Pangasinan State University

Bayambang, Pangasinan
Bayambang Campus
Institute of Nursing

NCM 113- Community Health Nursing 2: Population Groups and Community as Clients

Student Name: Elizabeth C. Corpuz

Year & Section: BSN III-1

Establishing a Working Relationship with the Client Family: Benjamin I. Corpuz

Name of Family Head

CRITERIA CHECK IF DONE

(INDICATE DATE)

1. Initiate contact through home visit

2. Introduce yourself and your agency
3. Communicate interest in family welfare
4. Maintain a two-way communication with the family
5. Show willingness to help with expressed need/s.
Establishing a Working Relationship with the Client Family: Eric C. Corpuz
Name of Family Head

CRITERIA CHECK IF DONE

(INDICATE DATE)

1. Initiate contact through home visit

2. Introduce yourself and your agency
3. Communicate interest in family welfare
4. Maintain a two-way communication with the family
5. Show willingness to help with expressed need/s.

Establishing a Working Relationship with the Client Family: Dionisio O. Cantor

Name of Family Head

CRITERIA CHECK IF DONE

(INDICATE DATE)

1. Initiate contact through home visit

2. Introduce yourself and your agency
3. Communicate interest in family welfare
4. Maintain a two-way communication with the family
5. Show willingness to help with expressed need/s.
Establishing a Working Relationship with the Client Family: Carlina O. Cantor
Name of Family Head

CRITERIA CHECK IF DONE

(INDICATE DATE)

1. Initiate contact through home visit

2. Introduce yourself and your agency
3. Communicate interest in family welfare
4. Maintain a two-way communication with the family
5. Show willingness to help with expressed need/s.

Establishing a Working Relationship with the Client Family: Andy C. Mendoza

Name of Family Head

CRITERIA CHECK IF DONE

(INDICATE DATE)

1. Initiate contact through home visit

2. Introduce yourself and your agency
3. Communicate interest in family welfare
4. Maintain a two-way communication with the family
5. Show willingness to help with expressed need/s.
Name of Family Head: Benjamin I. Corpuz
Address: #93 Zone 1 Flores, San Manuel, Pangasinan

List of Health Problems Nature of Problem

1. Hypertension Health Deficit

2. Diabetes Mellitus Health Deficit

3. Inadequate rest and sleep Health Threat

4. Presence of pests at home Health Threat

Name of Family Head: Eric C. Corpuz

Address: #92 Zone 1 Flores, San Manuel, Pangasinan

List of Health Problems Nature of Problem

1. Cough Health Deficit

2. Colds Health Deficit

3. Presence of pests at home Health Threat

4. Improper drainage system Health Threat

Name of Family Head: Dionisio O. Cantor
Address: #465 Zone 5 San Bonifacio, San Manuel, Pangasinan

List of Health Problems Nature of Problem

1. Iron Deficiency Health Deficit

2. Hypertension Health Threat

3. Inadequate rest and sleep Health Threat

4. Poor Nutrition intake Health Threat

5. Presence of pests at home Health Threat

6. Inadequate exercise Health Threat

7. Improper Drainage system Health Threat

8. Lack of relaxation activities Health Threat

Name of Family Head: Carlina O. Cantor
Address: #463 Zone 5 San Bonifacio, San Manuel, Pangasinan

List of Health Problems Nature of Problem

1. Hypertension Health Deficit

2. Diabetes Mellitus Health Deficit

3. Improper Drainage system Health Threat

4. Presence of pests at home Health Threat

Name of Family Head: Andy C. Mendoza

Address: #462 Zone 5 San Bonifacio, San Manuel, Pangasinan

List of Health Problems Nature of Problem

1. Hypertension Health Deficit

2. Diabetes Mellitus Health Threat

3. Cough Health Deficit

4. Presence of pests at home Health Threat

Family No. 1
Problem: ________________________________________________________
 Criteria Standard Score Weight Actual Score Justification

1. Nature of the Health Deficit 3/ 1 1/

problem Health Threat 2 2/3
Foreseeable Crisis 1 1/3
2. Modifiability of the Easily Modifiable 2 2 2
problem Partially Modifiable 1/ 1/
Not Modifiable 0 0
3. Preventive High 3/ 1 1/
potential Moderate 2 2/3
Low 1 1/3
4. Salience of the Needs immediate attention 2/ 1 1/
problem Does not need immediate
attention 1 1/1
Not a problem 0 0

