Final Requirements

Grp 1

Types of Family Nurse Contact

!. Definition, Advantages and disadvantages

● Clinical Visit

● Home Visit

● Group Conference

● Telephone Calls

● Written Communications

One related journal of your grp requirement and this is individualized.

Grp 2

All existing DOH Programs Related to Family Health , its coverage and importance.

One related journal of your grp requirement and this is individualized.

Grp 3

Ethical Considerations in Community Health Nursing

All Public Health Laws

One related journal of your grp requirement and this is individualized.

Grp 4

New Technologies Related to Public Health Electronic Information

Ehealth

Definition, Advantages and disadvantages

One related journal of your grp requirement and this is individualized.

LECTURE NOTES

Review of the Nursing Process

It is a scientific and systematized approach to health to care for individuals, families, and illness
prevention

It is the means by which nurses address the health needs and problems of their clients

It is a systematic, client-centered method or structuring the delivery of nursing care

Nursing process is a systematic, rational method of planning and providing individualized nursing
 care.

The purpose of nursing process

1. To identify client’s health status, actual or potential healthcare problems or need.

2. To establish plans to meet the identified needs and to deliver specific interventions to meet those
needs.
3. It provides a framework in which to practice nursing.

Characteristics of a nursing process:

4. Dynamic and cyclic

5. Patient centered
6. Goal directed
7. Open and Flexible
8. Problem Oriented
9. Planned
10. Universally accepted
11. Interpersonal and collaborative
12. Holistic
13. Systematic

Benefits of Nursing Process

14. Improves the quality of care that the client receives

15. Ensures a high level of client participation together with continuous evaluation designed to meet
the client’s unique needs
16. Enables nurses to use time and resources efficiently to both their own and their client’s benefit

The steps of the Nursing Process

17. Assessment
18. Nursing Diagnosis
19. Planning
20. Implementation
21. Evaluation

Nursing Assessment

The process of collecting, validating and recording data about a client’s health status.

It identifies patient’s strengths and limitations and is done continuously throughout the nursing process.

Nursing Diagnosis

In this phase the nurse sort, clusters and analyzes data.

These questions could serve as guidelines:

What are the actual and potential health problems for which the client needs nursing assistance?

What factors contributed to this problem?

Nursing diagnoses are identified through actual and potential health problems or responses to life
processes.

Types of nursing diagnosis:

It can be ACTUAL, POTENTIAL or WELLNESS DIAGNOSIS :

 ACTUAL – identifies an occurring health problem

POTENTIAL – identifies a high risk health problem

WELLNESS‐ focused on promoting or enhancing a patient’s level of wellness.

Planning

Planning expected outcomes to resolve or minimize the identified problems of the client.

In collaboration with the client, the nurse develops specific nursing intervention for each nursing
diagnosis.

Implementation

Also called intervention; putting the nursing care plan into action to achieve goals and outcomes

As you implement your plan, you continue to assess your patient’s responses and modify plan as needed.

The doing phase of the nursing process.

Care done should always be documented.

Evaluation

Assessing the client’s response to nursing interventions and then comparing the response to the goals or
outcome criteria written in the planning phase

FAMILY HEALTH

- The continuing ability to meet defined functions in interaction with other social, political, economic
and health system.
- Possessing the abilities and resources to accomplish family developmental tasks.

FAMILY HEALTH NURSING PROCESS

Family nursing process is the same, whether the focus is the famiily as patient or as environment. The
goal is to help the family reach and maintain its maximum health in a given situation.

PRINCIPLES OF FAMILY HEALTH CARE

1. Establishing good professional relationship with the family

2. Proper education and guidance should be provided
3. Gather all relevant information about family to identify problem and set priorities
4. Provide need-based support and services to the family to improve their health status
5. Health care services should be provided to the family irrespective of their age, sex, income,
religion, etc.
6. Duplication of health services should be avoided
7. Proper health message to be communicated to family in every contact

STEPS OF FAMILY HEALTH NURSING PROCES

1. ASSESSMENT

2. FORMULATION OF FAMILY NURSING PROBLEM/DIAGNOSIS

3. PLANNING

4. IMPLEMENTATION
5. EVALUATION PHASE

I. ASSESSMENT

Family Health Nursing Assessment

This involves a set of actions by which the nurse measures the status of the family as a client, its ability to
maintain itself as a system and functioning unit, and its ability to maintain wellness, prevent control and
resolve problems in order to achieve health and well-being among its members.
ASSESSMENT PHASE

- first major phase of nursing process in family health nursing

- Involves a set of action by which the nurse measures the status of the family as a client.
Its ability to maintain wellness , prevent, control or resolve problems in order to achieve
health and wellness among its members
- Data about present condition or status of the family are compared against the norms and
standards of personal , social, and environmental health, system integrity and ability to
resolve social problems.
- The norms and standards are derived from values, beliefs, principles, rules or expectation.
TWO MAJOR TYPES
22. FIRST LEVEL ASSESSMENT- a process whereby existing and potential health
conditions or problems of the family are determined (WS, HT, HD, SP or FC)
23. SECOND LEVEL ASSESSMENT- defines the nature or type of nursing problem that
family encounters in performing health task with respect to given health condition or
problem and etiology or barriers to the family’s assumption of the task
-
-

Data Collection Data Analysis Diagnosis

DATA COLLECTION

Two important things to ensure Effective and Efficient Data Collection in Family Nursing Practice:

Identify the types of kinds of data needed

Specify the methods of data gathering and necessary tools for gathering data

DATA ANALYSIS - sorting out and classifying or grouping data by type of nature.

ANALYZE DATA TO IDENTIFY NEEDS AND PROBLEMS

1. Criteria for analysis

2. Process for analysis

sorting of data

clustering of related cues

distinguishing relevant from irrelevant cues

identifying patterns

comparing patterns

interpreting results of comparison

making inferences and drawing conclusions

NURSING DIAGNOSIS

· The end result of the secondary level assessment and a set of family nursing problems for each
health condition or problem
· First major phase of nursing process in family health nursing
· It Involves a set of action by which the nurse measures the status of the family as a client. Its
ability to maintain wellness, prevent, control or resolve problems in order to achieve health and
wellness among its members

Data about present condition or status of the family are compared against the norms and
standards of personal, social, and environmental health, system integrity and ability to resolve social
problems.

The norms and standards are derived from values, beliefs, principles, rules or expectation.

TWO MAJOR TYPES

1. FIRST LEVEL ASSESSMENT- a process whereby existing and potential health conditions or
problems of the family are determined (WS, HT, HD, SP or FC)
2. SECOND LEVEL ASSESSMENT- defines the nature or type of nursing problem that family
encounters in performing health task with respect to given health condition or problem and
etiology or barriers to the family’s assumption of the task

DATA COLLECTION METHODS: SELECT APPROPRIATE METHOD

1. OBSERVATION

It is done through use of sensory capacities

The nurse gathers information about the family’s state of being and behavioral responses.

The family’s health status can be inferred from the signs /symptoms of problem areas within the
following areas:

a. communication and interaction patterns expected, used, and tolerated by family members

b. role perception / task assumption by each member including decision making patterns

c. conditions in the home and environment

Data gathered though this method have the advantage of being subjected to validation and reliability
testing by other observers.

2. PHYSICAL EXAMINATION

Health assessment of every member of the family, significant data about the health status of
individual members can be obtained through direct examination through IPPA, measurement of specific
body parts and reviewing the body systems.

Data gathered form substantive part of first level assessment which may indicate presence of health
deficits (illness state)
 3. INTERVIEW

Productivity of interview process depends upon the use effective communication techniques to elicit
needed response.

Problems encountered during interview:

a. How to ascertain where the client is in terms of perception of health condition or problems and the
patterns of coping utilized to resolve them

b. Tendency of community health worker to readily give out advice, health teachings or solutions

once they have identified the health condition or problems.

c. Provisions of models for phrasing interview questions utilization of deliberately chosen

communication

techniques for an adequate nursing assessment.

d. Confidence in the use of communication skills

e. Being familiar with and being competent in the use of type of question that aim to explore, validate,

clarify, offer feedback, encourage verbalization of thought and feelings.

What to collect during interview?

1. completing health history of each family member

Health history determines current health status based on significant:

a. PAST HEALTH HISTOI\RY e.g. developmental accomplishment, known illnesses, allergies,

restorative treatment, residence in endemic areas for certain diseases or sources of
communicable diseases.
b. FAMILY HISTORY e.g. genetic history in relation to health and illness.
c. SOCIAL HISTORY e.g. intra-personal and inter-personal factors affecting the family member
social adjustment or vulnerability to stress and crisis
2. Collecting data by personally asking significant family members or relatives questions regarding
health, family life experiences and home environment to generate data on what wellness
condition and health problem exist in the family (first level assessment) and the corresponding
nursing problems for each health condition or problem (2nd level assessment)
4. RECORDS REVIEW

Gather information through reviewing existing records and reports pertinent to the client

Individual clinical records of the family members, laboratory and diagnostic reports, immunization records
reports about home and environmental conditions

5. LABORATORY/ DIAGNOSTIC TEST

ANALYZE DATA TO IDENTIFY NEEDS AND PROBLEMS

24. CRITERIA FOR ANALYSIS:
25. PROCESS FOR ANALYSIS:
 SORTING OF DATA
 CLUSTERING OF RELATED CUES
 DISTINGUISHING RELEVANT FROM IRRELEVANT CUES
  IDENTIFYING PATTERNS
 COMPARING PATTERNS
 INTERPRETING RESULTS OF COMPARISON
 MAKING INFERENCES AND DRAWING CONCLUSIONS
Health Needs and Problems of the Family

- A situation which interferes with the promotion and / or maintenance of health

- It is a health problem when it stated as the family’s failure to perform adequately specific
health task to enhance the wellness state or manage a health problem

Tools Used in Family Assessment

Genogram

Ecomap

Initial Data Base

Family Assessment Guide

Genogram

Graphic representation of a family tree that displays detailed data on relationships among individuals

Goes beyond a traditional family tree by allowing the user to analyze hereditary patterns and
psychological factors that punctuate relationships

Information on disorders running in the family such as alcoholism, depression, diseases, alliances, and
living situations

Four Rules to build a Genogram:

1. The male parent is always at the left of the family and the female parent is always at the right of the
family.

2. In the case of ambiguity, assume a male-female or female-female relationship.

3. Spouse must always be closer to his/her first partner, then the second partner (if any), third partner,
and so on . . .

4. The oldest child is always at the left his family, the youngest child is always at the right his
family

FAMILY Health ASSESSMENT

INITIAL DATA BASE FOR FAMILY NURSING PRACTICE

I. Family Structure, characteristics and dynamics

II. Socio-economic and cultural characteristics

III. Home and environment

IV. Health status of each member

 V. Values and practices on health promotion/maintenance and disease prevention»

FAMILY STRUCTURE CHARACTERISTICS AND DYNAMIC

This includes the following:

a. composition and demographic data of the members of the family/household

b. their relationship to the head and place of residence

c. the type of family

d. family interaction/communication

e. Decision making patterns and dynamics

SOCIO-ECONOMIC AND CULTURAL CHARACTERISTICS

This includes the following:

a. Income and Expenses

b. Occupation, place of work, and income of each working member

c. Adequacy to meet basic necessities

d. Who makes decisions about money and how it is spent

e. Educational attainment of each family member

f. Ethnic background and religious affiliations

g. Significant others-roles they play in the family’s life

h. Relationship of the family to the larger community (membership in organizations)

C. Home and Environment

a. Housing:

Adequacy of living space

Sleeping arrangement

Food storage and cooking facilities

Water supply, toilet facilities

Presence of accident hazards

Garbage disposal

b. Kind of neighborhood

c. Social and Health Facilities

d. Communication and transportation facilities available

D. Health status of each member

a. Medical and nursing history indicating current and past significant illness or beliefs and practices
conductive to health and illness
 b. Nutritional and developmental status

c. Developmental assessment of infants, toddlers and preschoolers

d. Risk factor assessment

e. Physical assessment findings

f. Significant results of laboratory/diagnostic tests/screening procedures

g. Decision making on which or whom to seek advice regarding health

E. Values and Practice on health promotion/maintenance and disease prevention

a. Immunization status of the family members

b. Healthy lifestyle practices

c. Adequate of: rest/sleep, exercise/activities, use of protective measures, relaxation and stress

management

d. Utilization of health care facilities

FORMULATION OF FAMILY NURSING PROBLEM/DIAGNOSIS

Family profile and diagnosis

Family profile implies brief description of family structure and characteristics, family life cycle and
culture, socio economic conditions environmental factors health and medical history etc. Family health
diagnosis is the written statement of family health problems which are assessed from analysis of data
collected.

