COMMUNITY HEALTH NURSING RLE

PART A. INITIAL DATA BASE

I. CHARACTERS:
A. What is the type of family structure?
✓ Nuclear Single - Parent
Extended Others (specify)
B. What is the type of family based on authority?
✓ Patriarchal
Matriarchal
C. Who makes decisions regarding health care? Both
D. What is the present family relationship?
with conflicts between members
✓ without conflicts between family members
E. Activities of daily living:
1. Sleeping pattern:
Retiring/getting up hours 10pm – 7 am
Nap during the day <30 minutes
Do members sleep together X
2. Eating pattern
How many meals each day? 3-4
Who appears overweight? All
Who appears underweight?
3. Leisure time activities
How does each member spend leisure hours? Eating, Watching Netflix
Is it appropriate for the sex and age group? Yes
What is the effect on the family?
Any joint activity for leisure? Basketball, Zumba

II. FAMILY INFORMATION

Head of the family: Mother
Address: CALOOCAN
Members of the household: 4

NAME RELATIONSHIP AGE EDUCATIONAL

ATTAINMENT
GL FATHER 48 HS
LL MOTHER 45 HS
LOL SON 22 COLLEGE
LEL SON 28 HS

/avg 1
 III. SOCIO-ECONOMIC AND CULTURAL FACTORS
A. Income

NAME OCCUPATION PLACE INCOME /

MONTH
GL BUS DRIVER OFW PHP100k
LL ASSISTANT TEACHER OFW PHP100k

1. Does the working family member meet the basic necessities?

✓ Yes No
2. Who makes decisions regarding money matters? Both
3. Religious affiliation: Catholic
4. What roles does the family play in the community?

IV. ENVIRONMENTAL FACTORS

A. Housing
1. Ownership
✓ Owned Rented Rent-Free Others (specify)
2. Construction materials used
Light Mixed ✓ Strong
3. Living space
✓ Adequate Inadequate
4. Sleeping arrangement:
5. Adequacy in furniture
✓ Adequate Inadequate
6. Water source
✓ Private Public
7. Food storage
✓ Refrigerator Jars/container Others (specify)
8. Cooking facility
Electric stove Firewood Others (specify)
✓ Gas Stove Kerosene
9. Drainage facility
✓ Open drainage Blind drainage None
10. Toilet facilities/type
✓ Flushed Overhung latrine
Water-sealed latrine Bored-hole latrine
Pail system Others (specify)
11. Sanitary condition
Fair ✓ Good Poor
Provide brief description: Trash bins are scattered in the home with lids and disposed at night

12. Neighborhood
Congested Slum ✓ Other
/avg 2
 13. Availability of Health Care Facility
Describe briefly: 10 minutes from home
14. Garbage disposal
Dumped at street corner ✓ Picked up by garbage collector
Buried Burned then buried Others(specify)

V. HEALTH MEDICAL HISTORY

NAME PAST ILLNESS DIAGNOSED / ILLNESS STATE HEALTH ACTION
UNDIAGNOSED TAKEN
GL HIGH BLOOD DIAGNOSED CHRONIC MAINTENANCE
LL DIABETIC UNDIAGNOSED ACUTE HERBAL
LEL HEAVY DRINKER, DIAGNOSED CHRONIC SURGERY, REHAB
SMOKER,
GALBLADDER

VI. VALUE PLACED ON PREVENTION OF DISEASE

Vaccinations

NAME AGE COMPLETE INCOMPLETE

GL 48 ✓
LL 45 ✓
LOL 22 ✓
LEL 28 ✓

Other preventive practices employed by the family:

Sources of Health Care:
Health Center ✓ Government Hospital
Private Hospital Others (specify)

/avg 3
 PART B.

DETERMINE AT LEAST 3 FAMILY HEALTH PROBLEMS. IF NONE, DETERMINE THE FAMILY’S PROMOTIVE OR PREVENTIVE
PRACTICES.
FAMILY HEALTH PROBLEMS. / TYPOLOGY OF HEALTH PROBLEM
(WELLNESS STATE , HEALTH DEFICIT,HEALTH THREAT,
(IF NONE, FAMILY’S PROMOTIVE OR FORESEEABLE CRISIS)
PREVENTIVEPRACTICES.)

1. High blood Health Deficit

Health Threat
2. Alcoholism

3. Diabetic Health Deficit

PART C.

DO THE SCALING OF THE 3 IDENTIFIED HEALTH PROBLEMS OR PROMOTIVE PRACTICES OF THE FAMILY.

HEALTH PROBLEM 1: High Blood

CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION

NATURE OF THE PROBLEM

1 Some of the family members
has inappropriate eating
habits resulting into an
unhealthy lifestyle

MODIFIABILITY OF THE Lifestyle changes can

PROBLEM 2 alleviate the problem in
resolving the issue.
PREVENTIVE POTENTIAL Problems can be avoided by
1 educating about good health
and living a healthy lifestyle.
SALIENCE
1
The problem needs
immediate attention due to
lack of knowledge regarding
to the disease

TOTAL: 6.0

/avg 4
 HEALTH PROBLEM 2: Heavy Drinker

CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION

NATURE OF THE PROBLEM

0.67 Some of the family members
has inappropriate eating
habits resulting into an
unhealthy lifestyle

MODIFIABILITY OF THE Lifestyle changes can

PROBLEM 2 alleviate the problem in
resolving the issue.
PREVENTIVE POTENTIAL Problems can be avoided by
1 educating about good health
and living a healthy lifestyle.
SALIENCE
1
The problem needs
immediate attention due to
lack of knowledge regarding
to the disease

TOTAL: 4.67

/avg 5
 HEALTH PROBLEM 3: High Glucose Levels

CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION

NATURE OF THE PROBLEM

1 Some of the family members
has inappropriate eating
habits resulting into an
unhealthy lifestyle

MODIFIABILITY OF THE Lifestyle changes can

PROBLEM 2 alleviate the problem in
resolving the issue.
PREVENTIVE POTENTIAL Problems can be avoided by
1 educating about good health
and living a healthy lifestyle.
SALIENCE
1 The problem needs
immediate attention due to
lack of knowledge regarding
to the disease

TOTAL: 6.0

Surveyed by _________________________
Date ______________________________

/avg 6