ISLAMIC UNIVERSITY OF GAZA

FACULTY OF NURSING
Sample 2 : family and community care plan
A Family assessment and planning instrument :
This is an assessment and planning instrument to help you to organize your data .
Its not be taken into a home as an interviewing instrument.
1. FAMILY ROLE-RELATIONSHIP PATTERN :
Initial of family surname :
Persons living in the house hold :
Given name
only

Member

Date of birth

Age

Sex

Relation to head of
Household

Identify primary care giver :

Members of family not living in household :
Significant others :
Pets :
Occupation history of each adult member ( Past/Present ) :
Job Identification :
Exposure to health hazards :
Family dynamics :
Role

Primary function

Interaction with other

Communication pattern :

Occupation

Expression of feelings ( happiness , sadness , fear , anger )

Verbal and non-verbal :
How are message transmitted ?

Social relations

Who do the family members interact with outside the immediate family ,
and what community activities do they participate in ?
Extend family --------------- , Neighbors --------------- .
Friends --------------- , Mosques --------------- , Clubs --------------- .
Community activities ( list ) --------------------------------------------- .

Income

Family income : --------------------------------------------------------------------------- .

Source : salary --------------- , saving --------------- , investment --------------- .
Others ------------------------------------------------------------ .
Contribution of working members :
Member : --------------- , Amount : --------------- (JD, $ & SH )
Are expenses greater , less than or equal to income :
Who plans how the money is spent ?

1. FAMILY COGNITIVE / PERCEPTION PATTERN :

Educational level , What is the highest grade completed ?
Adults :
Children :
Members of the family with learning or developmental disabilities ?
Decision making : Who make the decisions ? Give examples :

2. FAMILY SELF PERCEPTION / SELF CONCEPT PATTERN :

Family's perception of their ability to maintain their family unit :
Family's pride in their home :
Family residence :

Type : Single : --------------- , Multifamily : --------------- , Own : --------------- ,

Rent : --------------Describe condition of home inside and outside :
Number of rooms : --------------Space : Adequate : --------------- , Inadequate : --------------Furniture : Adequate : --------------- , Inadequate : --------------Accident hazards :
Neighborhood :
Residential : --------------- . Industrial : --------------- . Rural : --------------- .
Urban : --------------- . Suburban : --------------- . Other : --------------- .
Condition of dwellings and streets :
Accessibility of :
Play area : Yes --------------- . No --------------Health facilities ( List ) : Yes --------------- . No --------------Mosques , Churches : Yes --------------- . No --------------2

Schools : Yes --------------- . No --------------Public transportation ? Type ?

Family's method of transportation :
Neighborhood health hazard :
Family's perception of safety in the neighborhood ?

3. FAMILY NUTRTIONAL-METABOLIC PATTERN :

Observation about kitchen and mealtimes :
Who does the grocery shopping ?
Who does the cooking ?
Therapeutic diets :
Observation of family member of nutritional 24-hrs food/fluid intake :
Break fast :
Lunch :
Dinner :
Snacks :
Analyze if diet provides nutrients ?
How is food stored ?
Water supply :
Municipal : ------------------------------ .
Well : ------------------------------ .
Other : ------------------------------ .

4. FAMILY ELIMINATION PATTERN :

Compliance with garbage regulations ?
Yes --------------- . No --------------- . If no , explain ?
Rodents ?
Yes --------------- . No --------------- .
Insects ?
Yes --------------- . No --------------- .
Toilet facilities ?
Yes --------------- . No --------------- .

5. FAMILY ACTIVITY-EXERCISE PATTERN :

Adults leisure --------------- . Children leisure --------------- .
Shared family activities ------------------------------------------------------------ .
Type of activities required for family roles : ------------------------------ .
Adults : --------------- . Children : --------------- .
Describe pace of family life :
Fast : ---------------. Moderate : --------------- . Slow : --------------- .
3

6. FAMILY ACTIVITY SLEEP-REST PATTERN :

Which family member sleep alone ?
What type of bed does each have ?
What are the usual hours of sleep ?
Bedtime , arising , rest periods for adult and children ?
Are they any disturbances in family sleep pattern ?

7. FAMILY SEXUALITY-REPRODUCTION PATTERN :

Sexual relationships :
Family planning :
Sex education of children :

8. FAMILY VALUE BELIFE PATTERN :

Ethnic background --------------- . Influence on health behavior .
Religious affiliation --------------- . Degree of family involvement --------------- .
Influences on health behavior :
Family's definition of health :
Health beliefs and attitudes :
Folk medicine :
Use of non-traditional healing methods :
Acceptance / non-acceptance of help from community agencies ?

9. FAMILY COPING STRESS TOLERANCE PATTERN :

How has the family managed in previous situation of illness or crises ?
Own resources --------------- . Extended family : --------------- .
Other relatives --------------- . Friends --------------- . Neighborhood --------------.
Significant others --------------- . Health professional --------------- . Other
--------------- .
Caregiver's perception of their ability to deal with crises :
Client perception of caregiver's / family ability to deal with demands of
care :

10.

FAMILY HEALTH PERCEPTION HEALTH MANAGEMENT PATTERN :

Reason for visit :
Family's perception of their level of health :
Medical diagnosis of each family member :
Familial disease ( heart , cancer , stroke , anemia , .. etc )
History of past significant illness and accident of each family member :
Risk factors ( tobacco , alcohol , obesity , lack exercise ) :
4

Family health practice :

Immunization status of each family member :

Self exam ( breast , testicular , .. etc )
Preventive exams ( dental , colon/rectal ) :
Names of physician / date of last appointment and next scheduled
appointment for each family member :
Medication : is any family member taken any medication ? Yes: ------. No :
------ .
If yes ( including over the counter drugs ) :

Name of the drug --------------- .

--------------- .

How often taken :

Drug action ----------------------- .

Side effects : ---------------------- .

Date of prescription : ----------- .

Number of refills : --------------- .

Physician : ------------------------- .

Pharmacist : ----------------------- .

Treatment prescribed for family members :

Level of compliance with prescribed medication and treatments :

Financing health care :

Health insurances : ------------------- .

Private insurances : ------------------ .
Own finance : -------------------------- .