Assessment

• Set of actions by which the nurse measures the status of the family as a client, its ability to maintain itself as a system and functioning unit, and its ability to maintain wellness, prevent, control or resolve problems in order to achieve health and well-being among its members.

• Set of actions by which the nurse measures the status of the family as a client, its ability to maintain itself as a system and functioning unit, and its ability to maintain wellness, prevent, control or resolve problems in order to achieve health and well-being among its members.

Assessment

• Data collection: First level or Second level assessment

• Data analysis or interpretation: sort data, cluster/group related data, distinguish relevant from irrelevant data, identify patterns, compare patterns with norms or standards, interpret results, make inferences/draw conclusions

• Problem definition or nursing diagnosis

• Data collection: First level or Second level assessment

• Data analysis or interpretation: sort data, cluster/group related data, distinguish relevant from irrelevant data, identify patterns, compare patterns with norms or standards, interpret results, make inferences/draw conclusions

• Problem definition or nursing diagnosis

Two major types of nursing assessment

• First-level Assessment - Process whereby existing and potential health conditions or problems of the family are determined.

• Second-level Assessment – Defines the nature or type of nursing problems that the family encounters in performing the health tasks with respect to a given health condition or problem, and the etiology or barriers to the family’s assumption of these tasks.

Five types of data for First Level Assessment

• Family structure, characteristics and dynamics• Socio-economic and cultural characteristics• Home and environment• Health status of each member• Values and practices on health

promotion/maintenance and disease prevention

• Family structure, characteristics and dynamics• Socio-economic and cultural characteristics• Home and environment• Health status of each member• Values and practices on health

promotion/maintenance and disease prevention

Constructing the Family Genogram

• A genogram is a pictorial display of a patient's family relationships and medical history.

• Uses symbols• Date of birth (death) above the symbol and

name beneath• Inside the symbol: age or disease condition• Connecting lines denote relationships

First Level AssessmentFirst Level Assessment

(1) Wellness state/s(2) Health threats(3) Health deficits(4) Stress points or foreseeable crisis situations

(1) Wellness state/s(2) Health threats(3) Health deficits(4) Stress points or foreseeable crisis situations

Presence of Wellness Condition

Wellness potential

• A wellness state or condition based on client’s performance, current competencies or clinical data, but NO explicit expression of client desire.

Wellness State

Potential for Enhanced Capability for:• Healthy Lifestyle – nutrition/diet, exercise• Health Maintenance/Health Management• Parenting• Breastfeeding• Spiritual Well-being • Others, specify

• Readiness for enhanced wellness state

• Wellness state or condition based on client’s current competencies or performance, clinical data and explicit expression of desire to achieve a higher level of state or function in a specific area on health promotion and maintenance.

Wellness State

Readiness for Enhanced Capability for:• Healthy Lifestyle• Health Maintenance/Health Management• Parenting• Breastfeeding• Spiritual Well-being

Presence of Health Threats

• Conditions conducive to disease, and accident or may result to failure to maintain wellness or realize health potential.

A.Presence of risk factors of specific diseases (lifestyle diseases, metabolic syndrome)

B.Threat of cross infection from a communicable disease case

C.Family size beyond what family resources can adequately provide

Presence of Health Threats

D. Accident hazardsE. Faulty/unhealthful nutritional/eating habits or

feeding techniques practicesF. Stress-provoking factorsG. Poor home/environmental condition/sanitationH. Unsanitary food handling and preparationI. Unhealthful lifestyle and personal

habits/practicesJ. Inherent personal characteristics

Presence of Health Threats

K. Health history which may precipitate/induce the occurrence of a health deficit.

L. Inappropriate role assumptionM. Lack of immunization/inadequate

immunization status specially of childrenN. Family disunityO. Others

Presence of Health Deficits

• Instances of failure in health maintenanceA.Illness states, diagnosed or undiagnosed by

medical practitionerB.Failure to thrive/develop according to normal

rateC.Disability –whether congenital or arising from

illness; transient/temporary or permanent

Presence of Stress Points/Foreseeable Crisis Situations

• Anticipated periods of unusual demand on the individual or family in terms of adjustment/family resources.

A.MarriageB.Pregnancy, labor, puerperiumC.ParenthoodD.Additional memberE.Abortion

F. Entrance at schoolG. AdolescenceH. Divorce or SeparationI. MenopauseJ. Loss of JobK. Hospitalization of a Family MemberL. Death of a MemberM. Resettlement in a new communityN. IllegitimacyO. Others

Second Level Assessment

• Should reflect the extent to which the family can perform the health tasks on each health condition or problem identified during the first level assessment.

