Nursing Assessment

Nursing Assessment in Family Nursing Practice

Nursing Assessment – first major phase of the nursing process.

- involves a 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, its ability to maintain wellness, prevent, control or resolve problems in order to achieve health and well-being among its members.

Nursing Assessment includes: Data collection Data analysis or interpretation Problem definition or nursing diagnosis – end result of two major types of nursing assessment in family health nursing practice.

First Level Assessment- is a process whereby existing and potential health conditions or problems of the family are determined.

Category of Health conditions/Problems: Wellness state/s Health Threats Health deficits Stress points or foreseeable crisis situations

Second Level Assessment- 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 the tasks.

Steps in Family Nursing Assessment

1.Data Collection – gathering of five types of data which will generate the categories of health conditions or problems of the family. a.) family structure, characteristics & dynamics – include the composition and demographic data of the members of the family/household, their relationship to the head and place of residence; the type of, and family interaction/communication and decision-making patterns and dynamics.

b.) socio-economic & cultural characteristics – include occupation, place of work, and income of each working member; educational attainment of each family member; ethnic background and religious

affiliation; significant others and the other role(s) they play in the family’s life; and, the relationship of the family to the larger community.

c.) home and environment – include information on housing and sanitation facilities; kind of neighborhood and availability of social, health, communication and transportation facilities in the community.

d.)health status of each member – includes current and past significant illness; beliefs and practices conducive to health and illness; nutritional and developmental status; physical assessment findings and significant results of laboratory/diagnostic tests/screening procedures.

e.) values and practices on health promotion/maintenance & disease prevention – include use of preventive services; adequacy of rest/sleep, exercise, relaxation activities, stress management or other healthy lifestyle activities, and immunization status of at-risk family members.

Data Gathering Methods & Toolsa.) Observation – method of data collection through the use of sensory

capacities --- sight, hearing, smell and touch. Data gathered through this method have the advantage of being subjected to validation and reliability testing by other observers.

b.) Physical Examination – done through inspection, palpation, percussion, auscultation, measurement of specific body parts and reviewing the body systems.

c.) Interview – completing the health history of each family member. The health history determines current health status based on significant past health history.

The second type of interview is collecting data by personally asking significant family members or relatives questions regarding health, family life experiences and home environment to generate data on what wellness condition and health problems exist in the family.

Productivity of the interview process depends upon the use of effective communication techniques to elicit the needed responses.

Second level assessment can be adequately done for each wellness state, health threat, health deficit or crisis situation by going through the following procedures:

Determine if the family recognizes the existence of the condition or problem. If the family does not recognize the presence of the condition or problem, explore the reasons why.

If the family recognizes the presence of the condition or problem, determine if something has been done to maintain the wellness state or resolve the problem. If the family has not done anything about it, determine the reasons why. If the family has done something about the problem or condition, determine if the solution is effective.

Determine if the family encounters other problems in implementing interventions for the wellness state/potential, health threat, health deficit or crisis. What are these problems?

Determine how all the other members are affected by the wellness state/potential, health threat deficit or stress point.

d.) Record Review – reviewing existing records and reports pertinent to the client. ( individual clinical records of the family members; laboratory & diagnostic reports; immunization records; reports about the home & environmental conditions.

e.) Laboratory/Diagnostic Tests – performing laboratory tests, diagnostic procedures or other tests of integrity and functions carried out by the nurse herself and/or other health workers.

2. Data Analysis - sort data- cluster/group related date- distinguish relevant from irrelevant data- identify patterns- compare patterns with norms or standards- interpret results- make inferences/draw conclusions

3. Nursing Diagnoses: Family Nursing Problems

* A wellness condition is a nursing judgment related with the client’s capability for wellness.

A health condition or problem is a situation which interferes with the promotion and/or maintenance of health and recovery from illness or injury.

NURSING DIAGNOSIS in the FAMILY NURSING PRACTICE - the family’s failure to perform adequately specific health tasks to enhance the wellness state or manage the health problem.

TYPOLOGY OF NURSING PROBLEMS IN FAMILY NURSING PRACTICE – classification system of family nursing problems.

FIRST- LEVEL ASSESSMENT

I. PRESENCE OF WELLNESS CONDITION – stated as Potential or Readiness

II. PRESENCE OF HEALTH THREATS – conditions that are conducive to disease and accident, or may result to failure to maintain wellness or realize health potential.

