CHAPTER II FAMILY CONSTELLATION The family constellation is the summary of the familys characteristics and general health status.

The members are presented according to their ordinal position. The data included in the following family constellation are the results of the initial assessment of the family members taken upon their first interaction with the researchers.

Name

Age

Position in the family

Sex

Educational Status

Present Health Status

Papa Bear

39 y/o

Father

Male

Elementary Graduate

Conscious and coherent, oriented to time and place No t-shirt and shorts with long and slightly curly hair which NOT properly combed, brown complexion. Vital signs taken and recorded as follows: BP: 130/40 mmHg T: 37C per axilla P: 99 bpm R: 24 cpm Ht= 167cm Wt- 60

Mama Bear

37 y/o

Mother

Female

Elementary Graduate

She was present during the initial home visit. Upon arrival, she was wearing gray colored t-shirt and black shorts. She looks very untidy

and not groomed, with presence of sweat over the face and the neck. Her skin is dry to touch and presence of scars on the peripheries. Her hair is thick and dry in texture with scalp lesions or flaking due to frequent scratching because of the presence of pediculosis. Has untrimmed and dirty finger and toenails. With dirty inner ears and on the back of the ears. Has presence of dirty inner nose, lips are slight dry, gums are pale, presence of 13 teeth with dental caries, gums pale, presence of lesions on the thoraxic area with cough noted, with stretch marks noted on the abdomen, with presence of scars and scratches on the extremities. The

following vital signs were noted: T=37.3C PR= 87 bpm RR= 22 cpm BP= 130/90 mmHg Ht= 163cm Wt= 63 kg Panda Bear 25y/o First child Male High School Undergraduate Polar Bear 22y/o Second child Female High school undergraduate Grizzly Bear 14y/o Third child Male High school Not seen During home visit Not seen During home visit Not seen During home visit Brown Bear Fourth child Male Never been to school Pogi Bear 10y/o Fifth child Male Elementary Upon arrival, he was white sando and short . Skin is dry to touch looks very untidy and poorly groomed, dirty face with presence of scratches on the peripheries, has thick and very dry in texture, with scalp lesions or flaking, presence of pediculosis. Has slight pale nail beds, with untrimmed and dirty finger and toenails, has dirty inner ears and on Deceased

the back of the ears, presence of dirty inner nose with presence of whitish nasal secretions, lips slight dry, pale gums 8 presence of teeth with dental caries. With cough noted, with lesions noted on the abdomen. T=36.5C PR=104 bpm RR= 22 cpm Ht= 120 cm Wt= 30 kg Handsome Bear 6y/o Sixth child Male Never Been to school Upon arrival, he was wearing dirty white sando. Skin is dry to touch looks very untidy and not groomed and has a dirty face with presence of scratches on the peripheries has blisters are documented on the inner thighs, buttocks and posterior thighs, has thick and very dry in texture, with scalp lesions or flaking, presence of

pediculosis. Has slight pale nail beds, with untrimmed and dirty finger and toenails, has dirty inner ears and on the back of the ears, presence of dirty inner nose, lips slight dry, pale gums, presence of 10 teeth with dental caries. With cough and colds has whitish secretions noted, with lesions noted on the abdomen. T=36.2C PR=112 bpm RR= 24 cpm Ht= 100cm Wt= 15 kg Ganda Bear 5y/o 7th child Female Never been to school Upon arrival, she was wearing a pink tshirt . and pink leggings Skin is dry to touch looks very untidy and not groomed has a dry and dirty hair and has a dirty face with presence of scratches on the

peripheries has pediculosis. Has slight pale nail beds, with untrimmed and dirty finger and toenails, has dirty inner ears and on the back of the ears, presence of dirty inner nose, lips slight dry, pale gums, presence of 9 teeth with dental caries. With cough and colds has whitish secretions noted, with lesions noted on the abdomen. T=36.5 PR=116bpm RR= 27 cpm Ht= 80 cm Wt= 10kg Pretty Bear 3y/o 8th child Female Never bee to school Upon arrival she is wearing a dirty white dress. Her skin is dry to touch. Looks very untidy and ungroomed. She has a long dirty and messy hair and has a dirty face. Has a dirty

inner ears presence of scratches and insect bites in her peripheries. Has a long dirty and untrimmed fingernails and toenails dirty inner nose and has a coughs and colds with whitish secretions has dental carries. Vital signs as follows: T- 36.4 P- 125 R- 27 Beautiful Bear 8 month old 9th child Female Never been to school
Upon arrival she is wearing a sando. Properly groomed. She has a moisten skin. And has a short clean hair. Her nails are short and clean. Presence of cough and cold with whitish secretions. Pinkish gums, pinkinsh lips and pinking palpebral conjunctiva. Vita signs as follows: T- 37.3 P- 133 R-28