FIRST LEVEL ASSESSMENT

Name or Categories of Health Problems

1. Presence of Wellness Condition

Stated as Potential or Readiness

A clinical or nursing judgment about a client transition form a specific level of wellness or
capability to a higher level (NANDA, 2001)

Wellness Potential

It is a nursing judgement on wellness state or performance current competencies expression of

client’s desire

E.g. Potential for Enhanced Capability for parenting

2. Presence of Health Threats

Readiness for Enhanced Wellness State

It is a nursing judgement on wellness state or condition based on client’s current competencies or

performance, clinical data and explicit expression of desire to achieve higher level or function in a specific
area on health promotion and maintenance.

e.g Readiness for Enhanced Capability for Healthy Lifestyle

2. Presence of Health Threats

These are conditions that are conducive to disease and accident, or may result to failure to
maintain wellness or realize health potential.

E.g. Presence of Risk Factors of specific disease, accident hazards, poor home/ environmental
conditions, family history of hereditary disease, threat of cross infection, faulty eating habits, poor
environmental sanitation, unhealthy lifestyle/personal habits

3. Presence of Health Deficits

These are instances of failure in health maintenance

e.g. Illness states, diagnosed or undiagnosed by medical practitioner, disability, transient (aphasia or
temporary paralysis after a CVA), permanent (leg amputation secondary to diabetes, lameness from
polio)

4. Presence of Stress Points/Foreseeable Crisis

Anticipated periods of unusual demand on the individual or family in terms of adjustment/family resources.

e.g. marriage, pregnancy, parenthood, divorce, separation, loss of job, menopause death

SECOND LEVEL ASSESSMENT

Determining family’s ability to perform the Family Health Tasks on each health threat, health deficit,
foreseeable crisis on wellness potential.

Family Health Condition - a statement of family’s capabilities to maintain health and prevent illness

Ability to recognize signs of health and development

Ability to manage health and non-health crisis

Ability to provide health care to its members

Ability to provide home environment conducive to good health and personal development

Ability to utilize community resources for health care

FAMILY NURSING PROBLEM

Five Main Types:

Inability to recognize the presence on the condition/problem due to…

Inability to make decisions with respect to taking appropriate health action due to…

Inability to provide nursing care to the sick, disabled, or dependent member of the family due to…

Inability to provides a home environment which is conducive to health maintenance and personal

development due to…

Failure to utilize community resources for health due to…

Typology of Problems in Family Health (Second Level)

1. Inability to recognize the presence on the condition/problem due to:

1. Lack of inadequate knowledge

2. Denial about its existence or severity as result of fear of consequences of diagnosis of

problem

3. Attitude/philosophy in life which hinders recognition/acceptance of a problem

2. Inability to make decisions with respect to taking appropriate health action due to:

1. Failure to comprehend the nature/magnitude of the problem/condition

2. Low salience of the problem

3. Feeling of confusion, helpnesness, and/or resignation brought about by perceived

magnitude/severity of the situation or problem

4. Lack of knowledge as the alternative courses of action open to them

5. Inability to decide which action to take from among a list of altenatives

6. Conflicting opinions among family members

7. Lack of knowledge of community resources for care.

8. Fear of consequences action

9. Negative attitude towards the health condition or problems

10. Prolonged disease or disability progression which exhausts supportive capacity of family

members

11.Altered role performance

3. Inability to provide nursing care to the sick, disabled, or dependent member of the family due to

1. Lack of inadequate knowledge about the disease/health condition

2. Lack of inadequate knowledge about child development and care

3. Lack of inadequate knowledge about the extent and nature of nursing care rendered

4. Lack of knowledge as the alternative courses of action open to them

5. Lack of knowledge and skill in carrying out the necessary treatment/procedure/care

6. Inadequate Family resources

7. Negative attitude towards the sick, disabled, dependent, vulnerable or at-risk member

8. Philosophy in life in which negates/hinders in caring for the sick, disabled, dependent, vulnerable or at-
risk member