III. PRESENCE OF HEALTH DEFICITS – instances of failure in health maintenance.

IV. PRESENCE OF STRESS POINTS/FORESEEABLE CRISIS SITUATIONS – anticipated periods of unusual demand on the individual or family in terms of adjustment/family resources.

SECOND-LEVEL ASSESSMENT

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

II. Inability to make decisions with respect to taking appropriate health action.

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

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

V. Failure to utilize community resources for health care.

DEVELOPING THE NURSING CARE PLAN

THE FAMILY CARE PLAN – is the 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 ( goals and objectives) and deliberately chosen of interventions, resources and evaluation criteria, standards, methods and tools.

DESIRABLE QUALITIES OF A NURSING CARE PLAN

1. It should be based on clear, explicit definition of the problems. A good nursing plan is based on a comprehensive analysis of the problem situation.

2. A good plan is realistic. 3. The nursing care plan is prepared jointly with the family. The nurse

involves the family in determining health needs and problems, in establishing priorities, in selecting appropriate courses of action, implementing them and evaluating outcomes.

4. The nursing care plan is most useful in written form.

THE IMPORTANCE OF PLANNING CARE

1. They individualize care to clients. 2. The nursing care plan helps in setting priorities by providing

information about the client as well as the nature of his problems. 3. The nursing care plan promotes systematic communication among

those involved in the health care effort. 4. Continuity of care is facilitated through the use of nursing care

plans. Gaps and duplications in the services provided are minimized, if not totally eliminated.

5. Nursing care plans, facilitate the coordination of care by making known to other members of the health team what the nurse is doing.

STEPS IN DEVELOPING A FAMILY NURSING CARE PLAN

1. The prioritized condition/s or problems based on: - nature of condition or problem

- modifiability - preventive potential - salience

2. The goals and objectives of nursing care. Expected Outcomes:

- conditions to be observed to show problem is prevented, controlled, resolved or eliminated.

- Client response/s or behavior> Specific, Measurable, Client-centered Statements/Competencies

3. The plan of interventions. Decide on:

- Measures to help family eliminate:. barriers to performance of health tasks. underlying cause/s of non-performance of health tasks

- Family-centered alternatives to recognize/detect, monitor, control or manage health condition or problems

- Determine Methods of Nurse-Family Contact- Specify Resources Needed

4. The plan for evaluating.- Criteria/Outcomes Based on Objectives of Care- Methods/Tools

COMMUNITY DIAGNOSIS

TYPES OF COMMUNITY DIAGNOSIS

1. COMPREHENSIVE COMMUNITY DIAGNOSIS – aims to obtain a general information about the community.

A. Demographic VariablesB. Socio-Economic and Cultural VariablesC. Health and Illness PatternsD. Health resourcesE. Political/Leadership Patterns

2. PROBLEM-ORIENTED COMMUNITY DIAGNOSIS – type of assessment that responds to a particular need.

PROCESS OF COMMUNITY DIAGNOSIS:

Collecting Organizing Synthesizing Analyzing and interpreting health data

STEPS IN CONDUCTING COMMUNITY DIAGNOSIS

1. DETERMINING THE OBJECTIVES – the nurse decides on the depth and scope of the data she needs to gather.

2. DEFINING THE STUDY POPULATION – the nurse identifies the population group to be included in the study.

3. DETERMINING THE DATA TO BE COLLECTED – the objectives will guide the nurse in identifying the specific data she will collect, and will also decide on the sources of these data.

4. COLLECTING THE DATA – the nurse decides on the specific methods depending on the type of data to be generated.

5. DEVELOPING THE INSTRUMENT – instruments/tools facilitate the nurse’s data-gathering activities.

Most common instruments: - survey questionnaire - interview guide- observation checklist

6. ACTUAL DATA GATHERING – the nurse supervises the data collectors by checking the filled-up instruments in terms of completeness, accuracy and reliability of the information collected.

7. DATA COLLATION – the nurse is now ready to put together all the information.

8. DATA PRESENTATION – will depend largely on the type of data obtained. (descriptive & numerical data)

9. DATA ANALYSIS – aims to establish trends and patterns in terms of health needs and problems of the community.

10. IDENTIFYING THE COMMUNITY HEALTH NURSING PROBLEMS

Health status problems – increased or decreased morbidity, mortality, fertility or reduced capability for wellness. Health resources problems – lack of or absence of manpower, money, materials or institutions necessary to solve health problems. Health-related problems – existence of social, economic, environmental and political factors that aggravate the illness-inducing situations in the community.

