MODULE 3: Family Nursing Process

Overview: Family Health Nursing Process is a systematic approach to help family to develop and strengthen its capability to meet its
health needs and solve health problem. Family health nursing process is closely related to community health nursing process. The main
objective or goals of family health nursing process are health promotion, prevention from disease and control of health problem. There
are different phases of family health nursing process.

Module Coverage
A Topic: Family Health Assessment
1.Tools for Assessment
Initial Data Base
Typology of Nursing Problems in Family Nursing Practice
Family Health Task
Family Coping Index
2.Family Data Analysis
 Socio-economic and cultural characteristics
 Home environment
 Family Health Status

TOPIC A: Family Health Assessment

- First major phase of nursing process
- this 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, and its ability to maintain wellness, prevent, control or resolve problems in order to achieve health
and wellbeing among its members.
- It deals with collecting, organizing, validating, and recording data about a client health status.

Two Major Types of Assessment

1.First Level Assessment - the process of determining existing and potential health conditions or problems of the family. These health
conditions are categorized as:
a.Wellness Condition – stated as Potential or Readiness, a clinical or nursing judgement about a client in transition from a
specific level of wellness or capacity to a higher one (NANDA, 2001)
b.Health Threats – conditions that are conducive to disease, accidents, or failure to realize one’s health potential. Ex. Family
history of asthma
c.Health Deficits – Instances of failure in health maintenance (disease, disability, development lag) Ex. Illness state such as
pulmonary tuberculosis
d.Stress Points/Foreseeable Crisis Situation – anticipated periods of unusual demand on the individual or family in terms of
adjustment or family resources. Ex. Fifth pregnancy for an unemployed couple.
2.Second Level Assessment data include those that specify or describe the family’s realities, perceptions about attitudes related to the
assumption or performance of family health tasks on each health condition or problem identified during the first level assessment.

Tools for Assessment

Data Collection
Initial Data Base for Family Nursing Practice
A. Family Structure Characteristics and Dynamics
1. Members of the household and relationship to the head of the family.
2. Demographic data-age, sex, civil status, position in the family
3. Place of residence of each member-whether living with the family or
elsewhere
4. Type of family structure-e.g. patriarchal, matriarchal, nuclear or
extended
5. Dominant family members in terms of decision making especially on
matters of health care
6. General family relationship/dynamics-presence of any obvious/readily
observable conflict between members, characteristics,
communication/interaction patterns among members.
B. Socio-economic and Cultural Characteristics
1. Income and expenses
a. Occupation place of work and income of each working member
b. Adequacy to meet basic necessities (food, clothing, shelter)
c. Who makes decision about money and how it is spent
2. Educational Attainment of each Member
3. Ethnic Background and Religious Affiliation
4. Significant others-role (s) they play in family’s life
5. Relationship of the family to larger community-nature and extent of
Participation of the family in community activities
C. Home Environment
1. Housing
a. Adequacy of living space
b. Sleeping in arrangement
c. Presence of breathing or resting sites of vector of diseases (e.g.
mosquitoes, roaches flies, rodents, etc.)
d. Presence of accident hazard
e. Food storage and cooking facilities
f. Water supply-source, ownership, pot ability
g. Toilet facilities-type, ownership, sanitary condition
h. Garbage/refuse disposal-type, sanitary condition
i. Drainage System-type, sanitary condition
 2. Kind of Neighborhood, e.g. congested, slum etc.
3. Social and Health facilities available
4. Communication and transportation facilities available
D. Health Status of Each Family Member
1. Medical Nursing history indicating current or past significant illnesses
or beliefs and practices conducive to health and illness
2. Nutritional assessment (especially for vulnerable or at risk members)
 Anthropometric data: measures of nutritional status of children-
weight, height, mid-upper arm circumference; risk assessment
measures for obesity: body mass index (BMI=weight in kgs. divided
by height in meters), waist circumference (WC: greater than 90
cm in men and greater than 80 cm. in women), waist hip
ration (WHR=waist circumference in cm. divided by hip
circumference in cm. Central obesity: WHR is equal to or greater
than 1.0 cm in men and 0.85 in women)
 dietary history specifying quality and quantity of food or nutrient
per day
 Eating/ feeding habits/ practices
3. Developmental assessment of infant, toddlers and preschoolers-e.g.
Metro Manila Developmental Screening Test (MMDST).
4. Risk factor assessment indicating presence of major and contributing
modifiable risk factors for specific lifestyle diseases-e.g. hypertension,
physical inactivity, sedentary lifestyle, cigarette/ tobacco smoking,
elevated blood lipids/ cholesterol, obesity, diabetes mellitus,
inadequate fiber intake, stress, alcohol drinking, and other
substance abuse.
5. Physical Assessment indicating presence of illness state/s (diagnosed
or undiagnosed by medical practitioners )
6. Results of laboratory/diagnostic and other screening procedures
supportive of assessment findings.
E. Values, Habits, Practices on Health Promotion,
Maintenance and Disease Prevention. Examples
Include:
1. Immunization status of family members
2. Healthy lifestyle practices. Specify.
3. Adequacy of:
 Rest and sleep
 Exercise/activities
 Use of protective measure-e.g. adequate footwear in parasite- Infested areas; use of bed nets and protective clothing
in malaria And filariasis endemic areas.
 Relaxation and other stress management activities
4. Use of promotive-preventive health services