Health Assessment In this chapter, the information necessary to determine the health status of the family members were crucially assessed. It includes the vital signs of each individual, as well as their nutritional status. It also includes the physical assessment and neurologic assessment which will be used in determining the presence of abnormalities in the family. Among its content include the immunization status of the children plus their growth and development. History of past and present illness and activities of daily living is also shown in this part

August 28, 2012 (Tuesday) Mama Bear Physical Assessment Mother Fiona, age 37 years old, is the mother of the 6 children. She stands 163cm tall and weighs 53 kilograms. Vital signs take and recorded as follows: T=37.3C, PR= 87 bpm, RR= 22 cpm, BP= 130/90 mmHg General Appearance and Mental Status Mother Fiona is cooperative during the interview, looks very untidy and not well groomed, with a BMI of 23.71 kg/m2 and an interpretation of Normal, conscious and coherent. She wears gray colored t-shirt and a black shorts. Skin dark skin complexion, warm and dry to touch, skin folds return to place after 3 seconds when lifted over forehead, presence of scars on the peripheries. No edema noted.

Hair Curly uncombed hair, black, thick and dry in texture, with presence of hair parasites or pediculosis. Nails Slight pale nailbeds. With untrimmed and dirty finger and toenails . Eyes She has a slightly yellow sclera.

Ears dirty inner ears and on the back of the ears; Nose and Sinuses She has a whitish secretions and dirty inner nose. Mouth and Throat Lips slightly dry; gums pale and black presence teeth with dental caries. Neck Neck is smooth with no nodules upon palpation, trachea is in midline position with the thyroid gland, it is firm and non-tender, and lymph nodes are not palpable, and non-tender. Thorax and Lungs Skin light brown with presence lesions, with cough noted; no tenderness, crepitus or masses; no rales, wheezes noted on auscultation. Abdomen , with stretch marks noted,

Peripheral Vascular warm and dry to touch without edema, bruising noted. With presence of scars on the extremities presence of scratches, light brown, warm and dry to touch without edema, bruising; no edema noted.

August 29, 2012 (Wednesday) General Appearance and Mental Status: untidy and not well groomed, with uncombed hair. She wears orange colored t-shirt and shorts VS: Skin: dry to touch, with presence of lesions Hair: uncombed, dry texture Nails: untrimmed and dirty fingernails Ears: presence of dirt on the back portion of the ears Mouth: presence of dental caries Thorax and Lung: presence of lesions Abdomen: presence of stretch marks

September 3 , 2012 (Monday)

General Appearance and Mental Status: Looks untidy and not well groomed, with presence of sweat over the face and neck with uncombed hair Skin: dry to touch, with presence of lesions Hair: uncombed, dry texture Nails: untrimmed and dirty fingernails Ears: dirty inner ears Mouth: presence of dental caries Thorax and Lung: presence of lesions Abdomen: presence of stretch marks September 4, 2012 (Tuesday) NOT seen during the last Home visit

Obstetric History Mother has an obstetric history of G10P10 T10 P0 A0 L9. She started her menarche when she was 13 years old and had her first baby when she was 16. She experienced UTI on her 5th baby, Her 4th child died because of Leukemia. Her 8 children Undergone Home delivery and her 9th child was born in the hospital. She didnt undergone BTL. She is currently taking contraceptive pills. .

Nutritional Status Mother Fiona stands 163 cm and weighs 53 Kg with a BMI of 19.94 Kg/m2 and interpreted under Healthy weight. Body Mass Index BMI = Height in meter square BMI = 53kg 1.63 m2 BMI= 19.94 Kg/m2 Weight in kilograms

BODY MASS INDEX BMI <18.5 18.6-22.9 >23 23.0 24.9 25.0 29.9 >30.0 Interpretation Underweight Healthy Weight Overweight At Risk Obese I Obese II

History of Past Illness Mama Bear has history of Conjunctivitis and chicken. During her 5th pregnancy she experienced UTI.

Activities of Daily Living The family eats three times a day: breakfast, lunch and dinner. Mama Bear usually prepares fish that her kids enjoy eating. Mama Bear starts preparing their breakfast at around 6 o' clock in the morning. They eat breakfast at around 7 in the morning before Papa Bear goes to work. After which, Mama Bear cleans the house and prepare the laundry while the children play with the other children. After which at around 11 in the morning, Mama Bear prepare for the lunch of the family while the she is also bathing the children. At around 12 noon, the family eats their lunch and at around 1 in the afternoon, the family sleeps together as their rest time and wakes up at around 3 in the afternoon.

Panda Bear Not seen in the entire Home visits. Polar Bear Not seen in the entire Home visits. Grizzly Bear Not seen in the entire Home visits. Brown Bear Not seen in the entire Home visits.

August 29, 2012 (Wednesday) Pogi Bear Physical Assessment Pogi Bear, age 10 years old, is 5th children of the bear family . He stands 120 cm tall and weighs 25 kilograms. Vital signs take and recorded as follows T=36.5C, PR= 104 bpm, RR= 22 cpm, General Appearance and Mental Status Pogi Bear went back to home from school when we first met him. he process, looks tired and hungry not well groomed and dirty, with a BMI of 17.36 and it is interpreted as underweight conscious and coherent. Skin His skin is cold and dry to touch.

