OLIVAREZ COLLEGE TAGAYTAY

E. Aguinaldo Highway, San Jose, Tagaytay

College of Nursing and Health Related Sciences 

 
 
 
 
 

Family Case Study

 

 
Submitted by:

dela Cruz, Jeanna Beatrice

Dionido, Anna Louise

Mendoza, Patricia Cathlyn

Monedera, Arvern

Paller, Warren

Parra, Antonette Clariz

Ramos, Cheska Ann

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

 
 
 
 
 Family Name: Siagan
Address: 116 Iba, Silang, Cavite
 
I. Demographic data:        
Household number:4                                     Brgy. Hous
e number: 116
 
II. Family Data:
Length of residency: 
Place of origin: Barangay Uno Iba, Silang, Cavite
Family size: Nuclear
Religion: Catholic
               Husband: Cristopher Panganiban
               Wife: Kimberly Siagan
Family Member’s Chart:

Family Age Sex Civil Sta Position Relationship Educationa  

Member’s (yrs./m (M/F) tus in  to family he l Occupation
Name o.) Family ad Attainment

Cristopher 34 M S Father   Highschool  Security

Panganiban Guard

Kimberly Siagan 29 F S Mother Wife Highschool None

Crys Styler 1yr 10mos M S First-born  Son     

Krys Zyra 2weeks F S  Youngest Daughter    

             

             

             

             
 Monthly Family Income Source:
A. Husband: 19,000-20,000
B. Wife: None
C. Others:
Monthly Family Income Sources Total: (check bracket)
    〇  Below Php 5,000.00
    〇  Above Php 5000.00 – 9,999.99
    〇  Above Php 10000.00 – 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:

General family relationship/dynamics:

A. Observations conflicts between family members:They appear to be wary of one
another
B. Characteristics of communication: Through gadgets and verbal
C. Interaction pattern among members: They get along well with her family.
Family traditions, events, or practices that may affect members’ hea
lth or family functioning: whom do you consult for health-related pro
blems?
    〇  Doctor:Pedia
    〇  Nurse
    〇  Midwife
    〇  Barangay health workers
    〇  Health center
    〇  Albularyo
    〇  Manghihilot
    〇  Others, specify: Medicine
 
For problems other than health, whom do you consult?
     〇  Family members: Husband
     〇  Relatives
     〇  Friends
     〇  Priest
     〇  Brgy. Officials
     〇  Others, specify:
Others:

Ecogram (relationship of the family to larger community)

IV. Home and environment
A. Is your lot owned?
      .    ✓   yes                                              
.         no
B. Is your house owned?
      . ✓      yes                                              
.         no
C. Type of housing materials
      .   ✓    Wood: Bungalow                                   
.        Makeshift
      .       Concrete                                          
.        others, specify:
D. Is the living space adequate?
      .     ✓  yes                                              
.         no
E. Number of rooms used for sleeping    2         .
F.  Type of lighting facilities:
      .   ✓    electricity                                      
.        candle
      .       kerosene                                          
.         others, specify:
G. What are the appliances owned by the family?
1. Refrigerator
2. Electric fan
H. Type of water supply:
      .       owned                                              
.        bought
 .  ✓     shared
I. Drinking water storage:
      .   ✓    covered                                          
.        refrigerated
      .       uncovered                                          
.        others, specify:
J. Containers used
      .    ✓   pitchers                                          
.         jars or clay pots
      .       bottles                                            
.        others, specify:
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:
N.  Type of drainage system?
      .  ✓     open                                              
.        closed
O. Pets/animals kept in the yard/home
1. Cat
2. Dog
3. 
4. 
P. Common household pests found at home:
1. Insect: Grasshopper, Mosquito
2. 
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:
  -Peaceful
T. Social and health facilities available:
  -None
U. Communication facilities:
  -Cellphone
V. Transportation facilities:
  -Motorcycle
V. Awareness of community organization
A. Are you aware of existing organizations in the community?
      .       yes                                                
.     ✓    no
B. List/name all organizations you know
1. 
2. 
3. 
4. 
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?NONE
      .       attend meeting                                     .
       planning
      .       give donation                                      
.        implementation
      .       give advice                                        
.        others, specify:
F. Name five(5) leaders (formal and non-formal of the community whom yo
u think can lead the people.
1.  Ate Joy
2. Ate Flor
3. 
4. 
5.  
 
VI. Health status of each family member
A. Medical and nursing history
Present health history (symptoms analysis (PQRST) for a sick me
mber of the family)
Past Health History

                   Common illness encountered for the past six (6) mo

nths and the treatment applied
Common illnes Treatment
s

 Diarrhea Medication in take 

Immunization status of the family members

Name of chi Immunization receiv Date received
ld ed
 Krys Zyra BCg, Hepa B 2weeks ago

     

     

     

     

B. Family health status/Health history (genogram)

C. Review symptoms of systems for each family member includes 1) pa
st and present health, 2) checks significant data omitted under
present illness (for sick member), 3)evaluates health promotion
(HP)

 
Fathe Mother Child 1
r
     
SKIN: (HP sun exposure)
     
hair 
     
head
     
Eyes (HP-glasses/contacts)
     
Ears (HP hearing loss, aids, exposure to noise)

     
Nose and sinuses
     
Mouth and throat (HP dental care)
     
neck
     
Breast (HP BSE)
     
axilla
     
Respiratory system (HP-chest x-ray)

     
Cardiovascular (HP-WCG/heart tests)

     
Peripheral vascular (HP-sitting/standing-support hose)

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

     
Urinary system (HP-prevention of urinary tract infectio
n)
      
Genitals:

female (HP-GYNE exam,pap smear)

sexual health

     
Musculoskeletal system (HP-interpersonal relationships,
coping)

     
Neurological system (HP-interpersonal relationships, co
ping)

     
Hematologic
     
Endocrine

 
D. Functional Assessment
COMPONENTS Father  Mother Child 1 Child 2

   
SELF CARE ABILITIES `

ADL’S
   
PERSONAL HABITS:

Alcohol use: Never Never Never

Tobacco use:
Never Never Never
Medications:
Never Never Never
(use of illegal drugs)
 
NUTRITION AND METABOLIC PATTERN  

Usual food intake  

Breakfast Egg Egg

Lunch  Fish/ Chicken meat Fish/

Chicken
Dinner Fish/ Chicken meat meat Breastfeed

 None Fish/
Chicken
Preferences  Water meat
usual fluid intake  None None
Any problem with the ability to eat  None Water None

Any supplements (Vitamin, feeding)   None None

  None
      
ELIMINATION PATTERN
4 4 Frequent
Bladder
1 2 Frequent
Bowel
   
ACTIVITY EXERCISE PATTERN

  Household chores Playing

Usual daily/weekly activities:

   
Any limitations of physical ability: None None

 
None None
history of dyspnea or fatigue

     
SLEEP REST PATTERN

 
Every 2hours awake 8hours of Every 2hours
Usual sleep pattern
sleep awake
No. of pillows 4
1 1

Night
Sleep routines Night Day time and
Night time
Any problems regarding sleep
     
COGNITIVE PERCEPTUAL PATTERN

Any deficits in sensory perception (he None None None

aring, sight, touch)

 
None None None
Ability to read and write. Any difficu
lty in learning?
None None None
 

Any complaints? (e.g. pain)

     
SELF PERCEPTION PATTERN:

Health goals: Be fit and healthy Be healthy Be healthy

None
Effect of present illness on the self None None
(for sick member)

 
 ROLE RELATIONSHIP PATTERN      

Language spoken Filipino Filipino

Manner of speaking Elocution Baby talk

Significant person to client Family

Complaints regarding family None None

Living with (member of the family) None None

     
SEXUALITY SEXUAL FUNCTION 

anticipated change in sexual relations

Yes
because of illness (for ill member)

knowledge of sexual functioning  She has knowledge about it

COPING STRESS MANAGEMENT PATTERN      

     

Decision making ability   She has the ability to make a  

decision
   

any significant stress in the past yea    

r  Family
   
   
   

management of stress  She went outside.

She anticipates that the nurse will

address her medical needs 
expectations from nurses
 

     
VALUE BELIEF SYSTEM
 
Her son and daughter
Source of strength or meaning

 
E. Development assessment of infants, toddlers, and preschoolers (MMD
ST)
F. Physical assessment of each member of the family.

AREAS ASS METHOD NORMAN FINDINGS DEVIATIONS FROM NO ACTUAL FINDINGS ACTUAL FINDINGS
ESSED RMAL
  (MOTHER) 

Hair /sca Inspectio Hair must be moistur Patchy areas, los Scalp is symmetri  Her hair is moisturized
lp n  ized and evenly dist s hair, brittle, d cal and no presen and evenly distributed
ributed ry and no presence ce of lesions.
palpation  of parasite

Scalp must be symm

etrical, smooth, f
irm, and no presen
ce of lesions,

Head Inspectio Skull is normocephal Uneven molding, as Skull is symmetri  Skull is normocepha
n ic, symmetrical, fea ymmetrical masses, cal. lic, symmetrical, fe
tures appropriate fo enlarged head, hyd atures appropriate f
Palpation r the size, the head rocephalus, microc or the size
may have odd shape d ephaly
ue to the molding of
childbirth

Face and Inspectio Shape may be oval o face a bump or sof Face shape is asy  Shape is oval. The face
cranial n n  r rounded; the face t, lumps on lesion mmetrical;Has no is symmetrical and there
erves V a is symmetrical: no i s observed, asymme involuntary movem is no involuntary
nd VII Palpation nvoluntary movements trical, distorted ents. movements
features.
Nose Inspectio Nose is symmetric an Lesions, asymmetri Nose has no prese  Nose is symmetric a
n d straight, there is cal, redness, dryn nce of discharge nd straight, there i
no discharge present ess, or cracked, t and is symmetrica s no discharge prese
Palpation and the color is the enderness l. The color is t nt and the color is
same as the face, no he same as the fa the same as the fac
tenderness and lesio ce  and has no le e, no tenderness and
ns were observed and sions. lesions were observe
palpated. The nasal d and palpated. The
system is intact and nasal system is inta
in the midline. A re ct and in the midlin
d glow is seen in th e. A red glow is see
e maxillary and fron n in the maxillary a
tal sinus during lig nd frontal sinus dur
ht illumination.  ing light illuminati
on. 

Eyes and Inspectio (+) PERRLA, the scle (-) PERRLA, asymme (+) PERRLA  The sclera is white no
Vision n ra is white no edema trical blink, inco edema or tearing, pal
or tearing, palpebra mplete closure, ra The sclera is whi pebral conjunctivae
Palpation l conjunctivae are s pid blinking, irre te. are smooth and pinki
mooth and pinkish re gular shape, incon sh red, no discharge
d, no discharge and sistent color, clo The eyes has no i and tenderness noted
tenderness noted upo udy lens, jerky ey nvoluntary moveme upon palpation of th
n palpation of the l e movements.  nts and are symme e lacrimal sac, the
acrimal sac, the cor trical when blink cornea is transparen
nea is transparent, ing. t, shiny smooth and
shiny smooth and bli blinks when it is to
nks when it is touch uched
ed.
Mouth Inspectio Lips are moist, red Asymmetrical mout Lips are moist an  Lips are moist, red
n and smooth, gums are h, dry, pale lips, d smooth, gums ar and smooth, gums are
pink, tongue is at t bleeding, white pa e pink, and the t pink, tongue is at t
Palpation he center and slight tches, broken teet ongue is at the c he center and slight
ly rough on top, it h, dental caries u enter and moves f ly rough on top, it
moves freely, teeth lcers present pres reely. moves freely, teeth
are not yet complete ents of lesions. are not yet complete
ly erupting, soft pa   ly erupting, soft pa
late is color pink a late is color pink a
nd hard palate is li Note: Cavity on t nd hard palate is li
ghter in color and p he left 2  molar
nd
ghter in color and p
ositioned in the mid tooth. ositioned in the mid
line. Pink and sooth line. Pink and sooth
ing and no discharg ing and no discharg
e; Consistency is ev e; Consistency is ev
en. en.

Ears and Inspectio Ears must be equal i Pinna positioned b Ears are equal in  Ears must be equal
Hearing n n size and similar i elow a line from a size and similar in size and similar
n appearance, auricl comet of auricles in appearance and in appearance, auric
Palpation es have the same col have the same colo have no presence les have the same co
or with the facial s r with the facial of discharge. lor with the facial
kin. They are symmet skin. They are sym skin. They are symme
rical and aligned wi metrical and align trical and aligned w
th the outer canthus ed with the outer ith the outer canthu
of the eye; they are canthus of the ey s of the eye; they a
firm and not tender, e;they are firm an re firm and not tend
no presence of disch d not tender, with er, no presence of d
arges. no presence of dis ischarges.
charges.
Neck Inspectio Muscles equal in siz Muscles equal in s The Head is at th  Muscles equal in si
n e head centered. ize head centered. e center. ze head centered.