A Typology of Nursing Problems in Family Nursing Practice

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
G. 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.Other 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
E Entrance at school
G. Adolescence
H. Divorce or separation
1. Menopause
J. Loss of job
K. Hospitalization of a family member
L. Death of a member
M. Resettlement in a new community
N. Illegitimacy
0. 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
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. 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
1. 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-e.i. 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 preoccupatio
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

Family Health Task

- Health task differ in degrees from family to family
- TASK- is a function, but with work or labor overtures assigned or demanded of the person
- Duvall & Niller identified 8 task essential for a family to function as a unit:

Eight Family Tasks (Duvall & Niller)

1. Physical maintenance- provides food shelter, clothing, and health care to its members being certain that a family has ample
resources to provide
2. Socialization of Family– involves preparation of children to live in the community and interact with people outside the
family.
3. Allocation of Resources- determines which family needs will be met and their order of priority.
4. Maintenance of Order– task includes opening an effective means of communication between family members, integrating
family values and enforcing common regulations for all family members.
5. Division of Labor – who will fulfill certain roles e.g., family provider, home manager, children’s caregiver
6. Reproduction, Recruitment, and Release of family member
7. Placement of members into larger society –consists of selecting community activities such as church, school, politics that
correlate with the family beliefs and values
8. Maintenance of motivation and morale– created when members serve as support people to each other

Family Health Tasks (Maglaya, A., 2004)

1. Recognizing interruptions of health development
2. Making decisions about seeking health care/ to take action
3. Dealing effectively health and non-health situations
4. Providing care to all members of the family
5. Maintaining a home environment conducive to health maintenance

Family Coping Index

Purpose:
 To provide a basis for estimating the nursing needs of a particular family.

Health Care Need

A family health care need is present when:
1. The family has a health problem with which they are unable to cope.
2. There is a reasonable likelihood that nursing will make a difference in the in the family’s ability to cope.

Relation to Coping Nursing Need:

 COPING may be defined as dealing with problems associated with health care with reasonable success.
 When the family is unable to cope with one or another aspect of health care, it may be said to have a “coping deficit”

Direction for Scaling

 Two parts of the Coping index:
1. A point on the scale
2. A justification statement
 The scale enables you to place the family in relation to their ability to cope with the nine areas of family nursing at the time
observed and as you would expect it to be in 3 months or at the time of discharge if nursing care were provided. Coping
capacity is rated from 1 (totally unable to manage this aspect of family care) to 5 (able to handle this aspect of care without
help from community sources). Check “no problem” if the particular category is not relevant to the situation.
 The justification consists of brief statement or phrases that explain why you have rated the family as you have.

General Considerations
1. It is the coping capacity and not the underlying problem that is being rated.
2. It is the family and not the individual that is being rated.
 3. Rating should be done after 2-3 home visits when the nurse is more acquainted with the family.
4. The scale is as follows
 0-2 or no competence
 3-5 coping in some fashion but poorly
 6-8 moderately competent
 9 fairly competent
5. Justification- a brief statement that explains why you have rated the family as you have. These statements should be
expressed in terms of behavior of observable facts. Example: “Family nutrition includes basic 4 rather than good diet.
6. Terminal rating is done at the end of the given period of time. This enables the nurse to see progress the family has made in
their competence; whether the prognosis was reasonable; and whether the family needs further nursing service and where
emphasis should be placed.

Scaling Cues
 The following descriptive statements are “cues” to help you as you rate family coping. They are limited to three points – 1 or
no competence, 3 for moderate competence and 5 for complete competence.