9. Member’s preoccupation with own concerns/interests

o 4. Inability to provides a home environment which is conducive to health maintenance

and personal development due to:

1. Inadequate family resources

2. Failure to see benefits of investment in home and environment improvement

3. Lack of knowledge of preventive measures

4. Lack of skill in carrying out measures to improve home environment

5. Ineffective communication patterns with the family

6. Lack of supportive relationship among family members

7. Negative attitude in life which is not conducive to health maintenance and personal development

8. Lack of competencies in relating to each other for mutual growth and maturation

5. Failure to utilize community resources for health due to:

1. Lack of knowledge of community resources for health

2. Failure to perceive the benefits health services

3. Lack of trust or confidence in the agency personnel

4. Previous unpleasant experience with health worker

5. Fear of consequences in action

6. Unavailability of required care

7. Inaccessibility of required care

8. Inadequate family resources

9. Feeling of alienation to the community.

10. Negative attitude in life which hinders effective utilization of community resources for health care.

III. PLANNING PHASE (FAMILY HEALTH AND NURSING CARE PLAN FORMULATION)

It is based on the analysis of diagnosed health problems and assessment of family’s ability to
resolve problems, establish priorities, setting goals and objectives, formulating family health nursing care
plan.

1. Analysis of diagnosed health problems and assessment of family’s ability to resolve problems
Family’s ability to resolve health problems can be assessed on the basis of:

a. ability to recognize the presence of health problems

b. ability to make decisions for taking appropriate health action

c. ability to provide desired care to the sick disabled

d. ability to maintain environment conducive to health promotion maintenance and personnel

development

e. ability to utilize community for health care

2. Establish priorities -means rank ordering of the health problems.

Four Criteria for Determining Priorities:

1. Nature of the condition or problem

These are categorized into wellness state/potential, health threat, health deficit or foreseeable crisis.
 The biggest weight is given to the wellness state or potential because of the premium on client’s
effort or desire to sustain/maintain high level of wellness.

The same weight is given to health deficit because of its sense of clinical urgency, which may
require immediate intervention.

Foreseeable crisis is given the least weight because culture linked variables/factors usually provide
our families with adequate support to cope with developmental or situational crisis.

2. Modifiability of the condition or problem

This refers to the probability of success in enhancing the wellness state improving the condition
minimizing, alleviating or totally eradicating the problem through intervention.

This is possibility of resolving the problem through nursing intervention which includes:

a. Current knowledge, technology and interventions to enhance the wellness state or manage the

problem.

b. Resources of the family

c. Resources of the nurse

d. Resources of the community

3. Preventive potential

This refers to the nature and magnitude of future problem that can be minimized or totally prevented if
interventions are done on the condition or problem under consideration.

It refers to the severity of the consequence of the problem and nature and magnitude of the
problem, interventions within available resources whether the problem can be prevented, eradicated or
controlled. These are:

1. Gravity or severity of the problem

It refers to the progress of the disease/problem indicating extent of damage on the patient/family;
also indicates prognosis, reversibility or modifiability of the problem. In general, the more severe the
problem is, the lower is the preventive potential of the problem.

2. Duration of the problem

This refers to the length of time the problem has existed. Generally speaking, duration of the
problem has a direct relationship to gravity; the nature of the problem is variable that may, however, alter
this relationship. Because of this relationship to gravity of the problem, duration has also a direct

relationship to preventive potential.

3. Current management-refers to the presence and appropriateness of intervention measures

instituted to enhance the wellness state or remedy the problem. The institution of appropriate intervention
increases condition’s preventive potential.

4. Exposure of any vulnerable or high-risk group-increases the preventive potential of condition or

problem

4. Salience
 This refers to the family’s perception and evaluation of the condition or problem in terms of
seriousness and urgency of attention needed or family readiness.

