I.

Family Assessment

A. STRUCTURE AND CHARACTERISTICS

Members Relationship to Date of Age Sex Civil Place of Educational Occupation income Other
of the head of the birth status residence attainment and place of sources
family family/position work of
income

 Type of family structure:

 Family member who decides on matter in health:

 General family relationship (presence of any obvious/readily observable conflict between members:
B. SOCIO-ECONOMIC AND CULTURAL CHARACTERSITICS:
1. Monthly family expenditure:
a. Food

b. Clothing

c. Shelter

d. Education

e. Utility

f. Others

2. Ethnic background (migrants/natives/member of cultural minority groups)

3. Religious affiliations

4. Nature & level of participation in community affairs (socio-civic, cultural, etc.)

C. HOME & ENVIRONMENTAL

 Housing
a. Adequacy of living space

b. Sleeping arrangement

c. Presence of breeding or resting sites of insect, rodents or other vectors

d. Presence of accidental hazards

e. Food storage &cooking facilities

f. Water supply(source, ownership, potability)

g. Toilet facility (type, ownership, sanitary considerations)

h. Garbage disposal ( type, sanitary conditions)

i. Drainage system (type, sanitary conditions)

  Kinds of neighborhood

 Social and health facilities available

 Communication and transportation

D. HEALTH STATUS OF EACH FAMILY MEMBER

1. Medical & nursing history indicating current or past significant illness or beliefs & practices conducive to heath and illness

2. Nutritional assessment (specially for vulnerable or at risk members)

a. Anthopometric data (BMI, weight, height, mid-arm circumference)

b. Dietary history

c. Eating/feeding habits & practices

3. Screen for risk factors leading to cardiovascular diseases, diabetes, cancer and respiratory conditions.
a. Smoking (frequency, no. of sticks/packs per day)
b. Nutrition/diet (number of servings of vegetables per day and usual types of vegetables eaten, number of servings of
fruits per day, number of servings of meat and poultry, frequency of eating fried foods, frequency of visiting fast
food/restaurants, frequency of eating preserved, canned and instant foods per week, amount of salt added when
cooking food)

c. Physical inactivity (types of physical activities indulged including duration/day and frequency per week)

d. Obesity (body mass index)

e. Alcohol (type, amount, frequency of intake)

f. Raised blood pressure (BP)

g. Blood glucose (indicate recent result)

 h. Blood lipids (indicate recent results)

i. others

4. physical assessment indicating the presence of illness state (only the affected system)

5. results of laboratory/diagnostic &other screening procedures supportive of assessment findings

E. VALUES, HABITS, PRACTICES ON HEALTH PROMOTION AND DISEASE PREVENTION

1. immunization status of family members

2. health lifestyle practices. Specify.

3. Adequacy of:
a. Rest and sleep

b. Exercise/activities

c. Use of protective devices

d. Relaxation & stress management

4. Use of promotive-preventive health services

 IV. FORMULATION OF FAMILY NURSING PROBLEMS BASED ON FAMILY’S PERFORMANCE OF THEIR HEALTH TASKS
1. Does the family recognize the presence of wellness state or health condition or problem identified?

2. Does the family make decisions about taking appropriate health actions to maintain wellness or manage the problem
identified?

3. Does the family provide nursing care to the sick, disabled, dependent or at risk members?

4. Does the family maintain a home environment conducive to health maintenance and personal development?

5. Does the family utilize community resources for health care?

 V. FAMILY NURSING CARE PLAN

HEALTH FAMILY GOAL OF CARE OBJECTIVE OF INTERVENTIONS METHOD/S OF RESOURCES EVALUATION

PROBLEM NURSING CARE NURSE-FAMILY REQUIRED
PROBLEM CONTACT
II. SUMMARY OF HEALTH PROBLEMS

CUES HEALTH PROBLEMS CLASSIFICATION

III. SCALE FOR RANKING HEALTH CONDITIONS & PROBLEMS ACCORDING TP PRIORITIES

CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION

NATURE OF THE PROBLEM

MODIFIABILITY OF THE
PROBLEM

PREVENTIVE POTENTIAL

SALIENCE OF THE PROBLEM

TOTAL SCORE
 CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION

NATURE OF THE PROBLEM

MODIFIABILITY OF THE
PROBLEM

PREVENTIVE POTENTIAL

SALIENCE OF THE PROBLEM

TOTAL SCORE

UNIVERSITY OF SAN CARLOS

 COLLEGE OF NURSING
CEBU CITY, PHILIPPINES

HEALTH TEACHING PLAN

TOPIC: DATE: VENUE:

GOALS/OBJECTIVES CONTENT TEACHING TIME PERSONS RESOURCES EVALUATION

STRATEGIES ALLOTMENT INVOLVED