OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF NURSING Steps in Nursing Assessment

NCM 101 1. Data Collection
 The process of identifying the types or kinds of data needed.
FAMILY HEALTH NURSING  Specify the methods necessary to collect such data.

Family Health Nursing Methods of Data Collection

 Is a special field in nursing in which the family is the unit of care, health as its goal and a. Observation is use of all sensory capacities. The family’s status can be inferred from
nursing as its medium or channel of care. the manifestations of problem areas reflected in the following:
1. communication & interaction pattern expected, used & tolerated by family
Family Nursing Process members
 It is a means by which the health care provider addresses the health needs and 2. role perceptions/ tasks assumptions by each member including decision-
problems of the client. making patterns
 It is a logical and systematic, way of processing information gathered from different 3. conditions in the home & environment
source and translating into meaningful actions or interventions.
b. Physical Examination is done through inspection, palpation, percussion &
Steps: auscultation
1. Relating c. Interview by completing health history for each member. Health history determines
 Establishing a working relationship. Results in positive outcomes such as good current health status.
quality of data, partnership in addressing identified health need and problems, and d. Record Review is the review existing records & reports pertinent to the client/ family
satisfaction of the nurse and the client. such as diagnostic reports and immunization records.
e. Laboratory/ Diagnostic tests
2. Assessment
 Data Collection, data analysis and data interpretation and problem definition or 5 Types of Date in Family Nursing Assessment (Initial Data Base)
nursing diagnosis. A. Family Structure, Characteristics and Dynamics
1. Members of the household and relationship to the head of the family
Two types of assessment: 2. Demographic data - age, sex, civil status, position in the family
1. First Level Assessment - Data on status/ conditions of family household 3. Place of residence of each member - whether living with the family or elsewhere.
members. 4. Type of family structure - e.g. matriarchal or patriarchal, nuclear or extended
5. Dominant family members in terms of decision-making, especially in matters of health
2. Second Level Assessment - Data on family assumption of health tasks on care.
each health problem identified in the First Level Assessment. 6. General family relationship / dynamics - presence of any obvious / readily observable
conflict between members; characteristic, communication / interaction pattern among
3. Planning members
 Determination of how to assist client in resolving concerns related to restoration,
maintenance or promotion of health. B. Socio-economic and Cultural Characteristics
 Establishment of priorities, set goals / objectives, selects strategies, describe 1. Income and expenses
rationale. a. Occupation, place of work and income of each working member
b. Adequacy to meet basic necessities (food, clothing, shelter)
4. Implementation c. Who makes decisions about money and how it is spent
 The carrying out of plan of care by client and nurse, make ongoing assessment, 2. Educational attainment of each member
update / revise plan, document responses. 3. Ethnic background and religious affiliation
4. Significant Others - role(s) they play in family's life
5. Evaluation 5. Relationship of the family to larger community - Nature and extent of participation of
the family in community activities.
 A systematic, continuous process of comparing the client’s response with written goal
and objective.
C. Home and Environment
 Determines progress and evaluate the implemented intervention as to:
1. Housing
1. Effectiveness
a. Adequacy of living space
2. Efficiency
b. Sleeping arrangement
3. Adequacy
c. Presence of breeding or resting sites of vectors of disease (e.g. mosquitoes,
4. Acceptability
roaches, flies, rodents, etc)
5. Appropriateness
d. Presence of accident hazards
e. Food storage and cooking facilities
I. Nursing Assessment
f. Water supply - source, ownership, sanitary condition
 Involves a set of actions by which the nurse measure the status of the family as a g. Garbage/ refuse disposal - type, sanitary condition
client, their ability to maintain wellness, prevent and control or resolve problems in h. Drainage system - type, sanitary condition
order to achieve health and well-being among its members. 2. Kind of neighborhood, e.g. congested, slum
 3. Social and health facilities available Family Nursing Problem - Stated as an inability to perform specific health task and the reasons /
4. Communication and transportation facilities available etiology) why the family cannot perform such task.

