ASSESSMENT DATA BASE IN FAMILY NURSING PRACTICE

Address: San Isidro Street Mercedes 2 FAMILY NUMBER: 12

Street/Road Barangay Zone

A. FAMILY STRUCTURE, CHARACTERISTICS, & DYNAMICS/RELATIONAL PATTERN

1. Members of the household

Birthdate
Members of the family Age Sex Civil status Position in the family Relationship to the head of the Family
Month Year
Rosalino G. Lopez 51 March 1971 M Married Father Husband

Juvima T. Lopez 48 October 1974 F Married Mother Wife

Kenzy T. Lopez 29 February 1993 M Married First Born Son
Ziatria T. Lopez 21 November 2001 F Single Second Born Daughter

2. Socio-demographic data of members not currently living in the household but with major role in resource generation and use

Birthdate Highest Occupation

Relationship to the
Name of Family Member Age Sex Marital Status Educational
Month Year Type of Work Place head of the family
Attainment
N/A

3. Length of Residency: ______10 years___________

 4. Type of family structure and form
Based on Composition Based on locus power Based on place of residency

Nuclear family Stepfamily/blended Patrifocal Patrifocal

Extended Single Matrifocal Matrifocal

Beanpole Same sex/Homosexual Egalitarian Bilocal

Single Parent Cohabiting Matricentric

5. Family dynamics, Communication patterns, interaction processes and interpersonal relationships.

Criteria Status Additional information

Observable conflicts between family members Conflict arises when disciplining the children due disobedience and conflict in terms of financial.

Characteristics of communication Indirect The family lacks communication within the household because family members are mostly out
Communication of the house.
Interaction patterns Exchange Family members help each other out. When one asks a favor to another, the other complies
with it with minimal complaint.
Others

B. SOCIO ECONOMIC & CULTURAL CHARACTERISTICS

Name of Family member Ethnic background Religion Highest educational Occupation Income
attainment

Rosalino G. Lopez Subanen Catholic College Graduate Teacher 9 (21K)

Juvima T. Lopez Subanen Catholic College Graduate Teacher 9 (21K)

Kenzy T. Lopez Subanen Catholic College Graduate Business 5 (10K+)

Ziatria T. Lopez Subanen Catholic Junior High Graduate Student N/A

Legend for monthly income

1- Below 2500 3. Above 5000 to 7500 5- above 10000 to 12500 7- above 15000 to 17500 9-above 20000 to 25000
 2- 2500 to 5000 4- above 7500 to 10000 6-above 12500 to 15000 8-above 17500 to 20000 10- above 25000

Income & Expenses

a. Adequacy to meet basic Necessities
The family meets their basic need interms of food shelter, and other
expenses.________________________________________________________________________________________________________________________________
______________________________________________________________________________________________

2. Family traditions, events or practices affecting members’ health or family functioning

__N/A________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
3. Significant others – role(s) they play in family’s life

Name Relation the family

N/A

4. Relationship of the family to the larger community- nature and extent of participation of the family in community activities

a. Awareness of existing organization Yes Name ___________________________ No

b. Membership in an organization Yes Name ____________________________ No

c. Involvement in an organization Yes Name _____________________________ No Why? The family are too busy with their respective work to
join any other organization in their community.

d. Potential or Existing leaders _N/A_________________________________________________________________________________________________

C. HOME AND ENVIRONMENT

1. Home
Ownership: owned rented free Constructional material used: light mixed strong
Lighting facilities: electricity kerosene others (specify) ____________________________________
Number of rooms used for sleeping and sleeping arrangement: _4_________________________________________________
2. Water Supply
Drinking: Source: private public Potability: Specify if safe for drinking safe unsafe
Storage direct from pipe covered container with faucet large uncovered without faucet

Other (specify): ____________________________

3. Food storage & cooking facilities

Cooking facility: electric gas stove firewood

Sanitary condition ______________________________________________________________________________________________

Drainage facility : Open drainage blind drainage None

4. Waste disposal
a. Refuse and Garbage
- Container: Covered Open None

- Method of disposal : Hog feeding open dumping burial in pit composing Open burning

Garbage collection Other (specify) ______________________________________

b. Toilet
- Type none Overhung latrine open pit privy Closed pit privy Bored hole latrine

Pail system antipolo system water sealed latrine flush type Others

- Distance from the house_Within the house________________________________________________________________________________________

- Sanitary condition ______________________________________________________________________________________________