Hair Clean cut hairstyle, black, thin and dry in texture, presence of hair parasites or pediculosis noted. Nails

With pinkish nailbeds. With untrimmed and Dirty fingernails; dirty toenails. Eyes No abnormalities present. With pinkish palpebral conjunctiva. Eyes are symmetrical. Head and Facial He has a dirty face. Has no lumps upon palpation. Ears Has dirty inner ears and has a dark brown cerumen. Nose and Sinuses Has whitish secretions because of colds. Mouth and Throat Lips pinkish and moist; Gums are pale presence of 4 teeth with dental caries.

Thorax and Lungs Skin brown with presence Lesions. And has a cough noted. Heart and Neck Vessels No pulsations visible; no heaves or vibrations; clear brief heart sounds throughout; no gallops, murmurs and rubs; Abdomen Abdomen is distended

Peripheral Vascular Arms s warm to touch has presence of insect bites and lesions. LEGS: Dry to touch has presence of scratches, insect bites and lesions.

Nutritional Status Pogi Bear stands 120 cm and weighs 25 Kg with a BMI of 17.36Kg/m2 and interpreted under Underweight. Body Mass Index BMI = Height in meter square BMI = 25kg 1.20 m2 BMI= 17.36 Kg/m2 Weight in kilograms

BODY MASS INDEX BMI <18.5 18.6-22.9 >23 23.0 24.9 25.0 29.9 >30.0 Interpretation Underweight Healthy Weight Overweight At Risk Obese I Obese II

August 28, 2012 Handsome Bear Physical Assessment Handsome Bear, age 6 years old, is the Sixth child of the Bear Family. She stands 90 cm tall and weighs 13 kilograms. Vital signs take and recorded as follows: T=36.2C, RR=112 bpm, RR: 24 cpm, General Appearance and Mental Status Handsome bear is alert and very naughty, looks very untidy and not groomed, with a BMI of 16.05 Kg/m2 considered underweight, play with her playmates, conscious and coherent, has rhythmic and coordinated movements, and mood is appropriate for situation. She wears a shorts not wearing any t-shirt and slippers. Skin Dark skin complexion, warm and dry to touch, skin folds return to place after 2 seconds when lifted over forehead, presence of scratches on the peripheries. Hair Straight black, thin and dry in texture, with scalp lesions or flaking due to frequent scratching because of the presence of pediculosis. Nails Slight pale nailbeds. With untrimmed and dirty finger and toenails . Eyes The eyebrows of Handsome bear are aligned and hair was evenly distributed, eyelashes are curved outward, skin on eyelid was intact and closes symmetrically; no edema noted. Absence of tenderness between

the eyelid and the nose upon palpation of the lacrimal gland, no discharges, the sclera appears normal, bulbar conjunctiva is transparent, the palpebral conjunctiva is shiny, she can still see objects when looking straight ahead, eyes are coordinated. Pupils black and equal in size, illuminated pupil constricts; pupil constricts when looking at near object; dilates at far object; pupils converge when the penlight is moved towards the nose. Head and Facial The skull of Handsome bear is normocephalic, Has presence of lesions and masses upon inspection and palpation, He was able to: smile, frown, raise her eyebrows, close her eyes, and show her teeth without difficulty. Ears Left and right auricles without deformity, has lesions; auricles and mastoid process non-tender; dirty inner ears and on the back of the ears . Bilateral auditory canals contain small amount of dark brown cerumen; Nose and Sinuses Presence of dirty inner nose. And has whitish secretions. Mouth and Throat Lips slightly dry, gums pale and has presence of 10 teeth with dental caries.

Thorax and Lungs Skin light brown with presence of scars or scratches; with cough noted; Heart and Neck Vessels No pulsations visible; no heaves or vibrations; clear brief heart sounds throughout; no gallops, murmurs and rubs;

Abdomen Rounded and enlarged bites noted, Peripheral Vascular ARMS: equal in size and bilaterally symmetric; warm and dry to touch without edema, bruising noted. With presence of scars, scratches on the extremities LEGS: small in size and bilaterally symmetric; skin intact but with presence of scratches , insect bites and lesions, light brown, warm and dry to touch without edema, bruising; no edema noted. without masses, with lesions and insect

August 29 , 2012 General Appearance: not groomed, uncombed hair, appears untidy Skin: dry to touch, with presence of lesions Hair: uncombed, dry texture, presence of parasites Nails: untrimmed and dirty fingernails and toenails Ears: dirty inner ears presence of dirt on the back portion of the ears Nose: Dirty inner nose and has whitish secretions Face: has a dirty face Mouth: presence of dental caries Neck: presence of sapat Thorax and Lung: presence of lesions and cough Abdomen: presence of scratches