D. Health Status of each Family Member  Consists of 2 parts: main category of problem (coming from unattained health task) and
1. Medical and nursing history indicating current or past significant illnesses or beliefs and specific problems (statement of factors contributory for the existence of the main
practices conducive to health and illness. problem.
2. Nutritional assessment ( specially for vulnerable or risk at-risk members)  Example: (general): Inability to utilize resources for health care due to lack of adequate
a. Anthropometric data : Measures of nutritional status of children- weight, height, family resources, specifically: (specific)
mid-upper arm circumference. a. financial resources
b. Dietary history specifying quality and quantity of food/ nutrient intake per day b. manpower resources
c. Eating/feeding habits /practices c. time
3. Developmental assessment of infants, toddlers, and preschoolers - e.g., Metro Manila  The more specific the problem definition, the more useful is the nursing diagnosis in
Developmental Screening Test (MMDST) determining the nursing intervention. Therefore, as many as three or four levels of
4. Risk factor assessment indicating presence of major and contributing modifiable risk problem definition can be stated.
factors for - e.g. hypertension¸ physical inactivity, sedentary lifestyle, cigarette/ tobacco
smoking, elevated blood lipids/ cholesterol, obesity, diabetes mellitus, inadequate fiber Typology of Nursing Problems in Family Nursing Practice
intake, stress, alcohol drinking and other substance abuse.
5. Physical assessment indicating presence of illness state/s (diagnosed or undiagnosed 1. First Level of Assessment – process whereby existing potential health
by medical practitioners. conditions/problems of the family are determined.
6. Results of laboratory / diagnostic and other screening procedures supportive of
assessment findings a. Presence of Wellness Condition – states as potential or readiness – a
clinical or nursing judgement about a client in transition from a specific level of
E. Values, Habits, Practices on Health Promotion, Maintenance and Disease Prevention wellness or capability to a higher level.
Such as:
1. Immunization status of family members. b. Presence of Health Deficits - Instances of failure in health maintenance.
2. Healthy lifestyle practices. A. Illness States, regardless of whether it is diagnosed or undiagnosed by medical
3. Adequacy of : practitioner
a. rest and sleep B. Failure to thrive/ develop according to normal rate
b. exercise / activities C. Disability - whether (1) congenital or (2) arising from illness
c. Use of protective measures - e.g. adequate footwear in parasite- infested
areas; use of bednets and protective clothing in malaria and filariasis c. Presence of Health Threats - Conditions that are conducive to disease, accident or
endemic areas. failure to realize one's health potential.
d. Use of relaxation and other stress management activities A. Family history of hereditary condition / disease
4. Use of promotive-preventive health services. B. Threat of cross infection from a communicable disease case
C. Family size beyond what family resources can adequately provide
2. Data Analysis D. Accident hazards .
Steps: 1. broken stairs
1. Sorting of data for broad categories (such as those related with health status or 2. pointed /sharp objects, poisons, & medicines improperly kept
practices – about home and environment). 3. fire hazards
2. Clustering of related cues to determine relationship among data. 4. fall hazards
3. Distinguishing relevant form irrelevant data. This will help in deciding what information 5. others (specify):________
is pertinent to the situation at hand and what information is immaterial. E. Faulty / unhealthy nutritional / eating habits or feeding techniques / practices.
4. Identifying patterns such as physiologic function, developmental, nutritional/dietary, 1. inadequate food intake both in quality and quantity
coping/adaptation or communication patterns. 2. excessive intake of certain nutrients
5. Compare patterns with norms or standards of health, family functioning and 3. faulty eating habits
assumption of health tasks. 4. ineffective breastfeeding
6. Interpreting results of comparisons to determine signs and symptoms or cues of 5. faulty feeding techniques
specific wellness state/s, health deficit/s, health threat/s, foreseeable crises/stress F. Stress-provoking factors
point/s and their underlying causes or associated factors. 1. strained marital relationship
7. Making conclusions about the reasons for the existence of the health condition or 2. strained parent-sibling relationship
problem, or risk for non-maintenance of wellness state/s which can be attributed to 3. interpersonal conflicts between family members
non-performance of family tasks. 4. care-giving burden
G. Poor home / environmental condition/ sanitation
3. Problem Definition/Nursing Diagnosis 1. inadequate living space
 End result of 2 major types of assessment. 2. lack of food storage facilities
3. polluted water supply
4. presence of breeding or resting sites of vectors of diseases
 5. improper garbage / refuse disposal 4. emotional / psychological issues / concerns
6. unsanitary waste disposal C. Attitude / philosophy in life which hinders recognition / acceptance of a problem
7. poor lightning and ventilation D. Others, specify ____________
8. noise pollution
9. air pollution II. Inability to make decisions with respect to taking appropriate health action
H. Unsanitary food handling and preparation due to :
I. Unhealthy lifestyle and personal habits /practices A. Failure to comprehend the nature/ magnitude of the problem / condition
1. alcohol drinking B. Low salience of the problem / condition
2. cigarette / tobacco smoking C. Feeling of confusion, helplessness and / or resignation brought by perceived
3. walking barefooted or inadequate footwear magnitudes / severity of the situation or problem, i.e., failure to break down
4. eating raw meat or fish problems into manageable units of attacks
5. poor personal hygiene D. Lack of / or inadequate knowledge / insight as to alternative courses of action to
6. self-medication/ substance abuse take
7. sexual promiscuity E. Inability to decide which action to take among the list of alternatives
8. engaging in dangerous sports F. Conflicting opinions among family members / significant others regarding action
9. inadequate rest or sleep to take
10. lack of / inadequate exercise / physical activity G. Lack of / or inadequate knowledge of community resources for care
11. lack of / inadequate activities H. Fear of consequence of action, specially:
12. non-use of self-protection measures (e.g. non-use of bednets in Malaria and  social consequences
Filariasis endemic areas)  economic consequences
J. inherent personal characteristics - such as poor impulses control  physical / psychological consequences
K. Health history which may precipitate / induce the occurrence of a health deficit, e.g. I. Negative attitude towards the health problem – By negative attitude is meant one
previous history of difficult labor. that interferes with rational decision making
L. Inappropriate role assumption - e.g. child assuming mother's role, father not J. Inaccessibility of appropriate resources for care, specifically:
assuming his role 1. physical inaccessibility
M. Lack of immunization / inadequate immunization status specially of children 2. cost constraints or economic / financial inaccessibility
N. Family disunity - e.g. self-oriented behavior of members (s), unresolved conflicts of
members(s), intolerable disagreement K. Lack of trust / confidence in the health personnel / agency
O. Others, specify : _____________ L. Others, specify______________

d. Presence of Stress Points / Foreseeable Crisis - Anticipated periods of unusual III. Inability to provide adequate nursing care to sick, disabled, dependent or
demand on the individual or family in terms of adjustment / family resources. vulnerable / at-risk member of the family due to:
A. Marriage A. Lack of / inadequate knowledge about the disease / health condition (nature,
B. Pregnancy, labor, puerperium severity, complications, prognosis and management );
C. Parenthood B. Lack of / inadequate knowledge about the child development and care;
D. Additional member - e.g. newborn, lodger Lack of / inadequate knowledge of the nature and extent of nursing care needed;
E. Abortion C. Lack of the necessary facilities, equipment and supplies for care;
F. Entrance at school D. Lack of or inadequate knowledge and skill in carrying out the necessary
G. Adolescence interventions / treatment / procedure / care (e.g., complex therapeutic regimen or
H. Divorce or separation healthy lifestyle program);
I. Menopause E. Inadequate family resources for care, specifically:
J. Loss of Job  Absence of responsible member
K. Hospitalization of a family member  Financial constraints
L. Death of a Member  Limitations / lack of physical resources – e.g. isolation room
M. Resettlement in a new community F. Significant person’s unexpressed feelings (e.g. hostility / anger, guilt, fear /
N. Illegitimacy anxiety, despair, rejection) which disable his / her capacities to provide care.
O. Other, Specify ______________ G. Philosophy in life which negates / hinder caring the sick, disabled, dependent,
vulnerable / At – risk member
2. Second Level of Assessment – defines the nature or type of nursing problems that the H. Member’s preoccupation with own concerns / interests
family encounters in performing health. I. Prolonged disease or disability progression which exhausts supportive capacity
of family members
I. Inability to recognize the presence of the condition or problem due to: J. Altered role performance – specify :
A. Lack of or inadequate knowledge a. role denial or ambivalence
B. Denial about its existence or severity as a result of fear of consequences of b. role strain
diagnosis of problem, specifically : c. role dissatisfaction
1. social-stigma, loss of respect of peers / significant others d. role conflict
2. economic / cost implications e. role confusion
3. physical consequences
 f. role overload
K. Others, specify _________________
Prioritizing Health Problems
IV. Inability to provide a home environment conducive to health maintenance 1. Nature of the Problem Presented - Categorized into wellness state, health threat,
and personal development due to : health deficit and foreseeable crisis.
A. Inadequate family resources, specifically:
a. financial constraints / limited financial resources 2. Modifiability of the Problem/Condition - Refers to the probability of success in
b. limited physical resources – e.g. lack of space to construct facility enhancing, improving, minimizing, alleviating or totally eradicating the problem through
B. Failure to see benefits (specifically long-term ones) of investment in home intervention.
environment improvement
C. Lack of / inadequate knowledge of importance of hygiene and sanitation 3. Preventive Potentials - Refers to the nature and magnitude of future problems
D. Lack of / inadequate knowledge of preventive measures that can be minimized or totally prevented if intervention is done on the problem
E. Lack of skill in carrying out measures to improve home environment under consideration.
F. Ineffective communication patterns within the family
G. Lack of supportive relationship among family members 4. Salience - Refers to the family's perception and evaluation of the problem in
H. Negative attitude / philosophy in life which is not conducive to health terms of seriousness and urgency of attention needed or family readiness.
maintenance and personal development
I. Lack of / inadequate competencies in relating to each other for mutual growth Scoring
and maturation (e.g. reduced ability to meet the physical and psychological 1. Decide a score for each of the criteria
needs of other members as a result of 2. divide the score by the highest possible & multiply by the weight
J. family’s preoccupation with current problem or condition)  Score x weight
K. Others, specify -------------------------- Highest score
3. Sum up the score of all criteria. The highest score is 5 equivalent to the total weight.
V. Failure to utilize community resources for health care due to : CRITERIA Weight
A. Lack of / inadequate knowledge of community resources for health care
B. Failure to perceive the benefits of health care / services
C. Lack of trust / confidence in the agency / personnel 1. Nature of the problems Presented 1
D. Previous unpleasant experience with health worker Scale:
E. Fear of consequences of action (preventive, diagnostic, therapeutic. -Health deficit / Wellness 3
Rehabilitative ), specifically : Health threat 2
a. physical / psychological consequences - Foreseeable crisis 1
b. financial consequences 2. Modifiability of the problem 2
b. social consequences – e.g. , loss of esteem of peer / significant others Scale:
F. Unavailability of required care / service  easily modifiable 2
G. Inaccessibility of required care / service due to:  Partially modifiable 1
a. cost constraints  Not modifiable 0
b. physical inaccessibility, i.e. location of facility 3. Preventive potential 1
H. Lack of or inadequate family resources, specifically ;
Scale:
a. manpower resources – e.g. baby sitter
 High 3
b. financial resources – e.g., cost of medicine prescribed
 Moderate 2
I. Feeling of alienation to / lack of support from the community, e.g., stigma due to
 Low 1
mental illness, AIDS, etc.
4. Salience 1
J. Negative attitude / philosophy in life which hinders effective / maximum utilization
of community resources for health care Scale:
K. Others, specify---------------- -A condition / problem needing 2
Immediate attention
II. Planning  A condition / problem not 1
needing Immediate
 The step in the process w/c answers the following questions:
attention 0
 What is to be done?
 Not perceived as a problem
 How is it to be done?
or condition needing
 When it is to be done?
change
 It is actually the phase wherein the health care provider formulates a care plan.

