Nursing Family Assessment

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FAMILY ASSESSMENT

Name of Family: A Family

Place of Residence: Tophill. Lahug

A. STRUCTURE AND CHARACTERISTICSMEMBERS

OF THE

FAMILY

RELATION TO THE

HEADDATE OF BIRTH AGE SEX

CIVIL

STATUSRELIGION OCCUPATION INCOME

OTHER

SOURCES OF

INCOME

EDUCATIONAL

BACKGROUND

PLACE OF

BIRTH

O.A Head 12.16.1978 30 M Married Cathol ic Carpenter

Php

290.00/day None Grade 6 Cebu

M.J.A Wife 09.10.1980 29 F Married Christian Housewife None Washwoman Grade 4Negros

occidental

J.A Son 11.27.1998 10 M Single Christian Student None None Grade 2 Cebu

J.A Daughter 10.2.2000 8 F Single Christian Student None None Grade 3 Cebu

N.J.A Daughter 09.15.2002 7 F Single Christian Student None None Grade 1 Cebu

J.A Son 10.17.2004 4 M Single Christian - None None None Cebu

J.K.A son 02.2.2008 1 M Single Christian - none none none Cebu


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TYPE OF FAMILY STRUCTURE: The family has a nuclear type of f amily structure

FAMILY MEMBER WHO DECIDES ON MATTERS IN HEALTH CARE: Both M.J and O decide on health care matters and whenever they need medical assistance.

GENERAL FAMILY RELATIONSHIP (PRESENCE OF ANY OBVIOUS/READILY OBSERVABLE CONFLICT BETWEEN MEMEBERS) : The children of M.J. and O are obse rved to be always

quarreling with each other but not on serious matters. Most of thei r misunderstandings are caused by toys and food. M.J and her children also verbalized that M.J. and O have

conflicts every time O comes home not in the mood and drunk.

B. SOCIO ECONOMIC AND CULTURAL CHARACTERISTICSINCOME AND EXPENSES

O is a carpenter and earns Php 290.00/day while M.J. was a washwoman but stopped for a whi le due to her pregnancy. O and M.J were abl e to provide their children of

their basic needs. The famil y is able to eat three times a day and someti mes can be able to provide snacks in the after noon. The clothes of some of the couples children are

observed to be already worn out but were still usable and appropriate for their respective gender (dress for the daughter and shorts and shirts for the boys). The couple is able

to provide the ir family with a house to live in. i n terms of decisions on money matters, O gives his sal ary to his wife and M.J will be the one who w ill budget the money which can

meet the f amilys basic necessities such as food, clothes, school supplies and the li ke.

EDUCATIONAL ATTAINMENT OF EACH MEMBER

Both M.J and O were not able to finish studying because of financial problems. O was able to graduate elementary while M.J stopped attendi ng school when she was i n

her 4thgrade. Three of thei r children are currently studying in a school near their home. J1, the eldest i s still in hi s second grade since he had failures in some of his subjects that

needed him to re-enroll to grade 2. J2 on the other hand is in her 3rdgrade and was an honor student when she was in grade 2. NJ is in his 1stgrade while the rest of the family

members are staying at home.

ETHNIC BACKGROUND AND RELIGIOUS AFFILIATION

M.J. was born in Negros Occidental while O is from Cebu. O is a roman catholic and M.J is a Christian. Both of them decided a nd agreed to have their children baptized as

Christians. On Sundays, both M.J and O goes to colon to attend Christi an mass. They dont bring their ch ildren with them since they are not stil l discipline enough with their

behavior and actions.


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RELATIONSHIP OF THE FAMILY TO LARGER COMMUNITY

M.J. attends some of the activiti es implemented by the Barangay Health Workers such as immunization, garbage disposal and the li ke. Because of her present condition,

she seldom participates i n the activities since their house is far from the location of the programs. M.Js family has a good relationship with their ne ighbors and is willing to help

whenever anyone is in need.

