BULACAN STATE UNIVERSITY

COLLEGE OF NURSING
City of Malolos

ASSESSMENT DATA BASE

Family Name: PAED FAMILY

Purok(s) 4 , Brg SAN PABLO , MALOLOS , Bulacan

Informant: Time Started:__________ Time Finished:____________

A. Family Structure, Characteristics, and Dynamics

Name of Family Age Sex Civil Position In Place of

Member Status the Family Residence

Type of family structure

( ) Nuclear ( ) Extended ( ) Dyad
( ) Single- parent ( ) Homosexual/Same Sex
( ) Cohabiting/Communal
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Dominant family members in terms of decision making

( ) Patrifocal/Patriarchal ( ) Matrifocal/Matriarchal
( ) Egalitarian ( ) Matricentric
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General family relationship/dynamics

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B. Socio-Economic and Cultural Characteristics

Family Member Occupation Income Educational Religion

Attainment

Relationship of the family to larger community

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C. Home and Environment

Housing

a. Adequacy of living space

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b. Sleeping arrangement

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c. Presence of breathing or resting sites of vector of diseases

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d. Presence of accident hazard

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e. Food storage and cooking facilities

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f. Water supply

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g. Toilet facilities
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h. Garbage/refuse disposal

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i. Drainage System

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j. Lighting Facilities

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Kind of Neighborhood
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Social and Health facilities available

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Communication and transportation facilities available

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D. Health Status of Family Member

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Medical History of Diseases

Name Age Gender Disease

Nutritional Assessment

Anthropometric Measurements
Age Wt. in Ht. in BMI Waist Hips Waist
Mid Arm
Name in kg. m (Wt. in Remarks Circumference Circumference Hips Remarks Circumference Remarks
kg / Ht. in (WC) in cm. (HC) in cm.
Ratio
mos m2) (WC/HC)
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24-hour Dietary Recall

Date Time of the day Food taken
BREAKFAST
SNACK
LUNCH
SNACK
DINNER
MIDNIGHTSNACK

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Developmental assessment of infant, toddlers and preschoolers

(See MMDST Tool)

Risk factor assessment

Cigarette Smoking
Is there a member of the family who is a cigarette smoker?
( ) Yes ( ) No ( ) frequency/sticks or packs/day ________

Name Age Age started smoking Reason

Use of prohibited / dangerous drugs

Is there a member of the family who uses prohibited/dangerous drugs?
( ) Yes ( ) No ( ) Types of Drugs : ______/Solvent_________

Name Age Age started using Reason

drugs

Drinks alcoholic beverages

Is there a member of the family who drinks alcoholic beverages? ( ) Yes ( ) No

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 Name Age Age started drinking Frequency Type Reason
alcohol

Physical Assessment
(See Physical Assessment Tool)

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

Prevention

Immunization status of family members

Incom Fully
Age Complete
DPT DPT DPT Hepa B Hepa B Hepa B OPV OPV OPV Meas plete Immun
Name in Gender BCG according
1 2 3 1 2 3 1 2 3 les accdg ized
mos to Age
to Age Child

Healthy lifestyle practices

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Adequacy of:

Rest and sleep

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Exercise/activities
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Use of protective measure

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Relaxation and other stress management activities

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Use of Promotive-Preventive Health Services

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GENOGRAM
(Draw your genogram here)

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ECOMAP
(Draw your Ecomap Here)

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First Level Assessment

Cues/Data Health Condition

A. Health Threat

B. Health Deficit

C. Stress Points/Foreseeable Crisis

Second Level Assessment

Health Condition Family Nursing Problem

A. Health Threat

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B. Health Deficit

C. Stress Points/Foreseeable Crisis

Scoring & Prioritization

A. ___________________________________________

Criteria Computation Actual Justification

Score
1. Nature of the
problem
2. Modifiability of
the Problem
3. Preventive
Potential
4. Salience of the
Problem
Total Score

B. _____________________________________________

Criteria Computation Actual Justification

Score
1. Nature of the
problem

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 2. Modifiability of
the Problem
3. Preventive
Potential
4. Salience of the
Problem
Total Score

C. _____________________________________________

Criteria Computation Actual Justification

Score
1. Nature of the
problem
2. Modifiability of
the Problem
3. Preventive
Potential
4. Salience of the
Problem
Total Score

Prioritization of Problems

Rank Score Problem

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Documentation

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