• Describes the family’s realities, perceptions and attitudes to the assumption or performance of health tasks.

Data for Second Level Assessment• Family’s perception of the problem• Decisions made and appropriateness; if none,

reasons• Actions taken and results; if none, reasons• Effects of decisions and actions on other

family members

Standard Health Tasks• Recognize the presence of a wellness state or

health condition or problem;• Make decisions about taking appropriate health

action to maintain wellness or manage the health problem;

• Provide nursing care to the sick, disabled, dependent or at-risk members;

• Maintain a home environment conducive to health maintenance and personal development

• Utilize community resources for health care.

Second-level Assessment

I. Inability to recognize the presence of the condition or problem due to:

A. Lack of or inadequate knowledgeB. Denial about its existence or severity as a

result of consequences of diagnosis of problem

C. Attitude/philosophy in life which hinders recognition/acceptance of a problem

D. Others

II. Inability to make decisions with respect to taking appropriate health actions due to:

III. Inability to provide adequate nursing care to the sick, disabled, dependent or vulnerable/at-risk member of the family due to:

IV. Inability to provide a home environment conducive to health maintenance and personal development due to:

V. Failure to utilize community resources for health care due to:

Nursing Diagnosis

• Cough and colds seen as a health deficit1.Inability to make decisions with respect to

taking appropriate health actions due to:a. Failure to comprehend the nature/magnitude of

the problem or condition

2. Inability to provide adequate nursing care to the sick member of the family due to:a. Inadequate knowledge about the health condition

Family Care Plan

• Blueprint of the care that the nurse designs to systematically minimize or eliminate the identified health and family nursing problems through explicitly formulated outcomes of care and deliberately chosen set of interventions, resources and evaluation criteria, standards, methods and tools.

Steps

1. Prioritization of identified health problems2. Statement of goals or objectives of care3. Selection of appropriate nursing

interventions4. Means of evaluation

Prioritization

Criteria:1.Nature of the condition or problem presented2.Modifiability of the condition or problem –

refers to probability of success in enhancing the wellness state, improving the condition, minimizing, alleviating or totally eradicating the problem through interventions

Prioritization

3. Preventive Potential – refers to the nature and magnitude of future problems that can be minimized or totally prevented if intervention is done on the condition or problem under consideration

4. Salience – refers to the family’s perception and evaluation of the condition or problem in terms of seriousness and urgency of attention needed or family readiness.

Scale

Criteria Weight

1. Nature of the Condition or Problem Presented

1

Wellness State 3

Health Deficit 3

Health Threat 2

Foreseeable Crisis 1

Criteria Weight

2. Modifiability of the Condition or Problem

2

Easily Modifiable 2

Partially Modifiable 1

Not Modifiable 0

Criteria Weight

3. Preventive Potential 1

High 3

Moderate 2

Low 1

Criteria Weight4. Salience 1A condition or problem needing immediate attention

2

A condition or problem not needing immediate attention

1

Not perceived as a problem or condition needing change

0

Scoring

1. Decide on a score for each of the criteria.2. Divide the score by the highest possible score

and multiply by the weight (Score/Highest Score) x weight

3. Sum up the scores for all the criteria. Highest score is 5, equivalent to the total weight.

Formulation of Goals of Care

• General statement of the condition or state to be brought about by specific courses of action.

• After nursing intervention, the family will manage PTB as a disease and threat.

Developing Intervention Plan

1. Analyze with family choices/possibilities based on lived experience of meanings/concerns.

2. Develop/enhance cognition (thinker), volition (doer) and emotion (feeler)

3. Focus on interventions to help the family perform the health tasks

3.1. Help the family recognize the problem.

3.2. Guide the family on how to decide on appropriate health actions to take.

3.3. Develop the family’s ability and commitment to provide nursing care to its members.

3.4. Enhance the capability of the family to provide a home environment conducive to health maintenance and personal development.

3.5. Facilitate the family’s capability to utilize community resources for health care.

4. Catalyze behavior change through motivation and support.

Developing an Evaluation Plan

• Specifies how the nurse will determine changes in health status, condition, or situation and achievement of the outcomes of care.

• Shall include criteria or indicators.

FAMILY NURSING CARE PLAN

Health Problem:Goal:Outcome Indicators:

Family Health Task

Interventions Evaluation

Implementation Phase

• Home Visits• Health Teachings• Referrals• Community Meetings• Skills Trainings and other training programs• Monthly Community Classes• Linkages• Provision of health services

Evaluation

• Comparing “what actually is” with “what should be”

• Based on the objectives and criteria set.