C. HOME AND ENVIRONMENT

The family is living in a two (2) room house and is besi de the house of M.Js sister. The house is just enough for the family. In the presence of J1s wound (matag-tiki) on

his gluteus, he stayed on the room of his parents while the rest are currently staying on the other room which also served as the famil ys dining room and living room. Breeding

sites of inse cts and rodents such as uncovered pails with water and stagnant canals were observed in their surroundings. Thei r kitchen is situated at the side of the entrance of

their house. They use wood for cooking. They dont have refrigerator to store their food so they see to it that there will be no leftovers. In some cases, they just cover thei r food

with plastic plates and store it at the side near the sink which is reachable to the dogs and cats. They get the ir water from their neighbor and pays Php 50.00 f or 10 gallons, Php

3.00 for one pail. They have thei r own bathroom but is sti ll under construction. They use empty sacks to cover their toilet. They have pour-flush type of toilet facility. They throw

their garbage far from their house and where there are no more houses and just leave it there.

KIND OF NEIGHBORHOOD

The family is settled in a congested slum area. The houses are situated side by side.

SOCIAL AND HEALTH FACILITIES AVAILABLE

The Barangay hall and health center is far from the ir house. They seldom avail medications from the health center since they f ind it too far from their house but M.J had

the effort to go on prenatal visits.

COMMUNICATION AND TRANSPORTATION FACILITIES AVAILABLE

The familys mode of transportation is just public vehicle or they just walk to save money. Whenever they need to call, the f amily just borrows the cell ular phone of M.Js

sister.


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D. HEALTH STATUS OF EACH FAMILY MEMBERMEDICAL AND NURSING HISTORY

J.K was hospital ized because he fell from their four-stepped stairs and luckily, he didnt e xperience any complications. J2 had a tetanus toxoid shot because she was

wounded by a rusty metal on her right foot. Three of M.Js children are currently experiencing cough and colds and health teaching was done to hel p alleviate the illness. J1 had

a deep wound with abscess/pus on his right gluteus.

NUTRITIONAL ASSESSMENT

The family was not observed with dehydration, underweight, overweight or any kind of malnutriti on.

DEVELOPMENTAL ASSESSMENT

None of the famil y has any problem with their dev elopment. No one is mentally retarded or had any problems with their learning abilities. M.J verbalized that all of their

children learned how to walk at approximately 1-1 years old.

PHYSICAL ASSESSMENT INDICATING PRESENCE OF ILLNESS STATES

Productive cough and mucosal secretions were observed in M.Js three children. Wounds were also noted on J.K and J3s scalp a nd legs and the deep wound of J1.

E. VALUES AND PRACTICES ON HEALTH PROMOTION/MAINTENANCE AND DISEASE PREVENTIONJ1 and J3 were not able to be immunized with measles while the rest of the children had BCG, DPT, Hep B and measles. M.J. cannot recall i f she had received any

immunization during her childhood. She didnt know if her husband has also be en immunized. The family takes in mul tivitamins daily whenever they have money to supply. They

usually go to sleep at around 8 in the eve ning and wakes up at 6-7 am.

F. CLASSIFICATION OF HEALTH PROBLEMSHEALTH DEFICIT HEALTH THREAT FORESEEABLE CRISIS

Cough and colds Deep wounds

Poor environmental sanitation Family size beyond family resources canadequately provide

Pregnancy


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G. HEALTH PROBLEMS ACCORDING TO PRIORITIESCOUGH AND COLDS

CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION

1. Nature of the problem2. Modifiability of the problem3. Preventive potential4. Salience of the problem

3/3x1

1/2x2

3/3x1

1/2x1

1

1

1

0.5

3.5

-It is a health deficit and demands immediate attention

-The resources and interventions are not available to the family. The familychooses not to take medications because they dont have enough money to

avail medications

-transmission of illness can be prevented if i t is managed well as soon as

possible

-the mother recognizes the problem but she didnt attend to the problem

immediately

DEEP WOUND


1. Nature of the problem2. Modifiability of the problem

3. Preventive potential4. Salience of the problem

3/3x1

2/2x2

3/3x1

2/2x1

1

2

1

1

5

-It is a health def icit since the cli ent experienced the illness and is vulnerable

