SAINT LOUIS UNIVERSITY

School of Nursing
FAMILY NURSING ASSESSMENT TOOL

Address of Family:
FAMILY NAME: Bilag SURVEYED/DATE GATHERED BY: Darianne Oteyza, Christine Belleza
INFORMANT: Patient (Mother) DATE SURVEYED / GATHERED: July 24,2013
NAME OF HEALTH CARE CENTER: Quirino Hill Health Center
A. FAMILY STRUCTURE, CHARACTERISTICS AND DYNAMICS/ RELATIONAL PATTERNS


FAMILY
RELATIONSHIP
TO THE HEAD
POSITION/ ORDER IN THE FAMILY /
OTHER ROLES
BIRTHDATE AGE GENDER
MARITAL
STATUS
PLACE OF RESIDENCE / DOMINANT OF DECISION
MEMBERS WORK / STUDY MAKERS IN MATTERS OF:
HEALTH & CARE MONEY &
TENDING EXPENSES


Head of family M
Wife of head M
S
S
Son S


Type of family: FAMILY DYNAMICS/COMMUNICATION PATTERNS/INTERACTIONAL PROCESSES:
According to structure & composition: among subsystems:
According to family head and decision making: Spouse subsystems
According to roles/bread-earning: Parent-Child subsystem
Sibling-sibling subsystem:

B. SOCIO-ECONOMIC AND CULTURAL CHARACTERISTICS:

FAMILY
HIGHEST
EDUCATIONAL RELIGIOUS AFFILIATION ETHNIC BACKGROUND OCCUPATION INCOME OTHER SOURCES
MEMBERS ATTAINMENT
RELIGIOUS SECT
WHERE WHAT RELIGIOUS SECT IS OF INCOME
BAPTIZED THE MEMBER ACTIVE






BUDGET AND ACTUAL EXPENSES
BASIC NECESSITIES BUDGET/MONTH
ACTUAL
EXPENSES CONCLUSION: ADEQUACY TO MEET BASIC NECESSITIES USING THE TOTAL INCOME, BUDGET AND ACTUAL EXPENSES AS BASIS
Food and water Adequate:


Shelter Inadequate:


Clothing More than adequate:


Education



Health



Electricity



Others



TOTAL

SIGNIFICANT OTHERS OF THE FAMILY
FAMILY TRADITIONS, EVENTS OR PRACTICES THAT AFFECT MEMBERS HEALTH OR FAMILY FUNCTIONING






RELATIONSHIP OF THE FAMILY TO THE LARGER COMMUNITY:



















C. HOME AND ENVIRONMENT:
1. HOUSING Owned: _____ Rented: ______
Total # of rooms of house: ____ Approx size of each sleeping room (sq m): _____
# of rooms for sleeping: _____ # of people occupying each room: _____
Type of materials used:
Light (bamboo, nipa, etc) : _____ Mixed (combination of wood, GI, cement): _____ Permanent/strong (cement): _____
Presence of breeding/resting places of vectors: None Observed: _____
Present: ____ Location: _____
Kitchen: Generally clean surroundings: ____ Generally unclean: ____
Pots and pans washed and kept in cupboards ___ Pots, pans, plates scattered and unclean ____
No flies/cockroaches/rats observed ____ Flies/cockroaches/rats visible ___
Food storage:
Refrigerator ___
Food cabinet: closed___ open ___
Pot/food keepers/plastic containers: with cover____ without cover____
None because all food is consumed every meal ___ Others ______
Presence of accident hazards
Sharps unkempt:
Medicine cabinet: Present ____ Absent ____
With lock ___ Where are medicines kept _____________________________________________
Without lock ____
Where are poisons kept:__________
Cooking facility: Gas range: ____ Gas stove: _____ Electric stove: _____
If gas stove or gas range: With safety device: ___ Without: ____
Dirty kitchen: ___ With clean surroundings: ____ With piled garbage/combustible debris near it: ____
Pugon: ____
Burning of food: Never occurred: ____ seldom occurs: ___ Commonly occurs: ____
Checking of stove before family members leave the house:
Not a practice: ___ Only a few members do this: ___ Consciously done by all members: ____
Electrical wiring checked annually: Yes___ No ___
Attitude of members leaving sockets with plugs still connected: Yes ___ No ___
Presence of stairs in the home: Yes ___ None __
If yes: with rails ___ None but necessary __ Not Necessary___
Members walking barefoot
When entering CR/bathroom: Yes ___ No ___
When going outside the house: Yes ___ No___
Slippery floors: Present ___ None ___
Domestic animals that bite: Present __ None ___
Highway in close proximity to the house: Yes ___ No ___
Others: _______
Lighting:
Water supply:
Source: Level 1 ___ Level 2 ___ Level 3 ___ Others ______________________________
Distance from the house: ________________ Distance from the first house being supplied: ___________________________
Ownership: Family owned ___ Shared with other families ___
Storage of drinking water:
Earthern jar: with cover ____ without cover ___
Bottles / plastics: with cover ___ without cover ___
Water dispenser: ___ Others ____ None ____
Storage of water used for cooking:
Water tank: with cover ___ without cover ___
Drums: Plastic ___ Tin drums ___
Others: _______
Potability: Boiled: Yes ___ No ___
Tested: Yes ___ Not tested ___
When last tested ___
Result of test ____________________________________________________________________________________________
Other comments: _________________________________________________________________________________________