11.PRIORITY-SETTING – prioritize which health problems can be attended to considering the resources available at the moment.

CRITERIA WEIGHTNature of the Problem Health status 3 Health resources 2 Health-related 1

1

Magnitude of the problem 75% - 100% affected 4 50% - 74% affected 3 25% - 49% affected 2 <25% affected 1

3

Modifiability of the problem High 3 Moderate 2 Low 1 Not Modifiable 0

4

Preventive potential High 3 Moderate 2 Low 1

1

Social Concern Urgent community concern; expressed readiness 2 recognized as a problem but not needing urgent attention 1 not a community concern 0

1

Nature of the condition/problem presented – problems classified by the nurse as health status, health resources or health-related problems.

Magnitude of the problem – refers to the severity of the problem which can be measured in terms of the proportion of the population affected by the problem.

Modifiability of the problem – probability of reducing, controlling or eradicating the problem.

Preventive potential – probability of controlling or reducing the effects posed by the problem.

Social concern – perception of the population or the community as they are affected by the problem and their readiness to act on the problem.

WHAT IS PLANNING? PLANNING – is a process that entails formulation of steps to be undertaken in the future in order to achieve a desired end.

Concepts of Planning: . Planning is futuristic. . Planning is change-oriented. . Planning is a continuous and dynamic process. . Planning is flexible. . Planning is a systematic process.

THE PLANNING CYCLE:

1. Situational Analysis- gather health data- tabulate, analyze and interpret data- identify health problems- set priority

2. Goal and Objective Setting- define program goals and objectives- assign priorities among objectives

3. Strategy/Activity Setting - Design CHN Program - Ascertain resources- Analyze constraints and limitations

5. Evaluation - determines outcomes- specify criteria and standards

Initial Database for Family Nursing Process

A. Family Structure, Characteristics and Dynamics

Civil Status

Religion Educational

Attainment

Occupation

Relationship to the Head of

the FamilyMarried R.

CatholicCollege

GraduateSSS

EmployeeHead of

the FamilyMarried R.

CatholicCollege

GraduateStudent Wife

Single R. Catholic

Toddler Student Son

The Busa Family is a typical nuclear type of family consists of the father, Mr. Mark Dexter Busa who is a SSS Employee, Mrs. Ana Marie Busa, a full time student and Sean Benedict, their 2 year old son.

Mr. and Mrs. Busa doesn’t have a hard time in terms of decision making because each of them tend to consider each others opinion first before coming up with the final decision especially regarding health matters. The family has a healthy communication among its members and have an interactive relationship with each other, although conflict is present at times most especially regarding the discipline of the child but the couple made weekly dates to promote an open relationship with each other.

Name of the Family Member

Sex Birthday Age

Mark Dexter Busa

M 05-20-82 27

Ana Marie Busa F 08-27-82 26Sean Benedict

BusaM 07-02-06 2

The father is the head and breadwinner of the family while the mother together with the housemaid takes care of the household chores and their son Sean Benedict.

All family members are Roman Catholic. To show their dedication they never fail to go to church every Sunday to give thanks and praise for all the blessings God has given them the couple is also an active member of Couples for Christ.

B. Socio-Economic Status

Monthly Income: P 10,000Weekly Budget: 2,000

Amount ExpenditureP1000 Foods( Groceries)

P500 Bills: Electricity and waterP250 Transportation (Father)P250 Savings

TOTAL: P2,000

Majority of the family’s budget is allocated to their food needs. Second to this is their budget to their billings like electricity and water. Based from the table above you can observe that they give importance to their savings. This is for the preparation of their child’s future and for emergency purposes. When it comes to their clothing you can observe it has not been indicated above for they seldom spend money in clothing.

Financial difficulties of the family are solved by borrowing money from friends and relatives, to be returned after the head of the family received his salary.