Areas to Be Assessed
1. Physical independence: This category is concerned with the ability to move about to get out of bed, to take care of daily
grooming, walking and other things which involves the daily activities.
2. Therapeutic Competence: This category includes all the procedures or treatment prescribed for the care of ill, such as giving
medication, dressings, exercise and relaxation, special diets.
3. Knowledge of Health Condition: This system is concerned with the particular health condition that is the occasion of care
4. Application of the Principles of General Hygiene: This is concerned with the family action in relation to maintaining family
nutrition, securing adequate rest and relaxation for family members, carrying out accepted preventive measures, such as
immunization.
5. Health Attitudes: This category is concerned with the way the family feels about health care in general, including preventive
services, care of illness and public health measures.
6. Emotional Competence: This category has to do with the maturity and integrity with which the members of the family are
able to meet the usual stresses and problems of life, and to plan for happy and fruitful living.
7. Family Living: This category is concerned largely with the interpersonal with the interpersonal or group aspects of family life
– how well the members of the family get along with one another, the ways in which they take decisions affecting the family
as a whole.
8. Physical Environment: This is concerned with the home, the community and the work environment as it affects family health.
9. Use of Community Facilities: generally keeps appointments. Follows through referrals. Tells others about Health
Departments services

Family Care Plan

Definition
 Is the blue print of the care that the nurse designs to systematically minimize or eliminate the identified health and nursing
problem through explicitly formulated outcomes of care (goals and objectives) and deliberately chosen set of interventions,
resources and evaluation criteria, standards, methods and tools.

Characteristics, which are Based on the Concept of Planning as a Process:

1. The nursing care plan focuses on actions, which are designed to solve or minimize existing problem.
o The cores of the plan are the approaches, strategies, activities, methods and materials, which the nurse hopes, will
improve the problem.
2. The nursing care plan is a product of the liberate systematic process.
3. The nursing care plan as with all other plans relate to the future.
o It utilizes events in the past and what is happening in the present to determine patterns. It also projects the future
scenario if the situation is not corrected.
4. The nursing care plan is based upon identified health and nursing problems.
5. The nursing care plan is a means to an end, not an end in itself.
o The goal in planning is to deliver the most appropriate care to the client by eliminating barriers to the family health
development.
6. The nursing care plan is a continuous process not a one shot deal.
o The results of evaluation of the plan’s effectiveness trigger another cycle of the planning process until the health and
nursing problems are eliminated.

Desirable Qualities of a Nursing Care Plan

 It should be based on clear, explicit definition of the problem(s).
 A good plan is realistic.
 The nursing care plan is prepared jointly with the family.
 The nursing care plan is most useful in written form.

Importance of Planning Care

 They individualize care to clients.
 The nursing care plan helps in setting priorities by providing information about the client as well as the nature of his problem.
 The nursing care plan promotes systematic communication among those involve in the health care effort.
 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.
 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 Care Plan

 The prioritized conditions of the problem
 Goals and objectives of the nursing care
 The plan of interventions
  The plan for evaluating care

Prioritizing Health Problems

Four Criteria for Determining Priorities:
1. Nature of the condition or problem – categorized into wellness state/potential, health threat, health deficit of foreseeable
crisis.
2. Modifiability of the condition or problem-refers to the probability of success in enhancing the wellness state improving the
condition minimizing, alleviating or totally eradicating the problem through intervention.
3. Preventive potential-refers to the nature and magnitude of future problem that can be minimized or totally prevented if
interventions are done on the condition or problem under consideration.
4. Salience-refers to the family’s perception and evaluation of the condition or problem in terms of seriousness and urgency of
attention needed or family readiness.

Factors Affecting Priority Setting

Nature of the problem
 The biggest weight is given to the wellness state or potential because of the premium on client’s effort or desire to
sustain/maintain high level of wellness.
 The same weight is given to health deficit because of its sense of clinical urgency, which may require immediate
intervention.
 Foreseeable crisis is given the least weight because culture linked variables/factors usually provide our families with
adequate support to cope with developmental or situational crisis.
Modifiability if the problem
1. Current knowledge, technology and interventions to enhance the wellness state or manage the problem.
2. Resources of the family
3. Resources of the nurse
4. Resources of the community
Preventive potential
 Gravity or severity of the problem-refers to the progress of the disease/problem indicating extent of damage on the
patient/family; also indicates prognosis, reversibility or modifiability of the problem. In general, the more severe the problem
is, the lower is the preventive potential of the problem.
 Duration of the problem-refers to the length of time the problem has existed. Generally speaking, duration of the problem has
a direct relationship to gravity; the nature of the problem is variable that may, however, alter this relationship. Because of this
relationship to gravity of the problem, duration has also a direct relationship to preventive potential.
 Current management-refers to the presence and appropriateness of intervention measures instituted to enhance the wellness
state or remedy the problem. The institution of appropriate intervention increases condition’s preventive potential.
 Exposure of any vulnerable or high risk group-increases the preventive potential of condition or problem

