TYPOLOGY OF NURSING PROBLEMS IN FAMILY NURSING PRACTICE

Health problem

 Is a situation or condition which interferes with the promotion and/or maintenance of health and
recovery from illness or injury.

Nursing problem

 Is a situation or condition which interferes with the promotion and/or maintenance of health and
recovery from illness or injury, and which is subject to change or modification through a nursing
intervention.

Health threats

 Are conditions conducive to disease, accidents or failure to realize one’s health potential. Examples:
family history of hereditary disease (diabetes, hypertension, cancer, heart disease blood disorders),
accidents hazards, inadequate immunization of children.

Health deficit

 Aare instances of failure in health maintenance and includes illness states, whether diagnosed or
undiagnosed, failure to thrive or develop according to the expected rate and personality disorders.

Stress point / Foreseeable crisis

 Includes anticipated periods of unusual demand on the individual or the family in terms of adjustment or
family resources.

First Level Assessment

I. Presence of Wellness Condition-stated as potential or Readiness-a clinical or nursing judgment about a

client in transition from a specific level of wellness or capability to a higher level. Wellness potential is a
nursing judgment on wellness state or condition based on client’s performance, current competencies, or
performance, clinical data or explicit expression of desire to achieve a higher level of state or function in a
specific area on health promotion and maintenance. Examples of this are the following

A. Potential for Enhanced Capability for:

1. Healthy lifestyle-e.g. nutrition/diet, exercise/activity

2. Healthy maintenance/health management
3. Parenting
4. Breastfeeding
5. Spiritual well-being-process of client’s developing/unfolding of mystery through harmonious
interconnectedness that comes from inner strength/sacred source/God (NANDA 2001)
6. Others. Specify.

B. Readiness for Enhanced Capability for:

1. Healthy lifestyle
 2. Health maintenance/health management
3. Parenting
4. Breastfeeding
5. Spiritual well-being
6. Others. Specify.

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. Examples of this are the following:

A. Presence of risk factors of specific diseases (e.g. lifestyle diseases, metabolic syndrome)
B. Threat of cross infection from communicable disease case
C. Family size beyond what family resources can adequately provide
D. Accident hazards specify.

1. Broken chairs
2. Pointed /sharp objects, poisons and medicines improperly kept
3. Fire hazards
4. Fall hazards
5. Others specify.
E. Faulty/unhealthful nutritional/eating habits or feeding techniques/practices. Specify.

1. Inadequate food intake both in quality and quantity

2. Excessive intake of certain nutrients
3. Faulty eating habits
4. Ineffective breastfeeding
5. Faulty feeding techniques
F. Stress Provoking Factors. Specify. .

1. Strained marital relationship

2. Strained parent-sibling relationship
3. Interpersonal conflicts between family members
4. Care-giving burden

. Poor Home/Environmental Condition/Sanitation. Specify.

1. Inadequate living space

2. Lack of food storage facilities
3. Polluted water supply
4. Presence of breeding or resting sights of vectors of diseases
5. Improper garbage/refuse disposal
6. Unsanitary waste disposal
7. Improper drainage system
8. Poor lightning and ventilation
9. Noise pollution
10. Air pollution

H. Unsanitary Food Handling and Preparation

I. Unhealthy Lifestyle and Personal Habits/Practices. Specify.

1. Alcohol drinking
2. Cigarette/tobacco smoking
3. Walking barefooted or inadequate footwear
4. Eating raw meat or fish
5. Poor personal hygiene
 6. Self-medication/substance abuse
7. Sexual promiscuity
8. Engaging in dangerous sports
9. Inadequate rest or sleep
10. Lack of /inadequate exercise/physical activity
11. Lack of/relaxation activities
12. Non-use of self-protection measures (e.g. non-use of bed nets in malaria and filariasis endemic
areas).

J. Inherent Personal Characteristics-e.g. poor impulse control

K. Health History, which may Participate/Induce the Occurrence of Health Deficit, e.g. previous history of
difficult labor.
L. Inappropriate Role Assumption- e.g. child assuming mother’s role, father not assuming his role.
M. Lack of Immunization/Inadequate Immunization Status Specially of Children
N. Family Disunity-e.g.
1. Self-oriented behavior of member(s)
2. Unresolved conflicts of member(s)
3. Intolerable disagreement
O. Others. Specify._________

III. Presence of health deficits-instances of failure in health maintenance.

Examples include:

A. Illness states, regardless of whether it is diagnosed or undiagnosed by medical practitioner.

B. Failure to thrive/develop according to normal rate
C. Disability-whether congenital or arising from illness; transient/temporary (e.g. aphasia or
temporary paralysis after a CVA) or permanent (e.g. leg amputation secondary to diabetes,
blindness from measles, lameness from polio)

IV. Presence of stress points/foreseeable crisis situations-anticipated periods of unusual demand on the
individual or family in terms of adjustment/family resources. Examples of this include:

A. Marriage
B. Pregnancy, labor, puerperium
C. Parenthood
D. Additional member-e.g. newborn, lodger
E. Abortion
F. Entrance at school
G. Adolescence
H. Divorce or separation
I. Menopause
J. Loss of job
K. Hospitalization of a family member
L. Death of a member
M. Resettlement in a new community
N. Illegitimacy
O. Others, specify.___________
Second-Level Assessment

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

A. Lack of or inadequate knowledge

B. Denial about its existence or severity as a result of fear of consequences of diagnosis of problem,
specifically:

1. Social-stigma, loss of respect of peer/significant others

2. Economic/cost implications
3. Physical consequences
4. Emotional/psychological issues/concerns

C. Attitude/Philosophy in life, which hinders recognition/acceptance of a problem D. Others. Specify

_________

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

A. Failure to comprehend the nature/magnitude of the problem/condition B. Low salience of the

problem/condition
B. Low salience of the problem/condition
C. Feeling of confusion, helplessness and/or resignation brought about by perceive magnitude/severity of
the situation or problem, i.e. failure to breakdown problems into manageable units of attack.
D. Lack of/inadequate knowledge/insight as to alternative courses of action open to
them
E. Inability to decide which action to take from among a list of alternatives
F. Conflicting opinions among family members/significant others regarding action to
take.
G. Lack of/inadequate knowledge of community resources for care
H. Fear of consequences of action, specifically:
1. Social consequences
2. Economic consequences
3. Physical consequences
4. Emotional/psychological consequences
I. Negative attitude towards the health condition or problem-by negative attitude is meant one that
interferes with rational decision-making.
J. In accessibility of appropriate resources for care, specifically:

1. Physical Inaccessibility
2. Costs constraints or economic/financial inaccessibility

K. Lack of trust/confidence in the health personnel/agency

L. Misconceptions or erroneous information about proposed course(s) of action
M. Others specify._________

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

A. Lack of/inadequate knowledge about the disease/health condition (nature, severity, complications,
prognosis and management)
B. Lack of/inadequate knowledge about child development and care
C. Lack of/inadequate knowledge of the nature or extent of nursing care needed D. D. D. Lack of the
necessary facilities, equipment and supplies of care

E. Lack of/inadequate knowledge or skill in carrying out the necessary intervention or treatment/procedure
of care (i.e. complex therapeutic regimen or healthy lifestyle program).
F. Inadequate family resources of care specifically:

1. Absence of responsible member

2. Financial constraints
3. Limitation of luck/lack of physical resources

G. Significant persons unexpressed feelings (e.g. hostility/anger, guilt, fear/anxiety,

despair, rejection) which his/her capacities to provide care.
H. Philosophy in life which negates/hinder caring for the sick, disabled, dependent,
vulnerable/at risk member
I. Member’s preoccupation with on concerns/interests
J. Prolonged disease or disabilities, which exhaust supportive capacity of family
members.
K. Altered role performance, specify.

1. Role denials or ambivalence

2. Role strain
3. Role dissatisfaction
4. Role conflict
5. Role confusion
6. Role overload

L. Others. Specify._________

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

A. Inadequate family resources specifically:

1. Financial constraints/limited financial resources

2. Limited physical resources-i.e. lack of space to construct facility

B. Failure to see benefits (specifically long term ones) of investments in home environment improvement

C. Lack of/inadequate knowledge of importance of hygiene and sanitation

D. Lack of/inadequate knowledge of preventive measures

E. Lack of skill in carrying out measures to improve home environment
F. Ineffective communication pattern within the family

G. Lack of supportive relationship among family members

H. Negative attitudes/philosophy in life which is not conducive to health maintenance

and personal development

I. Lack of/inadequate competencies in relating to each other for mutual growth and
maturation (e.g. reduced ability to meet the physical and psychological needs of other members as a
result of family’s preoccupation with current problem or condition.

J. Others specify._________

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

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
D. Previous unpleasant experience with health worker

E. Fear of consequences of action (preventive, diagnostic, therapeutic, rehabilitative) specifically :

1. Physical/psychological consequences
2. Financial consequences
3. Social consequences

F. Unavailability of required care/services

G. Inaccessibility of required services due to:

1. Cost constrains
2. Physical inaccessibility

H. Lack of or inadequate family resources, specifically

1. Manpower resources, e.g. baby sitter

2. Financial resources, cost of medicines prescribe

I. Feeling of alienation to/lack of support from the community, e.g. stigma due to mental illness, AIDS, etc.

J. Negative attitude/ philosophy in life which hinders effective/maximum utilization of

community resources for health care

K. Others, specify __________

II. Planning
 The step in the process w/c answers the following questions:
 What is to be done?
 How is it to be done?
 When it is to be done?
 It is actually the phase wherein the health care provider formulates a care plan.

Steps in developing a Family Nursing Care Plan

1. Prioritized problems
2. Goals and objectives of the nursing care
3. Plan of intervention
4. Plan for evaluating care

Prioritizing Health Problems

 1. Nature of the Problem Presented - Categorized into wellness state, health threat, health
deficit and foreseeable crisis.