Domestic Animals
TYPE OF NUMBER CHECK APPROPRIATE COLUMN
ANIMAL With cage Stray
Dog
Fowl
Cat
Pig
Others

Toilet facility:
Type: Level 1 ___ Level 2 ___ Level 3 ___
If open pit privy, specify location and distance from the kitchen

Ownership: Family owned ___ Public ___
Shared with other families ____ How many families ___
Sanitary condition: No smell ___ Foul-smelling ___ With flies ____ No flies ____
Garbage or refuse disposal:
Type: Landfill ___ Composting ___ Burying ___ Burning ___
Open dumping ___ Location and distance from the house ____
Garbage collection ___ Schedule of collection ___
Segregation of waste: Practiced by family __ Not practiced ___
Sanitary condition: No flies ___ No smell ___ With flies ___ With smell ___
Drainage System: Type: Closed/blind ___ Open ___ None __
Drainage continuously flow ___ With stagnation of drainage ___
Sanitary condition: Frequented by vectors ___ Not frequented by vectors ___
2. KIND OF NEIGHBORHOOD
Rural ___ RUrban ___ Urban ___ Slum area___
Distance of one house to another_____________ Population density: ____________
Conclusion: Congested ___ Not congested ___
3. SOCIAL / RECREATIONAL AND GOVERNMENT FACILITIES
FACILITY CHECK IF
DISTANCE
FROM FAMILY AWARENESS & UTILIZATION
PRESENT HOUSE CHECK IF FAMILY CHECK IF FAMILY
IS AWARE UTILIZES
Day care / nursery
Elementary school
High school
Vocational School
College
DSWD
DENR
Others:

Sports center
Others

Sari-sari store


4. HEALTH FACILITIES AND MANPOWER AVAILABLE


HEALTH FACILITY DISTANCE FROM
TYPE & # OF
MANPOWER FAMILY AWARENESS & UTILIZATION
HOUSE AVAILABLE CHECK IF FAMILY CHECK IF FAMILY
IS AWARE UTILIZES
Barangay Health Station


Rural Health Unit
Emergency Hospital


District Hospital
Others:




5. NON-GOVERNMENT / PRIVATE AND PEOPLES ORGANIZATIONS PRESENT / AVAILABLE
6. COMMUNICATION FACILITIES
Phones: Mobile __ Landline __ Transistor radio __ TV __ Computer __
Letter __ Word of mouth __ Others __
7. TRANSPORTATION FACILITIES ON A 24-HR BASIS: None ___
Private car __ Taxi __ PUJ __ Van __ Tricycle __ Passenger bus __