It refers to the family’s perception about the seriousness of the problem

Prioritizing Health Problems

Criteria Weight
Nature or conditions of the problem 1
Scale: wellness state (3)
health deficit (3)
health threat (2)
foreseeable crisis (1)
Modifiability of the problem
Scale: easily modifiable (2) 2
partially modifiable (1)
not modifiable (1)
Preventive potential
Scale: high (3) 1
moderate (2)
low (1)
Salience
Scale: needs immediate attention (2)
Does not need immediate attention (1) 1
Not perceived as a problem or condition
needing change (0)

SCORING :

1. Divide the score for each of the criteria

2. Divide the score by the highest possible score and multiply by the weight

3. Sum up the scores for all the criteria. The highest score is 5, equivalent to the total weight

26. Setting goals and objectives

Formulation of Goals and Objectives

F0rmulating Goals and Objective for Health Promotion and Maintenance

Goal is a general statement of the condition or the state to be brought about by specific course of action

Parts of a Nursing Objective

1. Time frame and condition

2. Terminal behavior or expected outcome

3. Criteria of acceptable performance

Example: After 2-3 months of the family will be able to maintain ability to recognize signs of health and
development

Objective refers to more specific statements of the desired results or outcomes of care

Example: At the end of 2-3 months the family will be able to:
Identify signs of health and development

Perform usual activities for health and development

They specify the criteria by which the degree of effectiveness of care is to be measured.

A cardinal principle in goal setting states that goal must be set jointly with the family. This ensures
family commitment to realization.

Basic to the establishment of mutually acceptable goals is the family’s recognition and acceptance of
existing health needs and problems.

Barriers to Joint Goal Setting Between the Nurse and the Family:

1. Failure on the part of the family to perceive the existence of the problem.
2. The family may realize the existence of the health condition or problem but is too busy at the
moment.
3. Sometimes the family perceives the existence of the problem but does not see it as serious
enough to warrant attention.
4. The family may perceive the presence of the problem and the need to take action. It may
however refuse to face and do something about the situation.

Reasons to this kind of behavior:

a.Fear of consequences of taking actions.

b.Respect for tradition.
c. Failure to perceive the benefits of action.
d.Failure to relate the proposed action to the family’s goals.
5. A big barrier to collaborative goal setting between the nurse and the family is the working
relationship.

Client focused goal- e.g. provide need based care to malnourished children

Nurse focused goal- e.g. after the nursing intervention the mother will be able to provide need based

care to malnourished children.

Factors influence the goal formulation

1.interpersonal relationship

2.families perception of the problem

3.families felt need

4.families perception about seriousness of the problem

5.families ability to face the reality

4. Family health nursing care plan

Prior to making of the FNCP, you need to review the following:

1. data analyzed

2. health problem prioritized

3. goals and objectives established

 4. nursing interventions decided

All of these components put together for the schematic representation of the care plan

It should be realistic, consistent with the goals, agreeable to the family, need active involvement of
the family members, review of plan and mobilization of resources.

FAMILY NURSING CARE PLAN

It is the blue print of the care that the nurse designs to systematically minimize or eliminate the identified
health and nursing problem through explicitly formulated outcomes of care (goals and objectives) and
deliberately chosen set of interventions, resources and evaluation criteria, standards, methods and tools.

Characteristics, which are Based on the Concept of Planning as a Process:

1. The nursing care plan focuses on actions which are designed to solve or minimize existing
problem. The plan is a blueprint for action. The coures of the plan are the approaches, strategies,
activities, methods and materials which the nurse hopes will improve the problem situation.
2. The nursing care plan is a product of a deliberate systematic process. The planning process is
characterized by logical analyses of data that are put together to arrive at rational decisions. The
interventions the nurse decides to implement are chosen from among alternatives after careful
analysis and weighing of available options.
3. The nursing care plan, as with all plans, relates to the future. It utilizes events in the past and
what is happening in the present to determine patterns. It also projects the future scenario if the
current situation is not corrected.
4. The nursing care plan is based upon identified health and nursing problems. The problems are
the starting points for the plan, and the foci of the objectives of care and intervention measures.
5. The nursing care plan is a means to an end, not an end in itself. The goal in planning is to deliver
the most appropriate care to the client by eliminating barriers to family health development.
6. Nursing care planning is a continuous process, not a one-shot-deal. The results of the evaluation
of the plan’s effectiveness trigger another cycle of the planning process until the health and
nursing problems are eliminated.