2. Modifiability of the Problem/Condition - Refers to the probability of success in enhancing,

improving, minimizing, alleviating or totally eradicating the problem through intervention.

3. Preventive Potentials - Refers to the nature and magnitude of future problems that can be
minimized or totally prevented if intervention is done on the problem under consideration.

4. Salience - Refers to the family's perception and evaluation of the problem in terms of
seriousness and urgency of attention needed or family readiness.

Scoring
1. Decide a score for each of the criteria
2. divide the score by the highest possible & multiply by the weight
 Score x weight
Highest score
3. Sum up the score of all criteria. The highest score is 5 equivalent to the total weight.

CRITERIA Weight
1. Nature of the problems Presented 1

Scale: 3
-Health deficit / Wellness Health threat 2
- Foreseeable crisis 1
2. Modifiability of the problem 2
Scale:
 easily modifiable 2
 Partially modifiable 1
 Not modifiable 0
3. Preventive potential 1
Scale:
 High 3
 Moderate 2
 Low 1
4. Salience 1
Scale:
-A condition / problem needing Immediate
attention 2
 A condition / problem not needing Immediate
attention 1
 Not perceived as a problem or condition
needing change 0
Factors affecting priority setting:
The nurse considers the availability of the following factors in determining the modifiability of a health
condition or problem.
1. Current Knowledge, technology and interventions
2. Resources of the family - physical, financial & manpower
3. Resources of the nurse - knowledge, skills and time
Resources of the community - facilities and community organization or support
Factors in Deciding Appropriate Score for Preventive Potential
1. Gravity or severity of the problem - Refers to the progress of the disease/ problem indicating
extent of damage on the patient / family. Also indicates the prognosis, reversibility of the
problem
2. Duration of the problem - refers to the length of time the problem has been existing
3. Current Management - refers to the presence and appropriateness of intervention
4. Exposure of any high risk group

Family Nursing Care Plan

 It is the blueprint of care that the nurse designs to systematically minimize or eliminate the
identified family health problem through explicitly formulated outcomes of care (goal and
objectives) and deliberately chosen set of interventions/resources and evaluation criteria,
standards, methods and tools.

Characteristics of Family Nursing Care Plan

1. It focuses on actions w/c are designed to solve or alleviate & existing problem.
2. It is a product of deliberate systematic process.
3. The FNCP as with other plans relates to the future.
4. It revolves around identified health problems.
5. It is a mean to an end and not a end to itself.
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.
2. A good plan is realistic, meaning it can be implemented w/ reasonable chance of success
3. It should be consistent w/ the goals & philosophy of the health agency.
4. It’s drawn w/ the family.
5. It’s best kept in written form.

Setting/ Formulating Goals & Objectives

 This will set direction of the plan.
 This should be stated in terms of client outcomes whether at the individual, family or community
level.
 The mutual setting of goals w/c is the cornerstone of effective planning consists of:
1. Identifying possible resources.
2. Delineating alternative approaches to meet goals.
3. Selecting specific interventions.
4. Operationalizing the plan - setting of priorities.

Goal
 It is a general statement of the condition or state to be brought about by specific courses of
action.

Cardinal Principle in Goal setting

 It must be set jointly with the family. This ensures family commitment to their realization.
 Basic to the establishment of mutually acceptable goal in the family’s recognition and acceptance
of existing health needs and problems.
Barriers to Joint Goal Setting
1. Failure in the part of the family to perceive the existence of the problem.
2. Sometimes the family perceives the existence of the problem but does not see it as serious
enough to warrant attention.
Characteristics of Goals/ Objectives
1. Specific
2. Measurable
3. Attainable
4. Realistic
5. Time bound

Objective
 Refers to a more specific statement of desired outcome of care.
 They specify the criteria by which the degree of effectiveness of care is to be measured.

Types of Objective
1.Short term or Immediate Objective
 Formulated for problem situation w/c require immediate attention & results can be observed in a
relatively short period of time.
 They are accomplished w/ few HCP-family contacts & relatively less resources.
2. Medium or Intermediate objective
 Objectives w/c is not immediately achieved & is required to attain the long ones.
3. Long Term or Ultimate Objective
 This requires several HCP-family contacts & an investment of more resources.

Plan of Actions/ Interventions

 Its aim is to minimize all the possible reasons for causes of the family’s inability to do certain
tasks.

It is highly dependent on 2 Major Variables:

1. nature of the problem
2. the resources available to solve the problem

Typology of Interventions
1. Supplemental - the HCP is the direct provider of care.
2. Facilitative - HCP removes barriers to needed services.
3. Developmental - improves client’s capacity.

III. Implementation
 Actual doing of interventions to solve health problems.

IV. Evaluation
 Determination whether goals / objectives are met.
 Determination whether nursing care rendered to the family are effective.
 Determines the resolution of the problem or the need to reassess, and re-plan and re-
implement nursing interventions.

According to Alfaro-LeFevre:

Evaluation is being applied through the steps of the nursing process:

 Assessment – changes in health status.

 Diagnosis – if identified family nursing problems were resolved, improved or 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