September 3, 2012 General Appearance: not well groomed, appears untidy; Skin: dry to touch, with presence of lesions Hair: dry texture, presence of parasites Mouth: presence of dental caries Thorax and Lung: presence of lesions and cough Abdomen: presence of scratches Face: has a dirty face Nose: has a whitish secretion September 4, 2012 General Appearance: not well groomed, appears untidy; Skin: dry to touch, with presence of lesions Hair: dry texture, presence of parasites Mouth: presence of dental caries Thorax and Lung: presence of lesions and cough Abdomen: presence of scratches Face: has a dirty face Nose: has a whitish secretion

Growth and Development In the third stage of Erickson's Theory of Psychosocial Development, the initiativeversus - guilt stage (ages 3 to 6 years), children's desire to act independently conflicts with the guilt that comes from the unintended and unexpected consequences of such behavior. Children in this period come to understand that they are persons in their own right and they begin to make decisions about their behavior. If parents react positively to children's attempts at independence, they will help their children resolve the initiativeversus-guilt crisis positively. Handsome Bear, 6 years of age, is in this stage of Psychosocial Development of Erikson's Theory. The student nurses observed that he has sense of independence. he bathes himself. '

Nutritional Status Handsome Bear stands 90 cm and weighs 13 Kg with a BMI of 16.09 Kg/m2 and interpreted under underweight. Body Mass Index BMI = Height in meter square BMI = 13kg .9 m2 BMI= 16.09 Kg/m2 Weight in kilograms

BODY MASS INDEX BMI <18.5 18.6-22.9 >23 23.0 24.9 25.0 29.9 >30.0 Interpretation Underweight Healthy Weight Overweight At Risk Obese I Obese II

History of Past Illness As stated by Mama bear during the interview, He had no known illness but the just the common cough and colds and fever. They also increase the fluid intake to prevent dehydration and to liquefy the secretions. They also engage in Hilots whenever Mama Bear suspect that the children had pilay.

November 9, 2011 Ganda Bear Physical Assessment Gand Bear, age 5 years old, is the fourth child among the children of Mother Fiona. She stands 102 cm tall and weighs 13 kilograms. Vital signs take and recorded as follows: T=36C, RR=108 bpm, RR: 22 cpm,

General Appearance and Mental Status Cinderella is busy playing with her playmates, looks very untidy and not groomed. According to FNRI, she considered underweight; conscious and coherent, has rhythmic and coordinated movements. She wears white t-shirt only without shorts and walks barefooted. Skin Slightly dark skin complexion, warm and dry to touch, skin folds return to place after 3 seconds when lifted over forehead, presence of scratches on the peripheries. No edema noted. Hair

Slightly curly hair, black, thick and very dry in texture; with scalp lesions or flaking due to frequent scratching because of the presence of hair parasites and lice. Nails Slight pale nailbeds. With untrimmed and dirty finger and toenails . No clubbing, has capillary refill of 3 seconds. Eyes The eyebrows of Cinderella are aligned and hair was evenly distributed, eyelashes are curved outward, skin on eyelid was intact and closes symmetrically; no edema noted. Absence of tenderness between the eyelid and the nose upon palpation of the lacrimal gland, no discharges, the sclera appears normal, bulbar conjunctiva is transparent, the palpebral conjunctiva is shiny, she can still see objects when looking straight ahead, eyes are coordinated. Pupils black and equal in size, illuminated pupil constricts; pupil constricts when looking at near object; dilates at far object; pupils converge when the penlight is moved towards the nose. Head and Facial The skull of Cinderella is normocephalic, absence of lesions and masses upon inspection and palpation, she was able to: smile, frown, raise her eyebrows, close her eyes, and show her teeth without difficulty. Ears Left and right auricles without deformity, lumps or lesions; auricles and mastoid process non tender; dirty inner ears and on the back of the ears; bilateral auditory canals contain small amount of dark brown cerumen; Nose and Sinuses Presence of dirty inner nose. External structure without deformity, asymmetry or inflammation; nares patent; turbinates and middle meatus pale pink without swelling, lesions or bleeding; nasal septum midline

without bleeding, perforation or deviation; frontal and maxillary sinuses non tender. Mouth and Throat Lips slightly dry; no lesions or ulcerations; buccal mucosa slightly pale and moist; no ulcers or nodules; gums pale and moist without inflammation, bleeding or discoloration; hard and soft palates smooth without lesions or masses; tongue midline when protruded; no lesions or masses; no lesions, discolorations, or ulcerations on floor of the mouth, oral mucosa or gums; uvula in midline; tonsils present without edema or enlargement; have presence of 6 teeth with dental caries. Neck Neck is smooth with no nodules upon palpation, trachea is in midline position with the thyroid gland, it is firm and non-tender, and lymph nodes are not palpable, and non-tender. Thorax and Lungs Skin light brown with presence of scars or scratches, no pulsation; no hair noted; thorax expands evenly bilaterally without retractions or bulging; no use of accessory muscles when breathing and no nasal flaring; respirations even, regular (21/min); with cough noted; no tenderness, crepitus or masses; no rales, wheezes noted on auscultation. Heart and Neck Vessels No pulsations visible; no heaves or vibrations; clear brief heart sounds throughout; no gallops, murmurs and rubs; Abdomen Rounded; symmetric without masses, with lesions noted, no pulsations or peristalsis noted; abdomen is free of hair; umbilicus in midline without herniation, swelling or discoloration; With no lesions, normal abdominal sounds of 28 bowel sounds per quadrant, with no abnormal findings upon percussion, no tenderness and masses found upon palpation.