Palpation     Coordinated muscl  

e movement and th
coordinated muscle m Coordinated muscle ere's no pain whe coordinated muscle m
ovement and there’s movement and ther n moving. ovement and there’s
no pain when moving. e’s no pain when no pain when moving.
moving
   
 
Lymph nodes are not Lymph nodes are not
palpable. Lymph nodes are no palpable.
t palpable.
   

There is no tenderne There is no tenderne

ss, no palpable lump ss, no palpable lump
s or masses, color i s or masses, color i
s the same as the fa s the same as the fa
ce. ce.

 
UPPER EXTREMITIES

AREAS ASSESSED METHOD NORMAL FINDINGS DEVIATION FROM NO ACTUAL FINDINGS ACTUAL FINDINGS
RMAL
   

Musculoskeleta Inspectio Able to perform RO Bone deformity, m Able to perform R  Able to perform R
l structure n M exercise, the ch uscle atrophy, no OM exercises. OM exercise, the c
es is symmetric, s t able to perform hest is symmetric,
Palpatio pine vertically al ROM exercises; li spine vertically a
n igned chest wall i mited ROM asymmet ligned chest wall
ntact, no tenderne rical. intact, no tendern
ss, no masses.  ess, no masses. 

Number of fingers Number of fingers

per each hand is f per each hand is f
ive iv
Skin Inspectio Uniform in color, Presence of lesio Skin is uniform i  Uniform in color,
n no lesion, no defo ns, deformities n color and has n no lesion, no defo
rmities, same colo o presence of les rmities, same colo
Palpatio r and temperature ions and deformit r and temperature
n as other body part ies. as other body part
s, skin springs ba s, skin springs ba
ck to previous  Same temperature. ck to previous 

Nails Inspectio Symmetrical, equal Pallor cyanotic n Nails are symmetr  Symmetrical, equa
n in length, pinkish ails: yellow disc ical and equal i l in length, pinki
in color. Capillar oloration;  n length. sh in color. Capil
y refill; prompt r lary refill; promp
eturn of pink (les beau lines; clubb Capillary refill t return of pink
s than 3 sec) ing;  is normal.(Turns
to pinkish color
thickened nails in less than 3 se
conds when presse
d)

 
ANTERIOR CHEST 

AREAS ASSES METHOD NORMAL FINDINGS DEVIATION FROM NO ACTUAL FINDIN ACTUAL FINDINGS
SED RMAL GS
 
 

Breast  Inspection  Breast even with chest Gynecomastia, swe Symmetrical c  Breast even with c
wall symmetrical, colo lling ulceration hest wall. hest wall symmetric
Palpation  r, varies from light p s, irregular hard al, color, varies f
ink to dark brown, no modules.  rom light pink to d
discharge, no masses, ark brown. Her breast
no modules, no tendern has milk
ess

Axilla  Inspection No masses, tenderness, Hair nodules mass No mass  No masses, tendern
or modules  es, tenderness no ess, or modules 
Palpation  ted upon palpatio
n
Precordium  Inspection Absence of abnormal he Murmurs, tachycar Absence of mu  Absence of abnorma
art sounds, rhythm, an dia, bradycardia, rmurs and abn l heart sounds, rhy
Auscultatio d murmurs snap split sound ormal heart s thm, and murmurs
n  s, thrills upon p ound.
  alpation   
Palpation 
Point of maximal impul
se is taping, 7 cm lat
eral to the midsternal
line in the 5th interc
ostal space 

 
ABDOMEN

AREAS ASSESSED METHOD NORMAL FINDINGS DEVIATION FROM NORM ACTUAL FIND ACTUAL FINDINGS
AL INGS
 
 

Abdomen Inspectio Flat, rounded (conve Generalized abdomin No scars an  scaphoid (concav
n x) or scaphoid (conc al distention, asym d the color e) in shape symmet
ave) in shape symmet metrical with organ of the skin ric contour, same
Palpation ric contour, same co enlargement  is the sam color with the bod
lor with the body, n e. y, no scars, good
Percussio o scars, good skin t skin turgor, no ma
n  urgor, no masses, no sses, no lumps, no
lumps, no tenderness tenderness
    
Liver, spleen, Percussio Liver span is 6 to 1 Liver span is great
kidneys n  2 cm in the right MC er than 12cm in the
L. Liver span is 4 t right MCL with enla
o 8 cm in midsternal rged liver. Dullnes
line: non tender, no s extends above the
masses 6th rib. 