for infection

-The nurses and familys resources are available. The nurse can help in

treating the wound through wound dressing. The mother gives medication to

the infected person

-Infection can be prevented if the problem is attended well like giving proper

medications and wound dressing

-the mother recognizes the problem and seek i mmediate attention


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POOR ENVIRONMENT




2/3x1

2/2x2

2/3x1

1/2x1

0.6

2

0.6

0.5

3.7

-it is a health threat since this can possibly cause diseases and illness like

dengue

-the family and the nurse have e nough resources to prevent the occurrence of

illnesses/diseases caused by poor sanitation

-the family is not the onl y one contributing to the problem

-the problem was recognized by the family but they didnt take any

immediate action to their condition

FAMILY SIZE BYOND FAMILY RESOURCES CAN ADEQUATELY PROVIDE


1. Nature of the problem

2. Modifiability of the problem3. Preventive potential4. Salience of the problem

2/3x1

2/2x2

3/3x1

2/2x1

0.6

2

1

1

4.6

-it is a health threat since the family can no longer provide the basic

necessiti es thus the members cannot have proper nutrition that can lead to

illness

-The nurses and familys resources are availableto solve the problem. The

nurse can help in budgeting the resources of the family

-The possibil ity of increasing family size is reduced through the use of

contraceptives like abstinence, condom, rhythm, pills and the like.

-the family recognizes it as a problem and believes that it needs immediate

attention and ensures that the sixth pregnancy will be the last


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PREGNANCY




1/3x1

1/2x2

3/3x1

1/2x1

0.3

1

1

0.5

2.8

-it is a foreseeable crisis since pregnancy needs attention to the health of both

the mother and the baby. Also, it needs financial expenses

-The nurses resources and intervention are available but the familys

resources are not to solve the problem

-complications associated with pregnancy can be highly prevented if utmost

attention is given to the health of the mother

-the family recognized it as a problem si nce this could add up to their

expenses but they dont find it to be needing immediate attention

H. RANKING OF PRIORITIES1. Deep wound as a heal th deficit52. Family size beyond family resources can adequately provide as a health threat4.63. Poor environmental sanitation as a health threat3.74. Cough and colds as a health deficit3.55. Pregnancy as a foresee able crisis2.8


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UNIVERSITY OF SAN CARLOS

COLLEGE OF NURSING

FAMILY NURSING CARE PLAN

HEALTH PROBLEM

FAMILY

NURSINGPROBLEMS

GOAL OFCARE OBJECTIVES OFCARE NURSING INTERVENTIONS

METHODS OF

NURSE-FAMILYCONTACT

RESOURCESREQUIRED EVALUATION

Cough and colds as a

health deficit

Subjective cues: nah,

gpang.ubo ni silang tulo

ay. Usahay naai tambal,

usaha y wala. Depende

kung naai kwarta as

verbali zed by the

mother

Objective cues Productive

cough

Averageamount in

sputum

Clear-yellowish in

color

Mucosalsecretions

noted

>inability to

provide

adequate

nursing care

to the sick,

disabled,

dependent, or

vulnerable at

ris k member

of the family

due to:

- Lack of/inadequate

knowledge

about the

disease/healt

h conditions

(nature,

severity,

complications,

prognosis and

management)

>failure to

utilize

community

resources for

health care

due to:

After the

nursing

intervention

, the family

will be able

to eliminate

the cough

and colds

and will

prevent the

recurrence

of thedisease in

the future.

After nursing

intervention, the

family will be able to:

a. Acquireadequate

information

about the

disease

including

signs and

symptoms of

the disease,immediate

health care

assistance

and

preventive

measures

1. Discuss with the family the ca uses,signs and s ymptoms and

complications of cough and col ds.