C. Home and EnvironmentThe Busa Family’s resides in a good compound with

their relatives at 58-B Osmeña Street Ormoc City, their house is owned by them and made of concrete and wood and has two bedrooms, one bathroom, a kitchen, and a living room which is just enough or adequate for their living space. Every member of the family has their own bedrooms. Mr. and Mrs. Busa together with their 2 year old sean share bedrooms while the housemaid have her own room. The Laundry area is outside the house and the garbage cans are the resting sites of vectors of disease such as flies, mosquitoes and roaches present in Busa family’s house. Their foods are stored in closed door cabinets and the refrigerator. The de Leon’s’ water supply comes from ORWASA. The water coming from ORWASA is used for washing, cleaning, and bathing and not for drinking purposes. The Busa family buys distilled water from water refilling stations. The Busa family has their own bathroom and toilet. Their bathroom is near the kitchen and is kept clean everyday by Mrs. Busa and sometimes the housemaid. Their garbage is taken out everyday and collected by garbage trucks everyday. They have three garbage cans inside the house, one is in the kitchen, the other, is in the bathroom and lastly, near the bedroom. Their neighborhood is safe and not congested, there is still room for trees and plants to grow and place to play and hang-out. They have their own telephone line and every family member except the child has their own cell phones. They also have a family car and motorcycle for their transportation facility.

D. Health Status of Each Member

Memb Heig Weig BMI Medical Nutritional

er of the

household

ht ht and nursing history

assessmentDieta

ry histo

ry

Eating habits and

practices

Mark Dexter Busa

5’8” 188.16 lbs

86/3.1329 = 23.62

Typhoid Fever

3x a day

Meat, fruits and

vegetables

Ana Marie Busa

5’1” 120 lbs

55/2.42 =

22.72

Asthma , Gastroenteritis, UTI, Allergies

2x a day

Meat, fish, fruits and

vegetables

Sean Benedi

ct Busa

3’3” 29.12 lbs

13.24/1.02 =12.98

Tonsillitis, UTI,

Asthma

4x a day

Meat, Milk, fish, fruits and

vegetables

Mr. Busa has a history of typhoid fever when he was young, he had completed his required vaccine and less likely to get sick even with a bad weather. Mrs. Busa has a history of gastroenteritis due to amoeba infestation; urinary tract infection, asthma and is allergic to chocolates, chicken, eggs, eggplant, mangoes, some peanuts, and seafoods except certain kinds of fishes; she has completed the

required vaccines. Sean, their son has a history of recurrent tonsillitis, he is under medication through prophylactic therapy, a 3-month long oral vaccine to enhance immunity of his throat, and he also has maintenance for his asthma. He has not yet completed his booster vaccines.

A constant intake of vitamins like Fern-C and Centrum is the primary prevention of the family to fight the most common diseases like colds and cough.

E. Values, Habits, Practices on Health Promotion, Maintenance and Disease Prevention

Member of the household

Immunization status of family members

Healthy lifestyle Practices

Mark Dexter Busa complete Basketball 3x/week

Ana Marie Busa complete Stretching and eating fruits

Sean Benedict Busa

Incomplete (Flu and Hepa-A booster vaccine)

Biking in the plaza

Adequacy of :


Rest/ sleep

Exercises/ activities

Use of protective measures

Relaxation and other stress management activities

Mark Dexter Busa

8 hours

1 hour Uses jacket, Helmet, sunglasses

Rest or watch TV or listen to Christian music

Ana Marie Busa

6-7 hours

30 minutes

Uses slippers in and out the house and umbrella when raining, and handkerchiefs

Rest and watch TV or surf the internet

Sean Benedict Busa

10-11 hours

3 hours depending on playtime

Uses jacket, umbrella when raining/under the sun, cap and helmet

Rest or eat

Mr. & Mrs. Busa has complete immunizations; their son, Sean has not yet finished his boosters this year like flu and Hepa-A.Since Mrs. Busa is a Student Nurse, she has applied all learning in the courses she has taken like proper handwashing, environmental sanitation, and therapeutic techniques. She makes sure that Sean has adequate sleep everyday that is why she lets him sleep during afternoons

Initial Database for Family Nursing Practice

A. Family Structure & Characteristics

1. Members of the household & relationship to the head of the family

2. Demographic data age, sex, civil status, position in the family & etc.

3. Place of residence of each members whether living w/ family or elsewhere

4. Type of family structure (ex. matriarchal or patriarchal, nuclear or extended) 5. Dominant family members in terms of decision-making in matters of health care