Formulation of Goals and Objectives

 GOAL-is a general statement of condition or state to be brought about by specific courses of action.
 OBJECTIVE-refers to a more specific statement of the desired results or outcomes of care. They specify the criteria by which
the degree of effectiveness of care is to be measured.
*A cardinal principle in goal setting states that goal must be set jointly with the family. This ensures family commitment to
realization.
* Basic to the establishment of mutually acceptable goals is the family’s recognition and acceptance of existing health
needs and problems.

Barriers to Joint Goal Setting Between the Nurse and the Family:
1. Failure on the part of the family to perceive the existence of the problem.
2. The family may realize the existence of the health condition or problem but is too busy at the moment.
3. Sometimes the family perceives the existence of the problem but does not see it as serious enough to warrant attention.
4. The family may perceive the presence of the problem and the need to take action. It may however refuse to face and do
something about the situation.
 Reasons to this kind of behavior:
1. Fear of consequences of taking actions.
2. Respect for tradition.
3. Failure to perceive the benefits of action.
4. Failure to relate the proposed action to the family’s goals.
5. A big barrier to collaborative goal setting between the nurse and the family is the working relationship.

Focus on Interventions to Help The Family Performs Health Tasks:

1. Help the family recognize the problem
o Increasing the family’s knowledge on the nature, magnitude and cause of the problem.
o Helping the family see the implications of the situation or the consequences of the condition.
o Relating the health needs to the goals of the family.
o Encouraging positive or wholesome emotional attitude toward the problem by affirming the family’s
capabilities/qualities/resources and providing information on available actions.
2. Guide the family on how to decide on appropriate health actions to take.
o Identifying or exploring with the family courses of action available and the resources needed for each.
o Discussing the consequences of action available.
o Analyzing with the family of the consequences of inaction.
3. Develop the family’s ability and commitment to provide nursing care to each member.
o Contracting-is a creative intervention that can maximize the opportunities to develop the ability and
commitment of the family to provide nursing care to its members.
4. Enhance the capability of the family to provide home environment conducive to health maintenance and personal
development.
 o The family can be taught specific competencies to ensure such home environment through environmental
manipulation or management to minimize or eliminate health threats or risks or to install facilities of
nursing care.
5. Facilitate the family’s capability to utilize community resources for health care.
o Involves maximum use of available resources through the coordination, collaboration and teamwork
provided by effective referral system.

Criteria for Selecting the Type of Nurse Family Contact

1. Effectivity
2. Efficiency
3. Appropriateness

Implementing the Nursing Care Plan

- During this phase, the nurse encounters the realities in family nursing practice that motivates her to try out creative
innovations or overwhelm her to frustration or inaction. A dynamic attitude on personal and professional development is,
therefore, necessary if she has to face up challenges of nursing practice.

Implementation Phase: A Phenomenological Experience

- Meeting the challenges of this phase is the essence of family nursing practice. During this phase, the nurse experiences with
the family a lived meaningful world of mutual, dynamic interchange of meanings, concerns, perceptions, biases, emotions
and skills. Just as the self aims to achieve body-mind integration to achieve wholeness in the experience of “being” and
“becoming” in expert caring. Unless there is such a dynamic and active involvement between the nurse and the family in
understanding and making choices in this meaningful world of coping, aspirations, emotions and skills the nurse can’t hope
to achieve expert caring.

Expert Caring: Methods and Possibilities

- Expert caring in the implementation phase is demonstrated phase is demonstrated when the nurse carries out interventions
based on the family’s understanding of the lived experience of coping and being in the world. Expert caring is developing the
capability of the family for “engage care” through the nurses skilled practice, the family learns to choose and carry out the
best possibilities of caring given the meanings, concerns, emotions and resources(skills & equipments) as experienced in the
situation. While the challenge for expert caring is a reality, the nurse is enriched as a result of such an experience (Benner &
Wrubel 1989).
- …By being experts in caring, nurses must takeover and transform the notions of expertise. Expert caring has nothing to do
with possessing privileged information that increases one’s control and domination of another. Rather, expert caring
unleashes the possibilities inherent in the self and the situation. Expert caring liberates and facilitates in such a way that the
one caring is enriched in the process.
- While expert caring does not happen overnight to the novice nurse, there are methods and possibilities that can enhance
learning towards expert caring. Such methods and possibilities need to be carried out and experienced in real contexts and
real relationships to achieve skillfully comportment and excellence in the current situation.