   

Spleen; small area o Enlarged spleen. pe

f dullness and 6th   rcussed note become
to 10th  ribs: tympa dull; painful upon
nic on inhalation; n palpation, superfic
ot normally palpabl ial masses,  spleen
e; nontender  enlargement 

Kidneys: not normall

y palpable, nontende
r, no masses, no inc
rease in abdominal g
irth, level of dulln
ess does not change 

 
POSTERIOR CHEST 

AREAS ASSESSED METHOD NORMAL FINDINGS DEVIATION FROM NORMA ACTUAL FINDI ACTUAL FINDIN
L NGS GS

   

Musculoskeleta Inspectio Skin is intact; spine is Pallor, cyanosis, bu Skin is inta  Skin is inta
l structures  n  vertically aligned; shoul lging retracting int ct and spine ct; spine is
der and hips are at same ercostals spaces, as is verticall vertically al
height   ymmetrical; depresse y aligned. igned; should
d or projecting ster er and hips a
num; spine not align re at same he
ed. ight  
Posterior thor Palpation  Symmetrical, fair complex Pain, tenderness asy No deformiti  
ax and lungs  ion, no deformities, no l mmetrical, tactile f es and no le
esion, skin intact, unifo remitus is increased sions.
rm temperature. Bilateral or decreased asymmet
symmetrical of vocal frem rical expansion adve
itus and it is heard most ntitious sounds 
clearly at the apex of th
e lungs. No adventitious
sounds. 

 
LOWER EXTREMITIES 

AREAS ASSESSED METHOD NORMAL FINDINGS DEVIATION FROM NO ACTUAL FINDINGS ACTUAL FINDINGS
RMAL
   

Musculoskeleta Inspectio Equal in length, sy Asymmetrical, def Asymmetrical in  Equal in length,

l structures  n  mmetrical, no lesio ormities, lesion length, no lesio symmetrical, no le
ns, no deformities, s, masses ns. sions, no deformit
Palpation  minimal or moderate ies, minimal or mo
hair distribution  derate hair distri
bution 

Skin Inspectio Uniform in color, n Presence of lesio Uniform in colo  Uniform in color,
n o lesions, no defor ns, deformities; r, no lesions, n had lesions, no de
mities, same color pallor, flushed; o deformities. formities, same co
Palpation and temperature as bluish; loss of r lor and temperatur
other body parts, s ed tones; general Same temperature e as other body pa
kin springs back to ized pale yellow; as other body pa rts, skin springs
previous state imme pigmented areas; rts. back to previous s
diately when pinche rough, thick tate immediately w
d hen pinched
Nails  Inspectio Symmetrical, equal Pale or cyanotic Symmetrical, equ  Symmetrical, equa
n in length, pinkish nails, yellow dis al in length, pi l in length, pinki
in color coloration, beau nkish in color sh in color
lines, clubbing,
thickened nails 

Musculoskeleta Inspectio Able to do flexions Bone deformity, m Limited ROM.  Able to do flexio
l functions  n  and ROM uscle atrophy, no ns and ROM
t able to perform
ROM exercises, li
mited ROM, asymme
trical 

 
Genitals  Inspectio Pubic skin intact, Nodules, growths, Pubic skin intac
n  no lesions, no infl lesions, drainage t, no lesions, n
ammation, no swelli chancres, enlarge o inflammation,
ng, no discharge  d with tenderness no swelling, no
purulent discharg discharge as des
es  cribed by the cl
ient.

 She has hemorrhoids

Anus/rectum Inspectio Intact anal skin, a Sphincter tighten Intact anal ski
n nal sphincter has g s, tenderness, he n, anal sphincte
ood tone morrhoids, nodule r has good tone
s, hardness as described by
the client.

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

VII. DATA ANALYSIS
CLASSIFICATION SIGNIFICANT DA SECOND LEVEL ASSESSMEN FAMILY NURSING PROBLE
TA T M
PRESENCE OF WELLNESS CONDITION (potenti      
al/readiness)
HEALTH DEFICIT      
HEALTH THREAT      
STRESS POINT/FORESEEABLE CRISIS      
 
VIII. Family nursing health condition
a. Prioritizing health condition
   Health condition/problem #: 
criteria computation Actual scor justificati
e on
Nature of the problem      
Modifiability of the pr      
oblem
Preventive potential      
Salience of the problem      
 
b. Family nursing care plan
Family nursing problem goal objective Intervention pla Evaluation pla
s s n n
Nature of the problem        
Modifiability of the pr        
oblem
Preventive potential        
Salience of the problem