University of San Jose-Recoletos

School of Allied medical Sciences

Nursing

FAMILY HEALTH ASSESSMENT FORM

Area Surveyed: Lower Yati, Barangay Quiot Pardo City

Head of the Family: Lando Bitonio
Date Surveyed: _____________________________________

I. FAMILY PROFILE: Members of the household:

Relation to the Birthdate Occupation

Educational
NAME Head of the Age/Sex Marital Status Physical Health
Month Year Attainment Type Occupation
Family
34 yrs. 3rd Year High Laundry
Lando Bitonio NS NS Married
Old/Male school Assistant
Luiza Diniza Quidlat Wife 29 yrs. NS NS Married High school Housewife Low Blood Pressure
Old/Female Graduate
Rene Son 13 yrs. old/ NS NS Single Grade 6 student N/A
Male
Renren Son 11 yrs. NS NS Single Grade 5 student N/A
Old/Male
Renan Son 9 yrs. Old/ NS NS Single Grade 3 student N/A
Male
Ronron Son 8 yrs. Old/ NS NS Single Grade 2 student N/A
Male
 A.. Type of Family form (nuclear or extended): _____Extended_______________________
B. Length of stay in the Area ( months or years): Approximately 7 years

C. Place of Origin: Lower Yati, Barangay Quiot Pardo City

II. HEALTH STATUS

A. Maternal Reproductive History (For each pregnancy, please answer the following questions using the chart found below):

PRENATAL OUTCOMES SEX DELIVERY FAMILY PLANNING METHOD

MATERNAL
PREGNANCY YES (by Depo
AGE NO DIED ABORTED LIVING Attendant Place Pills IUD Others
whom) Provera
Normal 16 yrs. old 1 Male
19 yrs. old 1 Male
21 yr. old 1 Male
23 yrs. old 1 Male
✓

For pregnant mothers, please answer the following questions:

If currently pregnant: LMP: _________________________ EDC: _______________________________ AOG: _____________________________
B. Child Care (For each child 12 years old and below please answer the following questions using the table below):

IMMUNIZATION
NAME OF CHILD AGE WEIGHT HEIGHT Nutritional Level DPT (# of OPV ( # of AMV (# of HEP B (#
BCG OTHERS
dose) dose) dose) of dose)
Renren 11 yrs. ✓ ✓ ✓ ✓ ✓
old
Renan 9 yrs. ✓ ✓ ✓ ✓ ✓
old
Ronron 8yrs. ✓ ✓ ✓ ✓ ✓
old
 Usual Source of Vaccine: (✓ ) Governement ( ) Private Breastfeeding: ( ) yes ( ) no (specify the reason)_______________________________
1. Health Care
1. Is there any member of the family who is sick at present? ( )No (✓ )Yes What Illness? Otitis Media
2. Is there any member of the family who is disabled? (✓ )No ( )Yes What type of disability? __________________ Age: ___________
3. Where do you usually go for medical care? ( ) Private ( )Government Hospital ( )Private Doctor
( )Hilot ( )Relatives ( ✓ ) Barangay Health Worker ( ) Self ( ) Others (specify): ______________________________
4. Approximate distance from the house to the nearest health center? Few meters

III. Physical Environment

A. Home
1. Ownership House ( ) owned ( ✓ )rental ( )others ___________________
Lot ( ) owned (✓ )rental ( )others ___________________
2. Number of rooms use for sleeping: 2________
3. Construction material used: ( ✓ )Light ( )Strong ( ) mixed
4. Home appliances (✓ )television ( ✓)radio ( )others: ______________________________________________________________________________
5. Drainage: ( ✓ )open ( )Close type
6. Safety Hazard: ( )loose rickety stairs (✓ )loose doors, walls, posts
Number of windows noted: ( ) only 1 ( ) more than 1
Presence of dangerous materials such as: ( ) sharp objects i.e. knife, scissors ( ) matches ( ) lighters
( ) corrosive liquids such as kerosene, insecticides ( ) medicines ( ) others (specify)
B. Water Supply
1. Sources: ( ) Level 1 ( ) Level 2 ( ) Level 3
2. Water decontamination: ( ✓ ) none ( )yes [ ]chlorination [ ] boiling [ ]others specify: _____________________
3. Approximate distance of the water source from the house: ___________________
4. Water ( )botelya ( )Balde ( )gallon ( )water jag ( )banga ( )others specify: _Pitcher_____________________
 C. Toilet
Ownership: ( )owned ( )shared (please indicate the total number of persons sharing the facility) _2_____________________________
Type: ( )antipolo ( )open pit privy ( )water sealed ( )others specify:Pail Type