TOTAL SCORE: ______________________________

Family No. 2
Problem: ________________________________________________________
 Criteria Standard Score Weight Actual Score Justification

1. Nature of the Health Deficit 3/ 1 1/

problem Health Threat 2 2/3
Foreseeable Crisis 1 1/3
2. Modifiability of the Easily Modifiable 2 2 2
problem Partially Modifiable 1/ 1/
Not Modifiable 0 0
3. Preventive High 3/ 1 1/
potential Moderate 2 2/3
Low 1 1/3
4. Salience of the Needs immediate attention 2/ 1 1/
problem Does not need immediate
attention 1 1/1
Not a problem 0 0

TOTAL SCORE: ______________________________

Family No. 3
Problem: ________________________________________________________
 Criteria Standard Score Weight Actual Score Justification

1. Nature of the Health Deficit 3/ 1 1/

problem Health Threat 2 2/3
Foreseeable Crisis 1 1/3
2. Modifiability of the Easily Modifiable 2 2 2
problem Partially Modifiable 1/ 1/
Not Modifiable 0 0
3. Preventive High 3/ 1 1/
potential Moderate 2 2/3
Low 1 1/3
4. Salience of the Needs immediate attention 2/ 1 1/
problem Does not need immediate
attention 1 1/1
Not a problem 0 0

TOTAL SCORE: ______________________________

Family No. 4
Problem: ________________________________________________________

Criteria Standard Score Weight Actual Score Justification

 1. Nature of the Health Deficit 3/ 1 1/
problem Health Threat 2 2/3
Foreseeable Crisis 1 1/3
2. Modifiability of the Easily Modifiable 2 2 2
problem Partially Modifiable 1/ 1/
Not Modifiable 0 0
3. Preventive High 3/ 1 1/
potential Moderate 2 2/3
Low 1 1/3
4. Salience of the Needs immediate attention 2/ 1 1/
problem Does not need immediate
attention 1 1/1
Not a problem 0 0

TOTAL SCORE: ______________________________

Family No. 5
Problem: ________________________________________________________

Criteria Standard Score Weight Actual Score Justification

1. Nature of the Health Deficit 3/ 1 1/

problem Health Threat 2 2/3
 Foreseeable Crisis 1 1/3
2. Modifiability of the Easily Modifiable 2 2 2
problem Partially Modifiable 1/ 1/
Not Modifiable 0 0
3. Preventive High 3/ 1 1/
potential Moderate 2 2/3
Low 1 1/3
4. Salience of the Needs immediate attention 2/ 1 1/
problem Does not need immediate
attention 1 1/1
Not a problem 0 0

TOTAL SCORE: ______________________________

Example:

Ranking Health Problems of Family Dela Cruz

PRIORIT PROBLEM SCORE
Y
1 cough & cold 4 2/3
2 Scabies 4
3 Malnutrition 3
4 No PWS 2
5 Pregnancy of Juana 1½

Ranking Health Problems of Family 1 Corpuz

PRIORITY PROBLEM SCORE

Ranking Health Problems of Family 2 Corpuz

PRIORITY PROBLEM SCORE

3
 4

Ranking Health Problems of Family 3 Cantor

PRIORITY PROBLEM SCORE

Ranking Health Problems of Family 4 Cantor

PRIORITY PROBLEM SCORE

1
 2

Ranking Health Problems of Family 5 Mendoza

PRIORITY PROBLEM SCORE

Family No.: _________________

 Ranking Health Problems of Families in the Five Families: ______________________________

PRIORITY 1 FAMILY NAME PROBLEMS SCORE

10

Family Name: _________________________________

Health Problems Family Nursing Problem

First Level Assessment Second level Assessment
Name of Family: _____________________________________________

HEALTH PROBLEMS FAMILY NURSING GOALS OBJECTIVES INTERVENTIONS METHODS OF NURSING RESOURCES EVALUATION
PROBLEMS METHOD FAMILY CONTACT REQUIRED
Prepared by:

NINA BLANCA F. FERRER, MAN QUEENY ANNE APIL, MAN CIELO C. FERNANDEZ, Ph.D.
Clinical Instructor Clinical Coordinator College Dean