1.1 cold-acute inflammation of themucous membrane of the upper

passages

1.2 causes: intake of cold food seasonal changes improper digestion of

food

1.3 s/s: running nose/blocked

nose

sneezing sore throat congestion headache low fever loss of appetite lethargy insomnia

1.4 complications ear infections sinus infections bronchitis pneumonia

1. Home visit2. Lecture3. discussion

Manpower:

Student

nurse

Family/client

Manhour:

Time and

effort of

family and

student

nurse

Materials:Visual aids


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-failure to

perceive the

benefits of

health

care/services

b. Be aware onhow to

reduce the

chances of

spreading

communicabl

e diseases to

other family

members

c. Identify lowcost home

remedies for

cough and

colds

d. Choose andperform

2. provide adequate knowledge on thevarious ways of maintaining

cleanliness in their s urroundings

2.1 ways: hand washing taking a bath everyday dispose garbage

properly

3. explain the importance of properfood preparation, good nutrition, rest

and sleep in strengthening ones

resistance against illness so as to

prevent the occu rrence of cough and

colds

3.1 importance prevent someone from

getting sick

prevent crosscontamination

prevent from spreadingthe disease

health promotion anddisease prevention

4. give the famil y some home remediesfor cough and colds

4.1 remedies SLK Lagundi leaves Black pepper and ginger Garlic (boiled with

sugar)

Chicken soup(colds)5. Help the client identify appropriate

remedy to be used


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correctly the

remedy

chosen

e. Utilizecommunity

resources

avail able in

resolving thecondition

experienced

f. Verbalizeunderstandin

g of proper

sanitation

and the

remedies

and

preventive

measures of

the condition

6. Assist cl ient in preparing the chosenremedy

7. Cite ways in eliminating the diseaseand limiting the occurrence of

transmission through medications

and al ternative medicines and

preventive measures such as coveringthe mouth when sneezing or

coughing and proper disposal of oral

and nasal discharges

8. Evaluate the familys understandingregarding proper sa nitation and

preventive measures of cough and

colds


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HEALTH PROBLEM

FAMILY

NURSINGPROBLEMS

GOAL OF

CARE

OBJECTIVES OF

CARENURSING INTERVENTIONS

METHODS OF

NURSE-FAMILYCONTACT

RESOURCES

REQUIREDEVALUATION

Presence of breeding

sites of vectors of

diseases

Subjectivecues:magpundo man

mi ug tubig kai wa man

mi amo.ang tubig, ang

uban wai takub.. nah

cana pud among canal

aiy pwerte cadaghan ug

lamok as verbalized by

the mother

Objective cues

uncovered pailwith water

observed stagnant canal

noted

unfinishedlaundry noted

unwasheddishes noted

>inability to

provide a

home

environment

conducive tohealth

maintenance

and personal

development

due to:

-ignorance of

the

importance of

hygiene and

sanitation

-lack of

knowledge

regardingpreventive

measures of

ill nesses and

diseases

After the

nursing

intervention

, the family

will be ableto eradicate

the

presence of

these

unwanted

sites of

vectors

causing

diseases and

therefore

will maintain

a home

environment conducive

to health.

After nursing

intervention, the

family will be able to:

a. Acquireknowledgeon the

importance

of proper

sanitation

especial ly at

home

b. Identifyvectors and

possiblebreeding

sites

1. Assess the clients home forbreeding sites and proper

sanitation/hygiene

2. Discuss to the family theimportance of proper sanitation

2.1reduce the numbers ofmicroorganisms such as

bacteria and viruses

2.2reduce transmission ofcommunicable and infe ctious

disease

2.3maintenance of health2.4promote health2.5prevent diseases and illnesses

3. explain to the client/family whatvector is and its different types

and breeding sites3.1vectors- described as any

agent that transmits a disease

organism

3.2examples include: bedbugs cockroaches flies lice mosquitoes rat fleas

3.3breeding sites include old tires clogged canals

Home visit Lecture discussion

Manpower:

Student

nurse

Family/client

Manhour:

Time andeffort of

family and

student

nurse

Materials:

Visual aids


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c. Enumeratemethods/

techniques

to eradicatethe breeding

sites of

vectors of

diseases

d. point outpossible

breeding

sites of

vectors of

diseases

e. choose fromthe

methods/tec

hniques

given to use

at home to

eradicate

breeding

sites

f. perform themethods

correctly

g. verbalizetheir

understanding of the

importance

of proper

plastic wrappers plants with large

leaves

4. familiarize to the client sometechniques and methods to

eradicate breeding sites

4.1use of mosquito/fly trap4.2use of mosquito repellent4.3use of mouse traps4.4proper sanitation of the

environment

5. help client in assessing their homefor possible breeding sites

6. assist client/family in choosing theappropriate techniques to be used

7. guide the client in performing thechosen methods/techniques

8. evaluate what the family haslearned and assess how they feel

about the activity


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sanitation

and its

effects to

humans

health


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HEALTH PROBLEM FAMILY

NURSINGPROBLEMS

GOAL OF

CARE

OBJECTIVES OF

CARE

NURSING INTERVENTIONS METHODS OF

NURSE-FAMILYCONTACT

RESOURCES

REQUIRED

EVALUATION

Health seeking

behaviors for health

maintenance and

promotion related to

the need to increaseintake of nutrients and

calori es during

pregnancy

Subjective cues:

gamay raman keu cog

caon nya sad coi

vitamins usahay cai wai

kwarta pero adto ko sa

health center para

prenatal a s verbali zed

by the mother

Objective cues:

9 monthspregnant

Average typeof body

>inability to

recognize the

presence of

the problem

due to:- lack of

inadequate

knowledge

regarding the

proper

nutrition

during

pregnancy

>inability to

make

decisions with

respect to

taking

appropriate

health action

due to:

-inaccessibility

of appropriate

resources

specifically

cost of

constraints or

economic/fina

ncial

inaccessibility

>failure to

utilizecommunity

resources due

After the

nursing

intervention

, the client

will be ableto

demonstrat

e changes in

her diet as

manifested

by proper

food

selection

and

achieved

proper

balanced

diet by

acquiring

the needed

nutrients

during

pregnancy

After nursing

intervention, the

cli ent will be able to:

a. Verbalizeunderstanding on the

importance

of proper

diet

especially

during

pregnancy

b. Enumeratefoods to be

included in

her diet as

well as

important

nutrients

c. Plan thedesired

meals with

properbalanced diet

suitable for

1. assess cleints attitude towardseating and her diet during

pregnancy

2. educate the client regarding theproper diet and its importance

during preganancy

3. educate the client about thevitamins and minerals that are

essenti al during her pregnancy

3.1protein3.2calcium3.3iodine3.4iron3.5carbohydrates3.6vitamin A3.7vitamin C3.8vitamin D3.9Folic Acid3.10 Water

4. Plan with the client her desiredmeals through providing her a

chart or the food pyramid as her

guide toward/on what foods sheshould prepare

5. Instruct client to avoid caffeinated

Home visit Lecture discussion

Manpower:

Student

nurse

Family/client

Manhour:

Time andeffort of

family and

student

nurse

Materials:

Visual aids


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to:

-

lack/inadequa

te knowledge

of community

resources for

health care

pregnant

women

d. Appreciatethe

importance

of prenatal

check-

ups/visits

e. Be aware ofthe

complication

associated

with

pregnancy

f. Recognizethe presence

of health

care facil ities

in their

barangay

that could

help herattain proper

health during

pregnancy

beverages. Caff einated beverages

may decrease the appetite andwill make the client feel full easily

6. Instruct client to avoid junk food7. Instruct client to follow the

required number of se rvings. Too

much or too littl e could bring

about complications8. Encourage client to maintain diet

throughout pregnancy and

puerperium

9. Assess clients vi ews on prenatalcheck-ups/visits

10.Assess i f client had prenatal check-ups/visits

11.Discuss to the client theimportance of prenatal check-up

for both mother and baby

12.Explain to the client thecomplications of pregnancy

13.Instruct client to seek medicalattention if client ex perienced

high risk pregnancy complications

14.Encourage client to recognize thepresence of their health care

centers and the faciliti es available

that could help them le arn more

about proper nutrition/health

during pregnancy


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Nursing Family Assessment

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