D. Garbage disposal: ( ) open dumping ( ) burning ( )buried in a pit ( ✓ )collected by garbage truck ( )composting ( ) others specify:__________

IV. Socio Cultural

1. Are you a member if any civic organization: ( ✓ )No( )Yes
2. Usual source of current information: (✓ )Radio ( )Newspaper ( )Neighbor
(✓ )television ( )Other family members ( )Others specify:________________
3. What is the usual means of relaxation: (✓ )sports ( )gambling ( )sleeping ( )TV/movies ( )others:___________________
4. Please list any taboo/s that you may be able to extract the respondents in terms of health practices: ___________________________________________________________

V. Economics
SOCIAL CLASS STATUS
1. Breadwinner: ________Lando Bitonio__________________________________
2. Average monthly family income: __________________________
3. Source of income/livelihood: ( )Business ( ✓)Salary ( )Pension ( )Others:______________________________
4. Is your home enough for your basic needs (food, shelter clothing, health): _No_______________________________
5. Problems usually affecting the family: The problems that affects the family are Small income, unstable job of the parents, Health problems such as Otitis media, and lack
of properties since the family only rents the house.
1. Nature of the Problem 3/3x1 1 Otitis Media
Health Deficit
2. Modifiability of the 1/2x2 1
Problem
Partially Modifiable

3. Preventative Potential 2/3x1 0.67

Moderate

4. Salience 2/2x1 1
A serious problem,
immediate attention

TOTAL: 3.67

2.) Family size beyond what family resources can adequately provide.

1. Nature of the Problem 2/3x1 0.67

Health Threat
2. Modifiability of the 1/2x2 1
Problem
Partially Modifiable

3. Preventative Potential 2/3X1 0.67

Moderate

4. Salience 2/2X1 1
A serious problem,
immediate attention

TOTAL: 3.34
3.) Risk for Unwanted Pregnancy

1. Nature of the Problem 1/3X1 0.33

Foreseeable Crises

2. Modifiablity of the 1/2X2 1

Problem
Partially Modifiable
3. Preventative Potential 2/3X1 0.67
Moderate
4. Salience 1/2X1 0.5
A problem but not needing
immediate attention

TOTAL: 2.5

Otitis Media is the highest prioritization.

 UNIVERSITY OF SAN JOSE-RECOLETOS
COLLEGE OF NURSING
CEBU CITY

FAMILY NURSING CARE PLAN

NAME OF FAMILY: ___Bitonio Family__________________________________________ DATE: _____________________

FAMIILY NURSING NURSING METHOD OF NURSE RESOURCES

HEALTH PROBLEM GOALS OF CARE OBJECTIVES OF CARE EVALUATION
PROBLEM INTERVENTIONS – FAMILY CONTACT REQUIRED
1. Otitis Externa Unaffordable 2 weeks span after the After the Treatment 1. Establish rapport. Visiting Homes Materials Goals are met as
Medications by the treatment , The child the child should know Resources: evidenced by:
2. Use a pain rating scale to
family. will be free from the what preventive assess the client's Otoscope, Pulse
infection . measures should he do description and frequency of Oximeter, BP Child Said that
 No to prevent this pain. Apparatus, there are no more
knowledge infection Thermometer. presence of the
3. Monitor vital signs.
 No proper infection .
Income 4. Encourage the mother to
 No proper assist and hold and comfort
medical the patient.
stocks for this 5. Have the child sit up, raise
kind of head on pads, or lie on
infection unaffected ear.

6. Apply warming cushion or

a warm hot water bottle.

7. Instruct family individuals

to cover mouths and noses
when sniffling or hacking
and to wash hands
habitually.
5. Evaluate hearing capacity
habitually. Empower
expanded liquid admissions,
great nourishment, and
satisfactory rest.
 HEALTH PROBLEM FAMILY NURSING GOALS OF CARE OBJECTIVES OF CARE NURSING METHOD OF NURSE- RESOURCES EVALUATION
PROBLEMS INTERVENTIONS FAMILY CONTACT REQUIRED
2.) Family size beyond Lack of knowledge Using the nursing After nursing 1. Discuss and Home Visit Material Resources: Goals are met as
what family resources and awareness in a interventions , the interventions examine crucial Visual Aids on evidence by :
can adequately proper health action. family will know how topics concerning the methods about
provide. to plan and to take  Will know marriage relationship fertility control
the right decisions in the and parental methods. The parents was able
maintaining family importance responsibilities with to understand the
size that can meet of family the couple. explanation about
the needs . planning.
2. Discuss possible family planning , and
 Know ways courses of action with the importance of
on how to the couple, as well as controlling family
prevent on the advantages and size.
keep adding risks of each.
the family
size

 Will make
the proper
plan for the
family.
 HEALTH PROBLEM FAMILY NURSING GOALS OF CARE OBJECTIVES OF CARE NURSING METHOD OF NURSE- RESOURCES EVALUATION
PROBLEMS INTERVENTIONS FAMILY CONTACT REQUIRED
3 Poor Environmental Can’t provide a home Through the use of When Nursing 1. Establish rapport. Home Visit Material Resources: Goal met:
Sanitation environment to nursing interventions interventions is Giving them visual aid
2. By discussion of
maintain health the family will make done the family will and also giving them
facts, highlight the
maintenance and more better be : environmental The family find more
importance of a clean
development of self perspective and will sanitation , and giving ways on cleaning the
and healthy
due to poverty and also have the them infographics on environment that
environment.
ignorance about awareness on a  Will know how helpful it is to would minimize the
preventive measures environment . how to lessen 3. Discuss to the clean the risk of there own
of infectious diseases. congestion . family the possible environment health due to the
 Follows Proper communicable problem of the
measurements disease as a result of drainage or their
of cleaning the poor sanitation. surrounding .
area .
4. Discuss to the
 They will know
family the ways to
the effects on
minimize the risk of
what the
having health
cause to the
problems due to
environment .
Open Drainage.
 They will give
more value to 5. Encourage the
the family to conduct a
environment schedule that
and the will includes regular
have more cleaning.
awareness.

NAME OF FAMILY: _________________ Ocariza ____________________________
HEALTH PROBLEM
1.)Family size beyond what family
resources can adequately provide.
COLLEGE OF NURSING
CEBU CITY
HOME VISIT PLAN
DATE: _____________________
NURSING INTERVENTIONS RESOURCES REQUIRED EVALUATION
1.) Provide Health Teaching to the family 1.) Give them A info graphic or a leaflet Goals are met when :
. about family planning in which they
2.)Provide them ideas on how to do a could easily understand and find
family planning ways to apply family planning . They both apply the family planning health
teaching , so that they will have knowledge
2.)Time and effort of both family and on how to have safe sex .
3.)Assess the level of understanding of health workers
the family regarding the problem.
4.)Assess the living condition of the
family.
.
1. Otitis Media Infection
1. Have the child sit up, raise head on pads, Material Resources: Otoscope Goals are met as evidenced by:
or lie on unaffected ear.
2. Apply warming cushion or a warm hot 1. Absence of yellowish discharge and Foul
water bottle. Human Resources: The time and effort of smell.
3. Instruct family individuals to cover both family and health care workers. 2. Absence of the pain.
mouths and noses when sniffling or hacking Absence of Infection
and to wash hands habitually.
4. Evaluate hearing capacity habitually.
Empower expanded liquid admissions, great
nourishment, and satisfactory rest.
5. Dispense with allergens and aviation
route aggravations such as tobacco, smoke,
and clean.