Peripheral Vascular ARMS: equal in size and bilaterally symmetric; warm and dry to touch without edema, bruising noted. With presence of scars, scratches on the extremities LEGS: small in size and bilaterally symmetric; skin intact but with presence of scratches, light brown, warm and dry to touch without edema, bruising; no edema noted.

Musculoskeletal Gait steady, smooth and coordinated with even base; full range of motion of lateral flexion and extension of supine; upper and lower extremities with full range of motion; muscles moderately firm bilaterally; no deviations, inflammations or bony deformities; moves upper and lower extremities against gravity and resistance. November 10, 2011 General Appearance: untidy with ruin dress, walks barefooted Skin: dry to touch, with presence of lesions Hair: uncombed, dry texture, presence of pediculosis Nails: untrimmed and dirty fingernails and toenails Ears: dirty inner ears; dirty inner ears presence of dirt on the back portion of the ears Nose: Dirty inner nose Mouth: presence of dental caries Thorax and Lung: presence of cough Abdomen: presence of scratches November 11, 2011 General Appearance: appears untidy; wears black sando and red shorts Skin: dry to touch, with presence of lesions

Hair: dry texture, presence of parasites Mouth: presence of dental caries Thorax and Lung: presence of lesions and cough

Growth and Development In the third stage of Erickson's Theory of Psychosocial Development, the initiativeversus - guilt stage (ages 3 to 6 years), children's desire to act independently conflicts with the guilt that comes from the unintended and unexpected consequences of such behavior. Children in this period come to understand that they are persons in their own right and they begin to make decisions about their behavior. If parents react positively to children's attempts at independence, they will help their children resolve the initiativeversus-guilt crisis positively. Cinderella, age 5 years old, is under the initiative-versus-guilt stage of Erickson's Psychosocial Theory. She manifested initiative. When mother Fiona tells them, the children, to take a bath. Cinderella prepares her clothes before taking a bath. And after which, she takes a bath and clothes herself and brushes her teeth. And finally, she combs her hair the way she likes.

History of Past History As mentioned by Mother Fiona during the interview, Cinderella had no known illness but the just the common cough and colds and fever. They manage using over the counter (OTC) drugs such as paracetamol, carbocisteine and antibiotics. They also increase the fluid intake to prevent dehydration and to liquefy the secretions. They also engage in Hilots.

November 9, 2011 Belle

Physical Assessment Belle, age 4 years old, is the eldest among the children of mother to her second husband. She stands 90 cm tall and weighs 15 kilograms. Vital signs take and recorded as follows: T=36.1C, HR=94 bpm, RR: 26 cpm, General Appearance and Mental Status Belle is cooperative but easily distracted, looks very untidy and poorly groomed, normal BMI, play with herself , conscious and coherent, She wears pink t-shirt and stripe shorts and walks barefooted. Skin Slightly dark skin complexion, warm and dry to touch, skin folds return to place after 2 seconds when lifted over forehead, presence of scratches on the peripheries. No edema noted. Hair Straight square-shaped hair, black, thick and dry in texture, with scalp lesions or flaking due to frequent scratching because of the presence of pediculosis. Nails Slight pale nailbeds. With untrimmed and dirty finger and toenails . No clubbing, has capillary refill of 2 seconds. Eyes The eyebrows of Belle are aligned and hair was evenly distributed, eyelashes are curved outward, skin on eyelid was intact and closes symmetrically; no edema noted. Absence of tenderness between the eyelid and the nose upon palpation of the lacrimal gland, no discharges, the sclera appears normal, bulbar conjunctiva is transparent, the

palpebral conjunctiva is shiny, she can still see objects when looking straight ahead, eyes are coordinated. Pupils black and equal in size, illuminated pupil constricts; pupil constricts when looking at near object; dilates at far object; pupils converge when the penlight is moved towards the nose. Head and Facial The skull of Belle is normocephalic, absence of lesions and masses upon inspection and palpation, she was able to: smile, frown, raise her eyebrows, close her eyes, and show her teeth without difficulty. Ears Left and right auricles without deformity, lumps or lesions; auricles and mastoid process non-tender; dirty inner ears and on the back of the ears. Bilateral auditory canals contain small amount of dark brown cerumen. Nose and Sinuses Presence of dirty inner nose. External structure without deformity, asymmetry or inflammation; nares patent; turbinates and middle meatus pale pink without swelling, lesions or bleeding; nasal septum midline without bleeding, perforation or deviation; frontal and maxillary sinuses non tender. Mouth and Throat Lips slightly dry; no lesions or ulcerations; buccal mucosa pink and moist; no ulcers or nodules; gums pale and moist without inflammation, bleeding or discoloration; hard and soft palates smooth without lesions or masses; tongue midline when protruded; no lesions or masses; no lesions, discolorations, or ulcerations on floor of the mouth, oral mucosa or gums; uvula in midline; tonsils present without edema or enlargement; have presence of 4 teeth with dental caries. Neck

Neck is smooth with no nodules upon palpation, trachea is in midline position with the thyroid gland, it is firm and non-tender, and lymph nodes are not palpable, and non-tender. Thorax and Lungs Skin light brown with presence of scars or scratches, no pulsation; no hair noted; thorax expands evenly bilaterally without retractions or bulging; no use of accessory muscles when breathing and no nasal flaring; respirations even, regular (26/min); with cough noted; no tenderness, crepitus or masses; no rales, wheezes noted on auscultation. Heart and Neck Vessels No pulsations visible; no heaves or vibrations; clear brief heart sounds throughout; no gallops, murmurs and rubs; Abdomen Rounded; symmetric without masses, with lesions noted, no pulsations or peristalsis noted; abdomen is free of hair; umbilicus in midline without herniation, swelling or discoloration; With normal abdominal sounds of 23 bowel sounds per quadrant, with no abnormal findings upon percussion, no tenderness and masses found upon palpation. Peripheral Vascular ARMS: equal in size and bilaterally symmetric; warm and dry to touch without edema, bruising noted. With presence of scars, scratches on the extremities LEGS: small in size and bilaterally symmetric; skin intact but with presence of scratches, light brown, warm and dry to touch without edema, bruising; no edema noted.

November 10, 2011 General Appearance: dresses inappropriately, walks barefooted Skin: dry to touch, with presence of lesions

Hair: uncombed, dry texture, presence of pediculosis Nails: untrimmed and dirty fingernails and toenails Ears: dirty inner ears; dirty inner ears presence of dirt on the back portion of the ears Nose: Dirty inner nose Mouth: presence of dental caries Thorax and Lung: presence of cough Abdomen: presence of scratches November 11, 2011 General Appearance: walks barefooted Skin: dry to touch, with presence of lesions Hair: dry texture, presence of pediculosis Ears: dirty inner ears presence of dirt on the back portion of the ears Nose: Dirty inner nose Mouth: presence of dental caries Thorax and Lung: presence of cough Abdomen: presence of scratches

Growth and Development In the third stage of Erickson's Theory of Psychosocial Development, the initiativeversus - guilt stage (ages 3 to 6 years), children's desire to act independently conflicts with the guilt that comes from the unintended and unexpected consequences of such behavior. Children in this period come to understand that they are persons in their own right and they begin to make decisions about their behavior. If parents react positively to children's attempts at independence, they will help their children resolve the initiativeversus-guilt crisis positively. The student nurses observed that Belle is manifesting initiative as evidenced by doing simple things such as grooming without being forced by her mother. It was also noticed by the student nurses that Belle is playing with her playmates.

History of Past Illness According to Mother Fiona, Belle has asthma. Whenever she had her attack, they usually go to the emergency department of Mabalacat Hospital. Mother Fiona manages Belle's condition using bronchodilator, Salbutamol. Belle also had common cough and colds and fever and they usually manage it by self-medicating using antibiotics (Cefalexin, Amoxicillin), Paracetamol, Carbocisteine and Salbutamol.

November 9, 2011 Ariel

Physical Assessment

Ariel, age 3 years old, is the second youngest among the children of mother Fiona. She stands 80 cm tall and weighs 11 kilograms. Vital signs take and recorded as follows: T=36.5C, HR=104 bpm, RR: 22 cpm, General Appearance and Mental Status Ariel is playing on her own, looks very untidy and poorly groomed. Based from the FNRI, she is considered underweight. She wears yellow dress and walks with slippers. Skin Slightly dark skin complexion, warm and dry to touch, skin folds return to place after 2 seconds when lifted over forehead, presence of scratches on the peripheries. No edema noted. Hair Dora-like hairstyle, black, thick and dry in texture, with scalp lesions or flaking due to frequent scratching because of the presence of pediculosis. Nails Slight pale nailbeds. With untrimmed and dirty finger and toenails . No clubbing, has capillary refill of 2 seconds. Eyes The eyebrows of Ariel are aligned and hair was evenly distributed, eyelashes are curved outward, skin on eyelid was intact and closes symmetrically; no edema noted. Absence of tenderness between the eyelid and the nose upon palpation of the lacrimal gland, no discharges, the sclera appears normal, bulbar conjunctiva is transparent, the palpebral conjunctiva is shiny. Head and Facial The skull of Ariel is normocephalic, absence of lesions and masses upon inspection and palpation, she was able to: smile, close her eyes, and show her teeth without difficulty.