Two such major methods and possibilities:

- Performance-focus learning through competency-based teaching
- Maximizing caring possibilities for personal and professional development

Competency-Based Teaching
- A substantive part of the implementation phase is directed towards developing the family’s competencies to perform the
health tasks. Competencies include the cognitive (knowledge), psychomotor (skills) and attitudinal or affective(emotions,
feelings, values). The following are examples of these family health competencies using the corresponding health task in our
case illustration:
- Health Task: The family recognizes the possibility of cross-infection of scabies to other family members.

Cognitive Competency:
1. The family explains the cause of scabies
2. The family enumerates ways by which cross-infection of scabies can occur among the family members.
3. Health Task: The family provides a home environment conducive to health maintenance and personal development of its
members.
Psychomotor Competency:
- The family carries out the agreed-upon measures to improve home sanitation and personal hygiene of family members.
- Health Task: The family decides to take appropriate health action.
Attitudinal or Affective Competencies:
1. Family members express feelings or emotions that act as barriers to decision-making
2. Family members acknowledge the existence of these feelings or emotions.
- In order to systematically work towards development of the family’s competencies, such competencies need to be
explicitly defined. Cognitive and psychomotor competencies are reflected explicitly as objectives in the family nursing
care plan. The attitudinal or affective competencies may also be translated into objective of care as feelings, emotions or
philosophy in life that enhance the family’s desire or commitment to behavior change and sustain the needed action.

Learning Principles and Teaching- Learning Methods and Techniques that the Nurse Can Use in Competency-Based Teaching:
1. Learning is both intellectual and emotional process.
2. Learning is facilitated when experience has meaning.
3. Learning is individual matter.

Learning is Both Intellectual and Emotional Process

Six General Methods and Techniques:
1. Provide information to shape attitude
2. Provide experiential learning activities to shape attitudes
 3. Provide examples or models to shape attitudes
4. Providing opportunities for small group discussion
5. Role playing exercises
6. Explore the benefits of power of silence

Learning is Facilitated When Experience Has Meaning

1. Analyze and process family members all teaching-learning based on their grasp on the live experience of the situation in
terms of the meaning for the self.
2. Involve the family actively in determining areas for teaching-learning based on the health tasks that members made to
perform.
3. Used examples or illustrations that the family is familiar with.

Learning is Individual Matter: Ensure Mastery of Competencies for Sustained Actions:

Some Techniques to Develop Mastery:
1. Make the learning active by providing opportunities for the family to do specific activities, answer questions or apply
learning in solving problems.
2. Ensure clarity. Use words, examples, visual materials and handouts that the family can understand.
3. Ensure adequate evaluation, feedback, monitoring and support for sustained action by:
- Explaining well how the family is doing
- Giving the necessary affirmations or reassurances
- Explaining how the skill can be improved
- Exploring with the family how modifications can be carried out to maximize situated possibilities or best options.

Tools of Public Health Nurse

Bag technique-a tool making use of public health bag through which the nurse, during his/her home visit, can perform nursing
procedures with ease and deftness, saving time and effort with the end in view of rendering effective nursing care.

Public health bag – is an essential and indispensable equipment of the public health nurse which he/she has to carry along when he/she
goes out home visiting. It contains basic medications and articles which are necessary for giving care.

Rationale
To render effective nursing care to clients and /or members of the family during home visit.

Principles
 The use of the bag technique should minimize if not totally prevent the spread of infection from individuals to families, hence, to
the community.
 Bag technique should save time and effort on the part of the nurse in the performance of nursing procedures.
 Bag technique should not overshadow concern for the patient rather should show the effectiveness of total care given to an
individual or family.
 Bag technique can be performed in a variety of ways depending upon agency policies, actual home situation, etc., as long as
principles of avoiding transfer of infection is carried out.

