta Inspection Equal in Asymmetrical Asymmetrica Asymmetrica Asymmetrica Asymmetrica

l structures length, , deformities, l in length, no l in length, no l in length, no l in length, no
symmetrical, lesions, lesions. lesions. lesions. lesions.
Palpation no lesions, masses
no
deformities,
minimal or
moderate
hair
distribution
Skin Inspection Uniform in Presence of Uniform in Uniform in Uniform in Uniform in
color, no lesions, color, no color, no color, no color, (+)
Palpation lesions, no deformities; lesions, no lesions, no lesions, no lesions and
deformities, pallor, deformities. deformities. deformities. (+)abrasion,
same color flushed; Has presence Has presence no
and bluish; loss of Same of scars. of scars. deformities.
temperature red tones; temperature Has presence
as other generalized as other Same Same of scars.
body parts, pale yellow; body parts. temperature temperature
skin springs pigmented as other as other Same
back to areas; rough, body parts. body parts. temperature
previous thick as other
state body parts.
immediately
when
pinched

Nails Inspection Symmetrical, Pale or Symmetrical, Symmetrical, Symmetrical, Symmetrical,

equal in cyanotic equal in equal in equal in equal in
length, nails, yellow length, length, length, length,
pinkish in discoloration, pinkish in pinkish in pinkish in pinkish in
color beau lines, color color color color
clubbing,
thickened
nails

Musculoskeleta Inspection Able to do Bone Full ROM. Full ROM. Full ROM. Full ROM.
l functions flexions and deformity,
ROM muscle
atrophy, not
able to
perform ROM
exercises,
limited ROM,
asymmetrical

Genitals Inspection Pubic skin Nodules, Pubic skin

intact, no growths, intact, no
lesions, no lesions, lesions, no
inflammation drainage inflammation
, no swelling, chancres, , no swelling,
no discharge enlarged with no discharge
tenderness as described
purulent by the client.
discharges

Anus/rectum Inspection Intact anal Sphincter Intact anal

skin, anal tightens, skin, anal
sphincter has tenderness, sphincter has
good tone hemorrhoids, good tone as
nodules, described by
hardness the client.

G. Laboratory and diagnostic findings supportive to assessment findings (if any).

 VII. DATA ANALYSIS
CLASSIFICATION SIGNIFICANT DATA SECOND FAMILY
LEVEL ASSESSMENT NURSING PROBLEM
PRESENCE OF WELLNESS  Active in health center
CONDITION (potential/readiness)  Balanced meal
HEALTH DEFICIT  Dislocated arm
 Lice infestation
 Malnourished
HEALTH THREAT  Risk for fall
 Environmental hazard
(fire and flashflood)
 Possible skin diseases
 Animal attack
 Pest infestation
 Dental cavities
STRESS POINT/FORESEEABLE  3rd party
CRISIS  Picky in food
 Unvaccinated
 Alcoholic and smoker
 Bullying

VIII. Family nursing health condition

a. Prioritizing health condition
Health condition/problem #:
criteria computation Actual score justification
Nature of the problem
Modifiability of the problem
Preventive potential
Salience of the problem

b. Family nursing care plan

Family nursing problem goals objectives Intervention plan Evaluation plan
Nature of the problem
Modifiability of the problem
Preventive potential
Salience of the problem
Summary

The Pagal Family is composed of a complete family that has six members. They
have been residing in Brgy. Iba Silang, Cavite, for 34 years, and their conflict is the
father's having another affair, she didn’t know anything about it where it was from and
how long it had been. Their dominant family member is the father, who supports his
family by being a fish vendor at Silang Wet Market. The 1st born is currently in grade 2
due to he can’t read, so the teacher decide to repeat him. Baby Shell is not yet in school
because she just turned 4years old. The family goes to a doctor, nurse, barangay health
worker, or health center when they feel something bad that can lead to illness. After all,
the family has a dog that was not vaccinated, which may lead to danger. Even the
whole family has never received an immunization or vaccination because they don't
want to. At the same time, the family's common illnesses are fever, cough, and common
colds, and wound which they treat with paracteamol, ambroxol, amoxicillin, solmux.and
neozep

Furthermore, as we did physical assessments, we came up with some problems

that we, as a student nurse, could assess. First, both children 1 and 2 have lesions and
scars on their skin. Second, in their hair, there is a presence of lice on the mother, child
1, and child 2. Third, at the mother's eye there is a presence of yellowish color; knowing
this, we make sure that the mother will have a proper health teaching, and we suggest
to her that she go to the RHU-Silang for her to clarify what illness she has. Fourth, child
2 has a cold. Fifth, the mother, child 1, and child 2 have a missing tooth. Sixth, the
mother is experiencing dyspnea. Seventh, there is diarrhea in children 1 and 2. Eighth,
child 2 has a UTI (urinary tract infection). Ninth, the family ate three times a day; their
meals included rice, fish (when the father had an excess of fish to bring home), and
vegetables. But unfortunately, the family is only drinking 2 glasses of water, which is the
one reason why the second child has a UTI. Tenth, bullying is the past trauma that
children 1 and 2 have experienced, which is evident by the presence of scars on their
skin.

Conclusion
 The Pagal family suffers from a number of health issues, some of which we have
identified. These include the high risk of contracting diseases brought on by the lack of
vaccinations as well as the environment, the improper fluid intake that results in UTI in
their second child, and the trauma that both of their children have experienced as a
result of bullying. However, despite these issues, it is clear that the parents continue to
provide for and care. Also, the student nurses were quite successful in classifying the
acknowledged medical concerns as a health hazard, a health deficiency, or an
anticipated crisis as they were able to identify current and potential issues that could be
a factor in limiting best possible health. The pupils were likewise unable to address
every issue because of the prevailing circumstances. The family now has enough
information, nevertheless, that they can use as necessary.

Recommendation

We, the student nurses of Olivarez College Tagaytay recommends;

For Mother:
• Encourage her to go to the RHU to check her yellowish eyes.
• Encourage them to use the shampoo Licealiz to ger rid of their louse and lice. A nit comb is an
additional choice; it has fine teeth and aids in removing both head lice and their eggs.
• Avoid dumping waste in the river.
• Maintain cleanliness and make proper waste management within household.
• Encourage her to brush her teeth daily to avoid tooth decay.
• When she has a free time , read books so that you can learn somehow.

Father:
• Always wear a protection when he is in contact with his partner or mistress to avoid HIV.
• Tell him to reduce his smoking and drinking alcohol.
• Ensure children's health through encouragement of parents and guardians in associate with
supporting purging or deworming.
• When he has a free time , read books so that you can learn somehow.

Twin:
• Learn to figure out where they fit, the difference between right and wrong, and what’s acceptable.
• Provide a support system to them.
• Encourage the twins that if they experience bullying again, they will be more courageous and make it
an inspiration instead of a distraction.
• Encourage them to have a good hygiene in their body.
• Encourage them to eat a lot of healthy foods and drink a lot of clean water.

The other siblings:

• Encourage them to eat a lot of healthy foods and drink a lot of clean water.
• Have a support and appreciate to each other
To the Barangay:
• It is good idea if they have a policy for people who live by the river not to throw garbage in the river.
• Set Goals and Commit to Ongoing Evaluation.

To the Rural Health Center:

• Improve access to care
• Always prioritize the patient who badly needed their care
• Primary healthcare or a generalist approach. In rural areas, the health professionals need to provide a
range of care, for a range of conditions to people across the life cycle

To the future researchers:

• Establish new gaps within the study.
• Be open minded to your patients situation