6. General family relationship presence of any obvious/ readily observable conflict bet. members,

characteristic communication patterns among members. B. Socio-economic & Cultural Factors

1. Income & expenses

a. Occupation, place of work & income of each working member

b. Adequacy to meet basic necessities (food, clothing & shelter)

c. Who makes decisions about the money & how it is spent

2. Educational attainment of each member 3. Ethnics background & religious affiliation

4. Significant others roles they play in the family life

5. Relationship of the members to the large community what’s the participation of the family in

community activities. C. Environment Factors

1.Ho u si ng

a. Adequacy of living space

b. Sleeping arrangement

c. Adequacy of furniture

d. Presence of insects & rodents

e. Presence of accidental hazards

f.Food storage & cooking facilities

g. Water supply source, ownership, & potability

h. Toilet facility type, ownership, sanitary condition i.Garbage/ refuse disposal type, sanitary condition

j.Drainage system type, sanitary condition

2. Kind of neighborhood (ex. congested, slum & etc.)3. Social & health facilities available

4. Communication & transportation facilities available

D. Health Assessment of Each Member

1. Medical & nursing history indicating past significant illnesses, beliefs & practices conducive to illness

a. Anthropometric data ex. weight, height, mid-upper arm circumferenceb. Dietary history indicating quality & quantity of food intake per day

c. Eating/f feeding/ habits/ practices

2. Developmental Assessment of infants, toddlers and preschoolers– e.g. Metro Manila

Developmental Screening Test (MMDST)

3.Nutritional assessment (especially for vulnerable or at risk members)

4.Physical Assessment /Current health status indicating presence of illness states (diagnosed or undiagnosed by medical practitioner) 5.Results of laboratory/diagnostic procedures supportive of physical assessment findings

E. Values and Practices on Health Promotion/Maintenance and Disease Prevention

1.Immunization status of children and family members

2.Use of other preventive services

3.Adequacy of:

a. Rest and Slee

b.Exe r ci se

c. Relaxation Activities

d. Stress Management Activities

F. Family Community Diagnosis Sequence of Activities in Family Nursing Practice

1.Establishment of working relationship with the family

a. initiates contact

b.communicates interest in family’s welfarec. expresses/ shows willingness to help w/ expressed needs

d.maintains a two-day communication w/ the family

2.Conducts an initial assessment to determine the presence of any health problem ¤ Tool Typology of Nursing Problem in Family Nursing Practice

3.Categories health problems into:

a. health threats

b.health deficits

c. stress points/ foreseeable crisis

¤ Tool Typology of Nursing Problem in Family Nursing Practice

4.Determine the nature & extent of the family’s performance of the health tasks on each of the health problems categorized in activity no. 3 : defines the family nursing problems ¤ Tool Typology of Nursing Problem in Family Nursing Practice second level assessment

5.Determine the priorities among the lists of health problems

a. consider the nature of the problems presented

b.evaluates the modifiability of the problem

c. evaluates the preventive potential of a problem

d.evaluates the family’s perception/ evaluation of each problem in the term of seriousness &

urgency of attention needed ¤ Tool Seals for Ranking Family health Problems Accdg. To priorities

6.Decides on what problems to take in the order of immediate, urgency based on priorities set.

7.Ranks health problems according to priorities

8.Defines nursing objectives in realistic measurable terms jointly w/ the family

9.Plans approaches, strategies of action/ intervention, criteria & standards of evaluation

10.Implements the plan of care

11.Evaluates the effectiveness of implemented aspects of the plan

12.Re-defines nursing problems & re-formulates objectives according to evaluation findings

FIRST LEVEL OF ASSESSMENT

I. Presence of Health threats, Health deficits, Foreseeable crisis/ stress

points of the family.

A. Health Threats (Color the applicable vertical scrolls)

Family history of hereditary diseases

Specify disease/s: Hypertension

Family size beyond family resources

Threats of cross-infection from a communicable disease

Specify disease/s: cough and colds, fever

Inappropriate immunization status especially of children:

Poor environmental situation

Inadequate living space

Inadequate personal belongings/utensils

Lack of food storage

Polluted water supply

Presence of breeding places of insects and rodents

Improper refuse disposal

Improper drainage system

Poor ventilation and lightning

Noise pollution

Unsanitary food handling and preparation

Others, please specify: ____________________________

Inherent personality characteristics

Short temper

Others, please specify:

_______________________________

Inappropriate role consumption

Child assuming mother’s role


_______________________________

Accident hazards

Broken stairs

Pointed sharp objects

Poison and medicines improperly kept

Fire hazards

Fall hazards

Others, please specify: Unprotected stairs

Nutritional

Inadequate food intake both in quality and quantity

Excessive intake of certain nutrients

Faulty eating habits


_________________________

Stress provoking factors

Strained marital relationship

Immature parents

Interpersonal conflicts between family members


_________________________

Personal habits/practices

Excessive smoking

Walking barefooted

Eating raw fish and meat

Poor personal hygiene

Self-medicated


_________________________

Health history that may precipitate the occurrence of a health

problem

Specify: Hypertension

Family disunity

Self-oriented behaviour

Unresolved conflicts

Intolerable disagreements


_________________________

B. Health Deficits (Enumerable and discuss briefly)

Malnutrition – The children shows signs and symptoms of

malnutrition (underweight, poor skin integrity)

Diarrhea – one their children shows impending characteristics

of diarrhea that predisposes him in dehydration that may alter

the normal functioning of his body. Some of the manifestation

are frequent defecation in just one day and watery stool.

C. Stress points/foreseeable crisis situations

SECOND LEVEL OF ASSESSMENT

I. Inability to recognize the presence of a problem due to:

Ignorance of facts

Fear of consequences of diagnosis of problem

Social (Stigma, loss of respect of peer/significant

others)

Economic (Cost)

Physical/Psychological

Attitude/Philosophy in life

II. Inability to make decisions with respect to taking appropriate health

actions due to: (Color applicable horizontal boxes)

Failure to comprehend the nature, magnitude or scope of the

problem

Low salience of the problem

Feeling of confusion and resignation brought about by failure

to breakdown problems into manageable units of attack

Lack of knowledge/insight as to alternative course of action

open to them

Inability to decide which action to take among the list of

alternatives

Conflicting opinion among members regarding action to take

Ignorance of community resources for health care

Fear of consequences of action

Social

Economic

Physical/Psychological

Negative attitude toward the health problem

Lack of trust/confidence in health personnel/agency

Misconception of erroneous information about proposed

course/s of action

Inability of appropriate resources of care

Pregnancy, labor, puerperium

Parenthood

Additional member of the family

Abortion

Entrance at school

Adolescence

Loss of job

Death of a member

Illegitimacy

Resettlement in a new community


______________________________

Physical (location)

Cost

III. Inability to provide nursing care to the sick, disabled, or dependent

member of the family due to: ( Color the applicable horizontal scrolls)

Ignorance of the facts about the disease/health condition

(Nature, severity, complications, prognosis, and management)

Ignorance of the nature and extent of the nursing care needed

Lack of necessary facilities (equipment and supplies) for care

Lack of knowledge and skill in carrying out the necessary

treatment/procedure/care

Inadequate resources for care

Responsible family member

Financial

Physical resources (e.g. isolation room)

Failure to see benefits (especially long term ones) of

investments in home environment improvement

Present of physical/psychological conflicts

Identify crisis/psychological conflicts

Jealousy/rivalry

Guilt feelings


_______________________________

Ignorance of preventive measures

Attitude/philosophy on life

Family disunity

Self-oriented behaviour of members

Intolerable disagreements

Lack of support to members in crisis


_______________________________

IV. Inability to utilize community resources for health due to: ( Put Color

Green to the applicable horizontal scrolls)

Ignorance of lack of awareness of community resources for

health care

Failure to perceive benefits of health care/services

Lack of trust/confidence in health agency/personnel

Previous unpleasant experience with health worker

Fear of consequences of action

Physical/psychological

Financial

Social

Unavailability of required care/services

Inaccessibility of required care/services

Cost

Physical

Inadequate family services

Manpower

Financial

Feelings of alienation/lack of support form from the

community

Attitude/philosophy in life:

_______________________________________________________________________.

INITIAL DATA BASE FOR FAMILY NURSING PRACTICE

A. Family Structure, Characteristics, and DynamicsMember of the household

Relationship to the head of the family

age sex Civil status Position in the family

Leland N. de Leon Father/ husband 45 Male Married Father/husbandMarciana S. de Leon

wife 44 Female Married Mother/wife

Mark Leland S. de Leon

Son 19 Male Single Eldest child/son/brother

Elaine S. de Leon daughter 18 Female Single Youngest child/daughter/sister


Place of residence of each member of the family

Type of family structure

Dominant family members in terms of decision making

General family relationship or dynamics

Leland N. de Leon Living independently

Patriarchal/nuclear

Short temper/ easily irritated

Marciana S. de Leon

Living independently

Patriarchal/nuclear

Good listener


Living with parents Patriarchal/nuclear

Joker

Elaine S. de Leon Living with parents Patriarchal/nuclear

Easily irritated

B. Socio-economic and Cultural CharacteristicsMember of the household

Income and expenses

occupation Place of work Income of each working member

Adequacy to meet basic necessities

Who makes decisions about money

Leland N. de Leon

Production manager

Bulacan P15,000.00/mo Adequate

Marciana S. de Leon

Landlady Manila P4,000.00/mo Adequate


BTM student PUP

Elaine S. de Leon

BSN student UERMMMC

C. Home and Environment

The de Leon Family’s House is made of concrete and has three bedrooms, one bathroom, a kitchen, and a living room which is just enough or adequate for their living space. Every member of the family has their own bedrooms. Mr. and Mrs. de Leon share bedrooms while the siblings have their own rooms. The Laundry area outside the house, kitchen sink cabinet and the garbage cans are the resting sites of vectors of disease such as flies, mosquitoes and roaches present in de Leon family’s house. Their foods are stored in closed door cabinets and the refrigerator. The de Leon’s’ water supply comes from deep well and not from NAWASA. They use water septic tank for their water supply. The water coming from the septic tank is used for washing, cleaning, and bathing and not for drinking purposes. The de Leon family buys distilled water from water refilling stations. The de Leon family has their own bathroom and toilet. Their bathroom is near the kitchen and is kept clean everyday by Mrs. de Leon and sometimes the siblings. Their garbage is taken out everyday and collected by garbage trucks everyday. They have three garbage cans inside the house, one is in the kitchen, the other, is in the bathroom and lastly, near the bedroom. Mr. de Leon built a poso negro near the laundry area and is been cleaned every once in a while to check for clogs. Their neighborhood is not congested, there is still room for trees and plants to grow and place to play and hang-out. They have their own telephone line and every family has their own cell phones. They also have a family van for their transportation facility.

D. Health Status of Each Member


Medical and nursing history

Nutritional assessment Risk factor assessment

Dietary history Eating habits and practices

Leland N. de Leon 4x a day Meat, fruits and vegetables

Cigarette and tobacco smoking

Marciana S. de Leon

Rheumatic heart disease

2x a day Sea foods


4x a day Meat, fish, fruits and vegetables

obesity

Elaine S. de Leon dengue 3x a day meat, fruits, less vegetables and fish

stress

E. Value, Habits, Practices on Health Promotion, Maintenance and Disease Prevention

Member of the household Immunization status of family members

Healthy lifestyle Practices

Leland N. de Leon complete Biking everyday

Marciana S. de Leon complete Stretching and eating fruits

Mark Leland S. de Leon complete Basketball (occasionally)

Elaine S. de Leon complete Badminton, Walking and eating fruits

Adequacy of :


Rest/ sleep

Exercises/ activities

Use of protective measures Relaxation and other stress management activities

Leland N. de Leon

9 hours 10-20 minutes

Uses jacket Rest or watch TV or listen to jazz music

Marciana S. de Leon

8 hours 5-10 minutes

Uses slippers in and out the house and umbrella

Rest and watch TV


6-8 hours

1 hour Use pads Rest or eat

Elaine S. de Leon

6 hours 1 hour Use umbrella when raining, and handkerchiefs

Rest and watch TV or surf the internet

FIRST LEVEL ASSESSMENT

SMOKING

Structured Questions:

1. Why do you smoke?

I smoke because it relieves my stress and it’s already been a habit and a part of my everyday practice.

2. Do you know the consequences of smoking?

I know that smoking is dreadful for the health especially for the lungs but smoking has already been a habit for me.

3. Did you try to stop smoking?I did not try to stop smoking.

STRESS


1. Why are you always stressed out?

There are a lot of things I have to do so I sleep late and have to wake up early to go to school.

2. Do you have enough rest or sleep?

No, because now that I’m in college. I usually sleep only for about 5 or 6 hours.

3. How do you relieve stress?

Whenever I came home from school, I tried to rest for an hour or just lay back and watch TV

RHEUMATIC HEART DISEASE


1. What do you do to improve your health?

I drink my medicine on time and eat right amount of food.

2. Do you have regular check-ups with your doctor?

I usually go to heart center on the date that the doctor asked me to come back

3. Do you take in alternative medicines or other herbal medicines you think that will improve you current health?

I intake herbal drink and herbal supplements from recommendations from friends and relatives. I also drink multivitamins and vitamin C tablets.

PRIORITIZATION

SMOKING

Criteria Computation Actual Score Justification1. Nature of the

Problem2/3 x 1 0.66 It is a health threat that

does not demand immediate action

2. Modifiability of the Problem

2/2 x 2 2 Resources are available and interventions are feasible

3. Preventive Potential 3/3 x 1 1 Smoking can be reduced or minimized

4. Salience of the Problem

1/2 x 1 0.5 The family recognizes it as a problem. It does not seem the problem as needing immediate action.

TOTAL SCORE 4.16

2. STRESS


Problem2/3 x 1 0.66 It is a health threat that

does not demand immediate action


2/2 x 2 2 Resources are available and interventions are feasible.

3. Preventive Potential 3/3 x 1 1 Stress can be reduced or minimized


1/2 x 1 0.5 The family recognizes it as a problem but does not required immediate action

TOTAL SCORE 4.16

3. RHEUMATIC HEART DISEASE


Problem3/3 x 1 1 It is a health deficit that

requires immediate attention and adequate management.


1/2 x 2 2 Current knowledge, interventions and

resources are available to solve the problem

3. Preventive Potential 3/3 x 1 1 Disease can be prevented.


2/2 x 1 1 The family perceives it as a serious problem

needing attention.

TOTAL SCORE 5

THE PRIORITIZED HEALTH PROBLEMS:

RANK 1 RHEUMATIC HEART DISEASE

5

RANK 2 SMOKING 4.16RANK 3 STRESS 4.16

FAMILY NURSING DIAGNOSISforget

HEALTH PROBLEMFAMILY

DIAGNOSIS

GOAL OF CARE OBJECTIVES NURSING INTERVENTIO

N

EVALUATION

Smoking1. inability to

recognize the presence of the condition or problem due to: attitude/philosophy in life which hinders recognition/acceptance of a problem

2. inability to make decisions with respect to taking appropriate health action due to: failure to comprehend the nature, magnitude and scope of the problem

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

To improve the condition of the client

General:To eliminate or minimized smoking habits.

Specific:1. to educate

about the cause and effects of smoking.

2. to provide activities that will disregard from smoking.

3. to give appropriate medication and counseling for the client

1. Health Teaching

2. Guide the family as motivational strategy.

3. discus with the family the cause and effects of smoking and how does it affects one’s health

1. the client will be able to recognize the bad effects of smoking.

2. the patient will be able to eliminate or minimized smoking.

lack of knowledge about the health condition

4. inability to provide a home environment conducive to health maintenance and personal development due to; negative attitude / philosophy in life which is not conducive to health maintenance and personal development

5. Failure to utilize community resources for health care due to: lack of inadequate knowledge of community resources for health care

HEALTH PROBLEMFAMILY DIAGNOSIS

GOAL OF CARE

OBJECTIVES EVALUATION

Stress1. inability to

recognize the presence of the condition or problem due to: lack of or inadequate

knowledge

2. inability to make decisions with respect to taking appropriate health action due to: failure to comprehend the nature/magnitude of the problem/condition

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

4. inability to provide a home environment conducive to health maintenance and personal development due to;

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

HEALTH PROBLEMFAMILY DIAGNOSIS

GOAL OF CARE

OBJECTIVES NURSING INTERVENTION

EVALUATION

Rheumatic Heart Disease1. inability to

recognize the presence of the condition or problem due to:

2. inability to make decisions with respect to taking appropriate health action due to:

3. Inability to provide adequate nursing care to the sick, disabled, dependent or vulnerable/at-risk

member of the family due to:

4. inability to provide a home environment conducive to health maintenance and personal development due to;

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

Documents

Nursing Assessment