D. HEALTH STATUS OF EACH FAMILY MEMBERS
a. Obstetrical history
NAME OF CHILD AGE OF MOTHER FREQUENCY OF PRENATAL PLACE OF DELIVERY TYPE OF REMARKS
DURING THIS PREGNANCY CHECKUPS ATTENDANT AT JUST CHECK IF DELIVERY
HOME HOSPITAL DELIVERY




b. Family developmental stage:
c. Developmental assessment of infants, toddlers and preschoolers through the MMDST
d. Nutritional assessment of vulnerable family members
VULNERABLE FAMILY WEIGHT HEIGHT MID-UPPER ARM FOOD PREFERENCES EATING/FEEDING
MEMBER CIRCUMFERENCE HABITS/PRACTICES












Dietary history indicating quality and quantity of food intake per day

CONTENT & BREAKFAST LUNCH DINNER
AMOUNT
Content and amount of
food intake (average)


Risk assessment measures for obese members of the family
MEASURE / INDICATOR EXPECTED NORMAL FINDINGS ACTUAL FINDINGS
OBESE FAM MEMBER FINDINGS





e. Assessment of common risk factors leading to non-communicable diseases

RISK FACTORS CHECK THOSE OBSERVED / NON-COMMUNICABLE DISEASES WHEREBY FAMILY MEMBER/S
PRESENT IN THE FAMILY ARE PREDISPOSED OF
CVD DM CANCER RESP CONDITION






f. Assessment of risk factors leading to common communicable diseases

POSSIBLE RISK
CHECK AS MANY
RISK COMMUNICABLE DISEASE FOR WHICH FAMILY ARE PREDISPOSED OF
FACTORS
FACTORS
PRESENT PTB
Other resp
dses Dengue & other Diarrheal dse

mosquito-borne
dse
Exposure to a suspected TB case
Exposure to a respitatory- related CD
Lives near a creek crowded with thick bushes
Does not regularly change practice the following habits
Changing water of flower vases
Not cleaning surroundings
Non-disposal of rubber tires, empty bottle and cans
Not keeping water containers covered
Too many hanging clothes inside the house
Poor en't sanitation
Non-potable water supply
Unsanitary food sources, prep & serving
Fond of eating street foods
Malnourished
Others as needed

g. Focused assessment results of vulnerable family members indicating presence of illness states
VULNERABLE CHIEF COMPLAINT FAMILY BELIEFS REMEDIES BY FAMILY
MEMBER AS TO CAUSES MEDICAL CONSULT HOME REMEDIES REMARKS

















h. Medical and nursing history indicating current or past significant illnesses or beliefs and practices conducive to health and illness
Family Member Past illness Reliefs as to Remedies don by family
Causes Home Hosp Remarks














i. Results of laboratory / diagnostic or screening procedures undergone by vulnerable family members


Family Member Laboratory/diagnostic/screening procedure
Procedure done Expected normal findings Actual findings






E. VALUES, HABITS, PRACTICES ON HEALTH PROMOTION, MAINTENANCE AND DISEASE PREVENTION
a. Beliefs and practices of promotive & preventive health services
Immunization status of the family members, especially children 0-8 years old and mothers of reproductive age (14-49 y/o)
FAMILY MEMBERS BCG HBV OPV DPT AMV TT
1 2 3 1 2 3 1 2 3 1 2 3 4 5






b. Check ups


Family members Age Promotive / preventive services

never goes for
check up
goes only
for
goes for
annual px
does monthly
SBE
Annual PAP's
smear dental exam
Annual eye
exam
annual
guiac test testicular exam
even if ill
check up
if ill














c. Practice of family planning methods
FP acceptor__ FP user __ FP Non-acceptor __
Method accepted: ______ Method being used _____
Reason for acceptance and use ___
Reason for non-acceptance / non-use: _________________________________________________________________________
Misconceptions heard about the use of FP: _______________________________________________________________________
d. VALUES, HABITS, AND PRACTICE OF OTHER HEALTH LIFESTYLES
Exercise, rest and sleep
Family members Rest and sleep Exercise Relaxation Stress mgmt
# of hours Interupted or naps present naps absent Nature of Frequency # of mins activities
activities
employed
per night continuous exercise per week per exercise



























Beliefs and practices about nutrition during menstruation, pregnancy, childbirth, illness, feeding babies, etc.
Menstruation:
Pregnancy:
Childbirth:
Feeding babies:
Illness:
Others: