COMMUNITY HEALTH NURSING

CASE PRESENTATION FORMAT

Level 2

Cover Page
Acknowledgment
Table of Contents

I. INTRODUCTION
A. Background of the Study
B. Objectives (General & Specific)
C. Theoretical Framework – choose a Nursing Theory on Community Health to be used in the
case study.
II. INITIAL DATA BASE

A. FAMILY STRUCTURE, CHARACTERISTICS AND DYNAMICS

1. Demographic Data

NAME OF RELATIONSHIP
CIVIL EDUCATIONAL ETHNIC
FAMILY AGE SEX TO HEAD OF RELIGION
STATUS ATTAINMENT BACKGROUND
MEMBER FAMILY

2. Place of Residence

3. Type of Family Structure

4. Dominant family members in terms of decision (health care)

5. General Family Relationship / Dynamics

6. Family History

a. Genogram

b. Narrative of Family History

B. SOCIO-ECONOMIC AND CULTURAL CHARACTERISTICS

1. Income and expenses

MONTHLY
FAMILY MEMBER OCCUPATION PLACE OF WORK
INCOME
A
 B
C
etc…
TOTAL

MONTHLY EXPENSES AMOUNT

Electricity
Water
Food
etc…
TOTAL

2. Adequacy to meet basic necessities (food, clothing, shelter)

3. Who makes decision about money and how it is spent

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 (provide photos)

1. Housing
a. Adequacy of living space
b. Sleeping arrangement
c. Presence of breeding or resting sites of vector of diseases
d. Presence of accident hazards
e. Food storage and cooking facilities
f. Water supply-source, ownership, potability
g. Toilet facilities-type, ownership, sanitary condition
h. Garbage/refuse disposal-type, sanitary condition
i. Drainage System-type, sanitary condition

2. Kind of Neighborhood

3. Social and Health facilities available

4. Communication and transportation facilities available

 D. HEALTH STATUS OF EACH FAMILY MEMBER

1. Patient’s Data

2. Patient’s History- indicating current or past significant illnesses or beliefs and practices
conducive to health and illness

a. Past Health History

b. Present Health History

3. Nutritional assessment (especially for vulnerable or at risk members)

a. Anthropometric Data Measurements

RISK ASSESSMENT MEASURES

NAME OF FAMILY NUTRITIONAL STATUS REMARKS
AGE SEX FOR OBESITY
MEMBER
WEIGHT HEIGHT MUAC BMI WC WHR

BMI=weight in kgs. divided by height in meters2

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.

b. Dietary history specifying quality and quantity of food or nutrient per day
c. Eating/ feeding habits/ practices

4. Developmental Data
a. Patient – any member of the family who is the focus on this study (e.g. pregnant mother
with or without complications, child, or vulnerable and at risk member of the family)

b. Child (additional for 0-6 years old)--assessment of infant, toddlers and preschoolers-
e.g. Metro Manila Developmental Screening Test (MMDST).
Present only the results and attach the MMDST form in the case study. During oral case presentation
provide video output for the entire MMDST process
RESULTS
NAME OF
AGE SEX PERSONAL- GROSS FINE REMARKS
CHILD LANGUAGE
SOCIAL MOTOR MOTOR

5. 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.
 6. PHYSICAL ASSESSMENT indicating presence of illness state/s (diagnosed or
undiagnosed by medical practitioners ) – for client with complications in pregnancy or
according to concept ---for normal pregnancy must include the result of the Leopold’s
Maneuver

7. Results of laboratory/diagnostic and other screening procedures supportive of assessment

findings. --For normal pregnant clients, who did not have a copy of their lab results, the
result for Urine Test for Albumin and Sugar in the PHN bag technique, may be included.

8. Pharmacology – Meds currently taken or prescribed as maintenance drug (include also

OTC drugs); patient’s understanding of the significance of the drug to the condition.

E. VALUES, HABITS, PRACTICES ON HEALTH PROMOTION, MAINTENANCE AND

DISEASE PREVENTION

1. Immunization status of family members

NAME OF
AGE VACCINE 1st dose 2nd dose 3rd dose REMARKS
CHILD
BCG
DPT
BABY A 3 Y.O.
OPV
etc…
BCG
DPT
BABY B 2 Y.O.
OPV
etc…

2. Healthy lifestyle practices

3. Adequacy of:
a. Rest and sleep
b. Exercise/activities
c. Use of protective measure: e.g. adequate footwear; use of bed nets and protective
clothing

4. Relaxation and other stress management activities

5. Use of promotive-preventive health services

III. TYPOLOGY OF NURSING PROBLEMS

A. First Level of Assessment
B. Second Level of Assessment

IV. FAMILY COPING INDEX

 V. PRIORITIZATION AND SALIENCE OF THE PROBLEM

VI. Anatomy and Physiology (involved system/s)**

VII. Pathophysiology**
A. Etiology:
1. Predisposing Factors
2. Precipitating Factors
B. Symptomatology
C. Schematic Diagram of the Disease Process / Pathophysiology Diagram

VIII. Drug Study**

IX. A. NURSING THEORIES (3) RELATED TO THE CLIENT CARE

B. CONCEPTUAL FRAMEWORK OF NURSING CARE – Concept map of nursing care

X. FAMILY NURSING CARE PLANS – prioritized according to the salience of the problem

XI. HEALTH TEACHINGS

XII. CONCLUSION AND RECOMMENDATIONS

A. Conclusion
B. Recommendations
1. Patient and Family
2. Nursing Education
3. Nursing Practice
4. Nursing Research

XIII. REFERENCES (APA 6th ed)

XIV. APPENDIX – documentation photos

** Note: These parts will be included for clients with complications, at risk and disease condition usually on
the 2nd semester of Level 2.

IDB source: http://www.rnpedia.com/nursing-notes/community-health-nursing-notes/initial-data-base-

family-nursing-practice/