Steps in Making Family Nursing Care Plan

Formulating a family care plan involves the following steps:

1. The prioritized condition/s or problems

2. The goals and objectives of nursing care
3. The plan of interventions
4. The plan of evaluating care

Desirable Qualities of a Nursing Care Plan

1. It should be based on clear, explicit definition of the problem(s).

2. A good plan is realistic.
3. The nursing care plan is prepared jointly with the family.
4. The nursing care plan is most useful in written form.

Importance of Planning Care

1. They individualize care to clients.

2. The nursing care plan helps in setting priorities by providing information about the client as well
as the nature of his problem.
 3. The nursing care plan promotes systematic communication among those involve in the health
care effort.
4. Continuity of care is facilitated through the use of nursing care plans.

Gaps and duplications in the services provided are minimized, if not totally eliminated.

5. Nursing care plans facilitate the coordination of care by making known to other members of the
health team what the nurse is doing.

Steps in Developing Care Plan

The assessment phase of the nursing process generates the health and nursing problems which
become the bases for the development of nursing care plan. The planning phase takes off from there.

1. The prioritized conditions of the problem

2. Goals and objectives of the nursing care
3. The plan of interventions
4. The plan for evaluating care

This is a schematic presentation of the nursing care plan process. It starts with a list of health
condition or problems prioritized according to the nature, modifiability, preventive potential and salience.

The prioritized health condition or problems and their corresponding nursing problems become
the basis for the next step which is the formulation of goals and objectives of nursing care. The goals and
objectives specify the expected health/clinical outcomes, family response/s, behavior of competency
outcomes.

Parts of a FNCP

1. Assessment

2.Family Nursing Diagnosis

3.Planning

4. Interventions

5. Rationale

6.Evaluation

Sample of a FNCP
IV. IMPLEMENTATION (ACTION PHASE/FAMILY HEALTH AND NURSING CARE PLAN
IMPLEMENTATION)

This is the doing phase of the nursing process that is putting into action planned care to be rendered to
solve the problem.

STEPS

1. review of plan and mobilization of resources

2. implementation

3. documentation

During the implementation phase the following should be considered:

a. help family to understand the situation

b. relate families exiting socio economic condition to health problem

c. motivate family to implement actions

d. utilize the equipment and supplies

e. help family to utilize the community resources

In selecting appropriate nursing intervention, there are Three types:

1. Supplemental -direct nursing care services by the CHN to the sick

2. Developmental -CHN prepares some family members to give similar care in her absence.

3. Facilitative -CHN improves family’s physical facilities either by modifying the existing

facilities or by developing new facilities or removing the barrier.

CHN has to consider the available resource while planning intervention.

CHN has to consider the available resource while planning intervention. They are:

1. Family resources -physical intellectual capabilities, physical facilities, finance etc.

2. Community resources -health programs, community organization etc.

3. Nurse resources -her competency, time, support etc.

For the nurse to undertake implementation there are three types of nursing function namely:

1. Independent nursing function

2. Dependent Nursing function

3. Collaborative or interdependent nursing function

Focus on Interventions- to help the family performs Health Tasks:

1. Help the family recognize the problem

Increasing the family’s knowledge on the nature, magnitude and cause of the problem.

Helping the family see the implications of the situation or the consequences of the condition.

Relating the health needs to the goals of the family.

Encouraging positive or wholesome emotional attitude toward the problem by affirming the family’s
capabilities/qualities/resources and providing information on available actions.

2. Guide the family on how to decide on appropriate health actions to take.

Identifying or exploring with the family courses of action available and the resources needed for each.

Discussing the consequences of action available.

Analyzing with the family of the consequences of inaction.

3. Develop the family’s ability and commitment to provide nursing care to each member.

Contracting-is a creative intervention that can maximize the opportunities to develop the ability and
commitment of the family to provide nursing care to its members.

4. Enhance the capability of the family to provide home environment conducive to health
maintenance and personal development.

The family can be taught specific competencies to ensure such home environment through environmental
manipulation or management to minimize or eliminate health threats or risks or to install facilities of
nursing care.

5. Facilitate the family’s capability to utilize community resources for health care.

Involves maximum use of available resources through the coordination, collaboration and teamwork
provided by effective referral system.