5. Domestic animal

Kind Number Where kept

Dog 1 Within the house

Cat 1 Within the house

6. Community in general
a. General sanitary condition: _Clean___________________________________________________________________________________________
b. Housing congestion __Not congested________________________________________________________________________________________________
c. Presence of breeding or resting sites of vectors of disease _None__________________________________________________________________
d. Recreational activity _None_________________________________________________________________________________________________
e. Availability of health care services _ Yes______________________________________________________________________________________
f. Distance of house from nearest health care facility __
10 minutes commute
________________________________________________________________________
g. Communication & transportation facilities available _Cellular Communication & Tricycle________________________________________________________________________
D. Health status of each family member
1. Medical history and nursing history

Family member Health status Family member Health status

Rosalino G. Lopez Hypertension N/A N/A

Juvima T. Lopez Tonsilitis N/A N/A

Kenzy T. Lopez No health issue N/A N/A

Ziatria T. Lopez Tonsilitis N/A N/A

2. Nutritional assessment
a. Anthropometric Data : Measure of Nutritional Status of Children

Anthropometric data (Children)

Name of the family member Weight Height Mid arm circumference

Anthropometric data (Adults)

Name of family member Weight Height Body mass index Waist circumference Waist hip ratio

Rosalino G. Lopez 65kg 5’6 23.1 - normal 93.98 cm 0.81 (mormal)

Juvima T. Lopez 55kg 5’4 20.8 - normal 71.12 cm 0. 76 (normal)
Kenzy T. Lopez 50kg 5’5 18.3 - normal 60.96 cm 0.79 (normal)
Rosalino G. Lopez 65kg 5’6 23.1 - normal 93.98 cm 0.81 (mormal)

b. Dietary History specifying quality and quantity of food intake per day
_They consume a healthy diet consisting of mostly rice with a combination of meat and vegetables. The family eats 3 times a day not including snacks._

c. Eating and feeding habits

They are fond of drinking soft drinks at least every other day.

_____________________________________________________________________________________________________________________________________________

d. Risk factor assessment indicating presence of major and contributing risk factors for specific lifestyle diseases

Lack of exercise and too much consumption of beverages such as

softdrinks.______________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________

e. Result of laboratory and other screening procedures supportive of assessment findings

N/A__________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________
__

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

1. Immunization status of family members

Name of child Immunization status Remarks

Rosalino G. Lopez V1 COVID-19 (Pfizer) - No booster

Juvima T. Lopez V1 COVID-19 (Pfizer) - No booster

Kenzy T. Lopez V1 COVID-19 (Pfizer) - No booster

Ziatria T. Lopez V1 COVID-19 (Pfizer) - No booster

2. Health lifestyle practices

__N/A_______________________________________________________________________________________________________________________________
 ____________________________________________________________________________________________________________________________________
__

3. Adequacy of
a. Rest and sleep Yes No
b. Exercise Yes Specify _______________________________________ No Why ______________________________

c. Use of protective measures Yes Specify _______________________________________ No Why ______________________________

d. Relaxation and other stress management activities Yes No

e. Opportunities which enhance feelings of self-worth, self-efficacy and sense of connectedness to self, others and a higher power essence of meaningfulness

Yes Specify ______________________________________ No

4. Use of promotive-preventive health services yes Specify ________________________ No Why _________________________

5. Use of Family Planning Method
a. Type
Natural

Abstinence Lactational Amenorrhea Method Basal Body Temperature Cervical Mucus Method
Symptothermal Method Standard Days Method Others: specify ____________________________________
Artificial
Hormonal
Oral Contraceptive Specify: Progesterone-Only Oral Contraceptive Low-Dose Combined Oral Contraceptive
Injectable [depot medroxyprogesterone acetate / Depo-Provera (DMPA)]
Norplant Implants
Barrier
Intrauterine Devices Condom Diaphragm Cervical Cap Other: specify___________________
Permanent
Tubal Ligation Vasectomy
None Are you willing to practice Family Planning Method? Yes No

What hinders you from practicing Family Planning Method? Biological Psychological Social Cultural
Religion Others, specify: ________________________

b. Who taught you about Family Planning Method?

 PHN/PHM BHW Friend Neighbor Print/Visual Ads Student Nurse Others; specify:_____________

c. Is your husband aware of your usage of Family Planning Method? Yes No

d. Do you know side effects of family planning method as a result of its use? Yes No
Changes in menstrual bleeding headache nausea weight gain moodiness
Delayed return of fertility dizziness acne in women nervousness change in appetite
Enlargement of ovaries/ovaran cyst hair loss breast tenderness others; specify: _____________________________

e. Do you have misconceptions about Family Planning Methods? Yes No

Some FP methods causes abortion Using contraceptives will render couples sterile Using contraceptive methods will result to loss of sexual desire
Others; specify: ____________________________________________________________