Steps in developing a Family Nursing Care Plan Factors affecting priority setting:
1. Prioritized problems The nurse considers the availability of the following factors in determining the modifiability of a
2. Goals and objectives of the nursing care health condition or problem.
3. Plan of intervention 1. Current Knowledge, technology and interventions
4. Plan for evaluating care 2. Resources of the family - physical, financial & manpower
 3. Resources of the nurse - knowledge, skills and time 2. Sometimes the family perceives the existence of the problem but does not see it as
4. Resources of the community - facilities and community serious enough to warrant attention.
organization or support
Characteristics of Goals/ Objectives
Factors in Deciding Appropriate Score for Preventive Potential 1. Specific
1. Gravity or severity of the problem - Refers to the progress of the disease/ problem 2. Measurable
indicating extent of damage on the patient / family. Also indicates the prognosis, 3. Attainable
reversibility of the problem 4. Realistic
2. Duration of the problem - refers to the length of time the problem has been existing 5. Time bound
3. Current Management - refers to the presence and appropriateness of intervention
4. Exposure of any high risk group Objective
 Refers to a more specific statement of desired outcome of care.
Family Nursing Care Plan  They specify the criteria by which the degree of effectiveness of care is to be
 It is the blueprint of care that the nurse designs to systematically minimize or eliminate measured.
the identified family health problem through explicitly formulated outcomes of care
(goal and objectives) and deliberately chosen set of interventions/resources and Types of Objective
evaluation criteria, standards, methods and tools. 1. Short term or Immediate Objective
 Formulated for problem situation w/c require immediate attention & results can be
Characteristics of Family Nursing Care Plan observed in a relatively short period of time.
1. It focuses on actions w/c are designed to solve or alleviate & existing problem.  They are accomplished w/ few HCP-family contacts & relatively less resources.
2. It is a product of deliberate systematic process. 2. Medium or Intermediate objective
3. The FNCP as with other plans relates to the future.  Objectives w/c is not immediately achieved & is required to attain the long ones.
4. It revolves around identified health problems. 3. Long Term or Ultimate Objective
5. It is a mean to an end and not a end to itself.  This requires several HCP-family contacts & an investment of more resources.
6. It is a continuous process, not one shot deal.