Ears Left and right auricles without deformity, lumps or lesions; auricles and mastoid process non tender; dirty inner ears and on the back of the ears.bilateral auditory canals contain small amount of dark brown cerumen; Nose and Sinuses Presence of dirty inner nose. With presence of whitish nasal secretions. External structure without deformity, asymmetry or inflammation; nares patent; turbinates and middle meatus pale pink without swelling, lesions or bleeding; nasal septum midline without bleeding, perforation or deviation; frontal and maxillary sinuses non tender. Mouth and Throat Lips slightly dry; no lesions or ulcerations; buccal mucosa pink and moist; no ulcers or nodules; gums pale and moist without inflammation, bleeding or discoloration; hard and soft palates smooth without lesions or masses; tongue midline when protruded; no lesions or masses; no lesions, discolorations, or ulcerations on floor of the mouth, oral mucosa or gums; uvula in midline; tonsils present without edema or enlargement; have presence of 6 teeth with dental caries. Neck Neck is smooth with no nodules upon palpation, trachea is in midline position with the thyroid gland, it is firm and non-tender, and lymph nodes are not palpable, and non-tender. Thorax and Lungs Skin light brown with presence of scars or scratches, no pulsation; no hair noted; thorax expands evenly bilaterally without retractions or bulging; no use of accessory muscles when breathing and no nasal flaring; respirations even, regular (22/min); with cough noted; no tenderness, crepitus or masses; no rales, wheezes noted on auscultation.

Heart and Neck Vessels No pulsations visible; no heaves or vibrations; clear brief heart sounds throughout; no gallops, murmurs and rubs; Abdomen Rounded; symmetric without masses, with lesions noted, no pulsations or peristalsis noted; abdomen is free of hair; umbilicus in midline without herniation, swelling or discoloration; Peripheral Vascular ARMS: equal in size and bilaterally symmetric; warm and dry to touch without edema, bruising noted. With presence of scars, scratches on the extremities LEGS: small in size and bilaterally symmetric; skin intact but with presence of scratches, light brown, warm and dry to touch without edema, bruising; no edema noted.

November 10, 2011 General Appearance: walks barefooted Skin: dry to touch, with presence of lesions Hair: dry texture, presence of pediculosis Nails: untrimmed and dirty fingernails and toenails Ears: dirty inner ears; dirty inner ears presence of dirt on the back portion of the ears Nose Dirty inner nose Mouth: presence of dental caries Thorax and Lung: presence of cough Abdomen: presence of scratches November 11, 2011

General Appearance: walks barefooted Skin: dry to touch, with presence of lesions Hair: dry texture, presence of pediculosis Ears: dirty inner ears presence of dirt on the back portion of the ears Nose: Dirty inner nose Mouth: presence of dental caries Thorax and Lung: presence of cough Abdomen: presence of scratches

Growth and Development

In the third stage of Erickson's Theory of Psychosocial Development, the initiativeversus - guilt stage (ages 3 to 6 years), children's desire to act independently conflicts with the guilt that comes from the unintended and unexpected consequences of such behavior. Children in this period come to understand that they are persons in their own right and they begin to make decisions about their behavior. If parents react positively to children's attempts at independence, they will help their children resolve the initiativeversus-guilt crisis positively. Ariel is in this stage of Psychosocial Development as noted by the student nurses that she dresses on her own after bathing.

History of Past Illness According to mother Fiona, Ariel had scabies last May resulting to the cutting of her hair. She had no other illness or diseases experienced other than the common cough and colds and fever that they usually manage by self medicating with Paracetamol, Salbutamol, Cefalexin or Amoxicillin and Carbocisteine.

November 9, 2011

Hercules Physical Assessment Hercules, age 2 years old, is the eldest among the children of mother to her second husband. He stands 76 cm tall and weighs 9 kilograms. Vital signs take and recorded as follows: T=36.2C, HR=112 bpm, RR: 24 cpm General Appearance and Mental Status Hercules is uncooperative and afraid of the student nurses, looks very untidy and not groomed. Based from the FNRI, he is considered underweight. He is cuddled by mother; he looks pitiful due to his burns. Skin Slightly dark skin complexion, warm and dry to touch, skin folds return to place after 4 seconds when lifted over forehead, presence of scratches on the peripheries. Edema on the surrounding tissues of the burn is noted; blisters are documented on the inner thighs, buttocks and posterior thighs. Hair Clean cut-shaped hair, black, thick and dry in texture, with scalp lesions or flaking due to frequent scratching because of the presence of pediculosis. Nails Slight pale nailbeds. With untrimmed and dirty finger and toenails . No clubbing, has capillary refill of 4 seconds. Eyes The eyebrows of Hercules are aligned and hair was evenly distributed, eyelashes are curved outward, skin on eyelid was intact and closes symmetrically; no edema noted. Absence of tenderness between the eyelid and the nose upon palpation of the lacrimal gland, no

discharges, the sclera appears normal, bulbar conjunctiva is transparent, the palpebral conjunctiva is shiny. Head and Facial The skull of Hercules is normocephalic, absence of lesions and masses upon inspection and palpation. With presence of burn area near the mouth area. With edema noted on the surrounding tissues. Ears Left and right auricles without deformity, lumps or lesions; auricles and mastoid process non tender; dirty inner ears and on the back of the ears.bilateral auditory canals contain small amount of dark brown cerumen; Nose and Sinuses Presence of dirty inner nose. External structure without deformity, asymmetry or inflammation; nares patent; turbinates and middle meatus pale pink without swelling, lesions or bleeding; nasal septum midline without bleeding, perforation or deviation; frontal and maxillary sinuses non tender. Mouth and Throat Lips slightly dry; no lesions or ulcerations; buccal mucosa pale and moist; no ulcers or nodules; gums pale and moist without inflammation, bleeding or discoloration; hard and soft palates smooth without lesions or masses; tongue midline when protruded; no lesions or masses; no lesions, discolorations, or ulcerations on floor of the mouth, oral mucosa or gums; uvula in midline; tonsils present without edema or enlargement; have presence of 2 teeth with dental caries. Neck Neck is smooth with no nodules upon palpation, trachea is in midline position with the thyroid gland, it is firm and non-tender, and lymph nodes are not palpable, and non-tender.

Thorax and Lungs Skin light brown with presence of scars or scratches, no pulsation; no hair noted; thorax expands evenly bilaterally without retractions or bulging; no use of accessory muscles when breathing and no nasal flaring; respirations even, regular (24/min); with cough noted; no tenderness, crepitus or masses; no rales, wheezes noted on auscultation. Heart and Neck Vessels No pulsations visible; no heaves or vibrations; clear brief heart sounds throughout; no gallops, murmurs and rubs; Abdomen Rounded; symmetric abdomen, with lesions noted, no pulsations noted; abdomen is free of hair; umbilicus in midline without herniation, with swelling noted on the surrounding tissues of burn area; with a moist pinkish to whitish burn area; Peripheral Vascular ARMS: equal in size and bilaterally symmetric; warm and dry to touch without edema, bruising noted. With presence of scars, scratches on the extremities LEGS: small in size and bilaterally symmetric; skin intact but with presence of scratches, light brown, warm and dry to touch without edema, bruising; no edema noted. November 10, 2011 General Appearance: looks afraid and in pain Skin: dry to touch, with presence of lesions and black blisters over the inner and posterior thighs, Hair: uncombed, dry texture, presence of pediculosis Nails: untrimmed and dirty fingernails and toenails Ears: dirty inner ears; dirty inner ears presence of dirt on the back portion of the ears Nose: Dirty inner nose

Face: presence of drying with scab formation the burn area near the left portion of the mouth Mouth: presence of dental caries Thorax and Lung: presence of cough Abdomen: tissues. presence of moist, pinkish with whitish and greenish appearance of the burn area; with edema noted on the surrounding

Growth and Development In the second stage of Erickson's Theory of Psychosocial Development, the autonomy-versus-shame and doubt stage (ages 1 1/2 to 3 years), toddlers develop independence and autonomy if exploration and freedom are encouraged, or they experience shame, self-doubt and unhappiness if they are overly restricted and protected. According to Erickson, the key to the development of autonomy during this period is for the child's caregivers to provide the appropriate amount of control. If parents provide too much control over their environment; if parents provide too little control, the children become overly demanding and controlling. Hercules is at this stage of psychosocial development according to age. The student nurses also observed that the child's caregiver (Mother Fiona) provides choices for Hercules to decide in order to develop autonomy. Hercules manifested dominantly the trust-versus-mistrust stage of psychosocial development. He usually cries and tries to hide himself away from the student nurses because he is worried that we might hurt him. He is not afraid of the student nurses if he knows that his mother is there.

History of Past and Present Illness Based from the interview of student nurses to Mother Fiona, she said that Hercules was diagnosed to have asthma. They manage it by bringing Hercules to the Emergency Room of Mabalacat Hospital during his acute attack. Hercules also experience fever, common cough and colds. The family manages these by using over the counter (OTC) medications such as Paracetamol for fever, Carbocisteine for cough and colds,

Salbutamol for asthma and antibiotics if the cough lasted longer than usual. Currently, Hercules had an accident while he was at home. According to Mother Fiona, Hercules is playing inside the house near the kalan with boiling water then he suddenly fell and accidentally hit the caserole resulting to first and second degree burns. The family manages this by self-medicating using Amoxicillin before the student nurses enter into their lives. After knowing about the incident, the student nurses together with their clinical instructor immediately refer this to the barangay midwife. The student nurses also initiated to clean the burn areas using Normal Saline Solution, gauze, and Betadine. The student nurses also taught the family the proper cleaning of the burn areas and gave health teachings in order to prevent complications such as infection.