Special Considerations in the Use of the Bag

1. The bag should contain all necessary articles, supplies and equipment which may be used to answer emergency needs.
2. The bag and its contents should be cleaned as often as possible, supplies replaced and ready for use at any time.
3. The bag and its contents should be well protected from contact with any article in the home of the patients. Consider the bag and
it’s contents clean and /or sterile while any article belonging to the patient as dirty and contaminated.
4. The arrangement of the contents of the bag should be the one most convenient to the user to facilitate the efficiency and avoid
confusion.
5. Hand washing is done as frequently as the situation calls for, helps in minimizing or avoiding contamination of the bag and its
contents.
6. The bag when used for a communicable case should be thoroughly cleaned and disinfected before keeping and re-using.

Contents of the Bag

 Paper lining
 Extra paper for making bag for waste materials (paper bag)
 Plastic linen/lining
 Apron
 Hand towel in plastic bag
 Soap in soap dish
 Thermometers in case [one oral and rectal]
 2 pairs of scissors [1 surgical and 1 bandage]
 2 pairs of forceps [ curved and straight]
 Syringes [5 ml and 2 ml]
 Hypodermic needles g. 19, 22, 23, 25
 Sterile dressings [OS, C.B]
 Sterile Cord Tie
 Adhesive Plaster
 Dressing [OS, cotton ball]
 Alcohol lamp
 Tape Measure
 Baby’s scale
 1 pair of rubber gloves
 2 test tubes
 Test tube holder
 Medicines
 Betadine
 70% alcohol
  Ophthalmic ointment (antibiotic)
 Zephiran solution
 Hydrogen peroxide
 Spirit of ammonia
 Acetic acid
 Benedict’s solution

Steps/Procedures
Actions Rationale
1. Upon arriving at the client’s home, To protect the bag from contamination
place the bag on the table or any flat
surface lined with paper lining, clean side
out (folded part touching the table). Put
the bag’s handles or strap beneath the
bag.
2. Ask for a basin of water and a glass of To be used for handwashing.
water if faucet is not available. Place To protect the work field from being wet.
these outside the work area.
3. Open the bag, take the linen/plastic To make a non-contaminated work field
lining and spread over work field or area. or area.
The paper lining, clean side out (folded
part out).
4. Take out hand towel, soap dish and To prepare for handwashing.
apron and the place them at one corner of
the work area (within the confines of the
linen/plastic lining).
5. Do handwashing. Wipe, dry with Handwashing prevents possible infection
towel. Leave the plastic wrappers of the from one care provider to the client.
towel in a soap dish in the bag.
6. Put on apron right side out and wrong To protect the nurses’ uniform. Keeping
side with crease touching the body, the crease creates aesthetic appearance.
sliding the head into the neck strap.
Neatly tie the straps at the back.
7. Put out things most needed for the To make them readily accessible.
specific case (e.g.) thermometer, kidney
basin, cotton ball, waste paper bag) and
place at one corner of the work area.
8. Place waste paper bag outside of work To prevent contamination of clean area.
area.
9. Close the bag. To give comfort and security, maintain
personal hygiene and hasten recovery.
10. Proceed to the specific nursing care or To prevent contamination of bag and
treatment. contents.
11. After completing nursing care or To protect caregiver and prevent spread
treatment, clean and alcoholize the things of infection to others.
used.
12. Do handwashing again.
13. Open the bag and put back all articles
in their proper places.
14. Remove apron folding away from the
body, with soiled sidefolded inwards, and
the clean side out. Place it in the bag.
15. Fold the linen/plastic lining, clean;
place it in the bag and close the bag.
16. Make post-visit conference on matters To be used as reference for future visit.
relevant to health care, taking anecdotal
notes preparatory to final reporting.
17. Make appointment for the next visit For follow-up care.
(either home or clinic), taking note of the
date, time and purpose.

After Care
 Before keeping all articles in the bag, clean and alcoholize them.
 Get the bag from the table, fold the paper lining ( and insert), and place in between the flaps and cover the bag.
Evaluation and Documentation
 Record all relevant findings about the client and members of the family.
 Take note of environmental factors which affect the clients/family health.
 Include quality of nurse-patient relationship.
 Assess effectiveness of nursing care provided.

Types of Nurse Family Contact

Home Visit
 - While it is expensive in terms of time, effort and logistics for the nurse, it is an effective and appropriate type of family nurse
contact if the objectives and outcomes of care require accurate appraisal of family relationship, home and environment and
family competencies. i.e. The best opportunity to serve the actual care given by family members.

Clinic or Office Conference

- It is less expensive for the nurse and provides the opportunity to use equipment that can’t be taken to the home. In some
cases, the other team members in the clinic may be consulted or called in to provide additional service.