Desirable Qualities of Family Nursing Care Plan

1. It should be based on a clear definition of the problem. Plan of Actions/ Interventions
2. A good plan is realistic, meaning it can be implemented w/ reasonable chance of  Its aim is to minimize all the possible reasons for causes of the family’s inability to
success do certain tasks.
3. It should be consistent w/ the goals & philosophy of the health agency.
4. It’s drawn w/ the family. It is highly dependent on 2 Major Variables:
5. It’s best kept in written form. 1. nature of the problem
2. the resources available to solve the problem
Setting/ Formulating Goals & Objectives
 This will set direction of the plan. Typology of Interventions
 This should be stated in terms of client outcomes whether at the individual, family or 1. Supplemental - the HCP is the direct provider of care.
community level. 2. Facilitative - HCP removes barriers to needed services.
 The mutual setting of goals w/c is the cornerstone of effective planning consists of: 3. Developmental - improves client’s capacity.
1. Identifying possible resources.
2. Delineating alternative approaches to meet goals. III. Implementation
3. Selecting specific interventions.  Actual doing of interventions to solve health problems.
4. Operationalizing the plan - setting of priorities.
IV. Evaluation
Goal  Determination whether goals / objectives are met.
 It is a general statement of the condition or state to be brought about by specific  Determination whether nursing care rendered to the family are effective.
courses of action.  Determines the resolution of the problem or the need to reassess, and re-plan
and re-implement nursing interventions.
Cardinal Principle in Goal setting
 It must be set jointly with the family. This ensures family commitment to their According to Alfaro-LeFevre:
realization.
 Basic to the establishment of mutually acceptable goal in the family’s recognition and Evaluation is being applied through the steps of the nursing process:
acceptance of existing health needs and problems.
 Assessment – changes in health status.
Barriers to Joint Goal Setting  Diagnosis – if identified family nursing problems were resolved, improved or
1. Failure in the part of the family to perceive the existence of the problem. controlled.
  Planning – are the interventions appropriate & adequate enough to resolve
identified problems.
 Implementation – determine how the plan was implemented, what factors aid in
the success and determine barriers to the care.

Types of Evaluation:
 Ongoing Evaluation – analysis during the implementation of the activity, its relevance,
efficiency and effectiveness.

 Terminal Evaluation – undertaken 6-12 months after the care was completed.

 Ex-post Evaluation – undertaken years after the care was provided

Steps in Evaluation:
1. Decide what to Evaluate.
 Determine relevance, progress, effectiveness, impact and efficiency
2. Design the Evaluation Plan
 Quantitative – a quantifiable means of evaluation which can be done
through numerical counting of the evaluation source.
 Qualitative – descriptive transcription of the outcome conducted through
interview to acquire an in-depth understanding of the outcome.
3. Collect Relevant Data that will support the outcome
4. Analyze Data - What does the data mean?
5. Make Decisions
 If interventions are effective, interventions done can be applied to other
client / group with the similar circumstances
 If ineffective, give recommendations
6. Report / Give Feedbacks

Dimensions of Evaluation
1. Effectiveness – focused on the attainment of the objectives.
2. Efficiency – related to cost whether in terms on money, effort or materials.
3. Appropriateness – refer its ability to solve or correct the existing problem, a
question which involves professional judgment.
4. Adequacy – pertains to its comprehensiveness.

Tools Being used during Evaluation

 Instruments are tools are being used to evaluate the outcome of the nursing
interventions:

 Thermometer
 Tape measure
 Ruler
 BP apparatus
 Weighing scale
 Checklist
 Key Guide Questionnaires
 Return Demonstrations

Methods of Evaluation
1. Direct observation
2. Records review
3. Review of questionnaire
4. Simulation exercises