Telephone Conference
- May be effective, efficient, and appropriate if the objectives and outcomes of care require immediate access to data given
problems on distance or travel time. Such data include monitoring of health status or progress during the acute phase of an
illness state, change in schedule of visit or family decision, and updates on outcomes or responses to care and treatment.

Written Communication
- It is another less time consuming option for the nurse in instances when there are large number of families needing follow-up
on top of problems of distance or travel time.

School Visit or Conference

- It is done to work with family and school authorities on how to appraise the degree of vulnerability of and worked out
interventions to help children and adolescence on specific health risks, hazards or adjustment problems.

Industrial or Job Site Visit

- It is done when the nurse and family need to make an accurate assessment of health risks or hazards and work with employer
or supervisor on what can be done to improve on provisions for health and safety of workers.

Industrial or Job Site Visit

- It is done when the nurse and family need to make an accurate assessment of health risks or hazards and work with employer
or supervisor on what can be done to improve on provisions for health and safety of workers.

Records in Family Health Nursing Practice

Records are necessary for the continuation of delivery of family health care services and its evaluation while evaluation of family
health services is necessary to identify the new and continuing family health needs.

Family records include information based on factual events, observation results or measurements taken such as height, weight, body
circumference or laboratory examinations carried out like hemoglobin, urine test, stool test and sputum examination depending upon
the Problem of the family. These also includes records of immunization, nutritional status, medical Prescription and curative
procedures carried out. Demographic data and individual personal History are also included in the family folders.

Health records refer to forms on which information about an individual and family is noted. Information varies from socio-economic,
psychological, environmental factors etc. Records are a Practical and indispensable aid to the doctor, nurse and other health care
workers in giving best Service to individual, family or community. Recorded facts have value and scientific accuracy and Are
guidelines for better administration of family health services. Contributions of health team Members are reflected in case records.
Records are also a means of communication between a Health worker and the families.

Importance and Uses

- Provides documentation of services that have been rendered and supply data that are essential for program planning.
- To provide the practitioner with data required for application of professional services for improvement of family's health
- Records are tools of communication.
- Effective health record shows health problem in the family and other factors that affect health-standardized sheet/form.
- Records indicate a plan for future.
- Provides baseline data to estimate long-term changes related to services.
- Provides opportunity for providing evaluation of the situation.

Purpose of documenting Family Health History which is an important component of family health records are the following:
- Provides facts that are necessary for evaluating health situation of the family; it should
- Also describe the nature and impact on health threat. It should describe the health
- Condition and interacting forces within the family in their daily living.
- To provide an opportunity for mutual exploration of the health situation by the nurse and By the family so that they can
explain to each other their concern, expectations and Probable actions
- To provide baseline and periodic data from which to estimate the long-term changes,
- Services provided and response of the family to these changes and services.

Family health records should represent a comprehensive, systematically organized data and information that are essential for nursing
care decisions. The community health nurse must ensure adequacy of support records for her action.

Though each agency has its own system of recording, the community health nurse can find her own ways of adapting family history
and progress record to her own practice, style and informational needs. Her records may be a valuable resource when agency records
are being revised or the system is being reorganized. The community health nurse may need to build into
the records, methods for incorporating information necessary for case planning and assessing
health service utilization

Criteria for Recording in Family Health Records

The criteria should reflect both the purpose and process of community health nursing practice:
 - Records should concentrate on the family and community focus of care. It should reflect not only the health of the members
of the family but also the ways in which the functioning of the family as a unit has an impact on the health of family as a
whole. It should also specify the ways in which family functions within its physical and social environment.
- Family health records should serve as guides for comprehensive care. These should include health threats and health
behaviors that have significance for family health. For example, an adequately immunized family may have a health threat
from emotionally immature and impulsive parents.
- An apparently healthy family may have poor nutritional habits and poor housekeeping practice inviting accidents. It is
important that records show the problem as it develops so that the change can be identified.
- The record should indicate the expected outcomes and also the degree to which outcomes are m achieved. This means that
the goals of care to a family are also defined in the records.
- The family health record should have specified actions planned for the family actions actually taken and distribution of
responsibility to family and other community resources so that necessary activities are carried out. Action taken should be
recorded in such a way that it can be easily located and future planning can be done.
- The family record should indicate family response to nursing action.
- Since initial planning and implementation can redefine a problem the record must show revision in the status of the problem
so that further planning can be done accordingly.
- Record system should possess sufficient uniformity to make recording, tabulation and collection easy and to permit inter-unit
in-service comparisons and easy reference.
- Maintenance of records should require a minimal amount of time. Unimportant and irrelevant data reading may also require
more time and lengthy records may result in errors.
- Family records should be quickly available to the user. Accessibility is not always easy to achieve. Compiled individual and
family records can be made available at a central location for easy reference only for professional use.
- Family records require reasonable storage space. As the number of individuals are increased, the records also increase and
require more storage space and facilities.
- Depending upon the number of years, records should be retained, according to agency policies and storage space will be
required.
- Family record system should provide confidentiality of record content. For example, sometimes a mother in the family may
not like information about family planning methods she has adopted to be shared with other members of the family or her
neighborhood women. There should be provision for such confidential information and sometimes official records in the
agency do not have provisions for such recording. The community health nurse must find her own ways to I incorporate such
summarization into her recording so that priority needs can be attended to first.

Use of Records
1.For a Nurse
- Provides basic facts for services. Shows health condition as it is and as accepted by individual/family
- Provides a basis for analyzing needs, short and long-term planning
- Prevents duplication of services and helps follow up effectively
- Helps the nurse to evaluate care and teaching
- Helps to organize her work in an orderly way and to make effective use of time
- Serves as a guide to professional growth
- Enables the nurse to judge the quality and quantity of work done
2.For Individual/Family
- Help them to become aware and to recognize their health needs
- Can be used as a teaching tool too
3.For the Doctor
- Serves as a guide for diagnosis, treatment and evaluation of services
- Indicates progress
- May be used in research
4.For the Organization and Community
- Helps to assess the health assets and needs of the community
- Helps in making studies for research, legislative action and planning budget is legal evidence of the services rendered by each
worker
- Provides a justification for expenditure of funds

B. Types of Records and Reports

1) Cumulative or continuing records
- This is found to be time saving, economical and also it is helpful to review the total history of an individual and evaluate the
progress of a long period. (e.g.) child’s record should provide space for newborn, infant and preschool data.
- The system of using one record for home and clinic services in which home visits are recorded in blue and clinic visit in red
ink helps coordinate the services and saves the time.
2) Family records
- The basic unit of service is the family. All records, which relate to members of family, should be placed in a single family
folder. This gives the picture of the total services and helps to give effective, economic service to the family as a whole.
- Separate record forms may be needed for different types of service such as TB, maternity etc. all such individual records
which relate to members of one family should be placed in a single family folder.

The records may be grouped according to:

1. Age of the family member for whom records are used
- a New boll1 care
- Road to health card -e
- Toddler card e
- Old age or elderly card e
- Mother-child link card

2. Health care requirement cards as per health conditions and morbidity status
- Pregnant women or antenatal card
- Intra natal card or labor record
- Person with illnesses (e.g. Tuberculosis record, Diabetes record, Hypertension case card)
- Drug addicts or alcoholics record
- Any chronic care records
 - Immunization record

Usually for family health service a family folder including different cards is maintained. This includes socio-demographic
information, children’s health status (including height, weight, immunization and feeding habits etc.) maternal records, morbidity
records and observations of general health status of family and the environment of the family.

These records have individual formats and styles of recording which is prescribed for each agency. The method of recording is usually
a standard one and general Nursing instructions are provided.

FILLING OF RECORDS
Different systems may be adopted depending on the purposes of the records and on the merits of a system. Records could be arranged
in the following ways:
- Alphabetically
- Numerically
- Geographically and
- With index cards

REGISTERS
It provides indication of the total volume of service and type of cases seen. Clerical assistance may be needed for this. Registers can
be of varied types such as immunization register, clinic attendance register, family planning register, birth register and death register.

REPORTS
Reports can be compiled daily, weekly, monthly, quarterly and annually. Report summarizes the services of the nurse and/or the
agency and may be in the form of an analysis of some aspect of a service. These are based on records and registers and so it is relevant
the nurses to maintain the records regarding their daily case load, service load activities. Thus, the data can be obtained continuously
and for a long period.

PURPOSES OF WRITING REPORTS

- To show the kind and quantity of service rendered over to a specific period.
- To show the progress in reaching goals.
- As an aid in studying health conditions.
- As an aid in planning.
- To interpret the services to the public and to other interested agencies.

In addition to the statistical reports, the nurse should write a narrative report every month which provides as opportunity to present
problems for administrative considerations.

Maintaining records is time consuming, but they are of definite importance today in the community health practice in solving its
health problems.