Implementing the Nursing Care Plan

During this phase, the nurse encounters the realities in family nursing practice that motivates her to try out
creative innovations or overwhelm her to frustration or inaction. A dynamic attitude on personal and
professional development is, therefore, necessary if she has to face up challenges of nursing practice.

Implementation is a phenomenological experience. Actual situations and problems are identified as the
basis of implementation.

Meeting the challenges of this phase is the essence of family nursing practice. During this phase, the
nurse experiences with the family a lived meaningful world of mutual, dynamic interchange of meanings,
concerns, perceptions, biases, emotions and skills.

Just as the self aims to achieve body-mind integration to achieve wholeness in the experience of
“being” and “becoming” in expert caring. Unless there is such a dynamic and active involvement between
the nurse and the family in understanding and making choices in this meaningful world of coping,
aspirations, emotions and skills the nurse can’t hope to achieve expert caring.

Expert Caring: Methods and Possibilities

Expert caring in the implementation phase is demonstrated when the nurse carries out interventions
based on the family’s understanding of the lived experience of coping and being in the world.

Expert caring is developing the capability of the family for “engage care” through the nurses skilled
practice, the family learns to choose and carry out the best possibilities of caring given the meanings,
concerns, emotions and resources (skills & equipment) as experienced in the situation.

By being experts in caring, nurses must takeover and transform the notions of expertise. Expert caring
has nothing to do with possessing privileged information that increases one’s control and domination of
another. Rather, expert caring unleashes the possibilities inherent in the self and the situation. Expert
caring liberates and facilitates in such a way that the one caring is enriched in the process.

Reasons that may bring about inappropriate choices of nursing intervention:

1. The tendency of the nurse to use “patterned” or “canned” approaches in working with families

2. Inadequate appreciation of social or cultural factors or realties

3. Inadequate or limited repertoire of intervention techniques and skills in the face of complicated
behavioral problems in family life.
 Factors/conditions that may bring non-compliance or non-acceptance of the family to take actions on
its each health problems:

The family’s information may be inadequate or inaccurate.

The family has the necessary information but fails to relate them to the problem condition.

The family is not willing to face the reality of the situation.

The members may not be willing to oppose family, peer or social pressure.

There may be adherence to patterned behavior.

There is failure to relate the needed actions to family goalsThe lack of confidence in the action proposed

IV. EVALUATION PHASE (FAMILY HEALTH AND NURSING CARE EVALUATION)

Evaluation - specifies how the health care provider will determine the achievement of the outcome of the

desire

Evaluation – reflection off objectives

Standards - desired achievable level of performance against which actual practice is compared, it serves
as a guide in the formulation of objective

It is the assessment of the client’s response to nursing interventions and then comparing that
response to predetermined standards or outcome criteria.

Evaluation is defined as the judgment of the effectiveness of nursing care to meet client goals; in
this phase nurses compare the client behavioral responses with predetermined client goals and outcome
criteria. –

Evaluation, the final step of the nursing process, is crucial to determine whether, after application
of the nursing process, the client’s condition or well-being improves. The nurse applies all that is known
about a client and the client’s condition, as well as experience with previous clients, to evaluate whether
nursing care was effective. The nurse conducts evaluation measures to determine if expected outcomes
are met, not the nursing interventions.

The expected outcomes are the standards against which the nurse judges if goals have been met
and thus if care is successful. Providing health care in a timely, competent, and cost-effective manner is
complex and challenging. The evaluation process will determine the effectiveness of care, make
necessary modifications, and to continuously ensure favorable client outcomes.

It determines the extent of services rendered to the family. It accounts the number of visits, clinic
visits, no. of immunization completed, reduction in mortality and morbidity.

Activities in Evaluation Phase

a. Identifying criteria and standards

Nurses evaluate the nursing care by knowing what to look for. A client’s goal and expected
outcome give the objective criteria needed in a client’s response to care.

b. Collecting evaluative data

Evaluating a client’s response to nursing care requires the use of evaluative measures. (e.g.
Skills and Techniques- like doing Physical Assessment, observation of the client’s performance,
discussions of the client’s feelings etc.)and decision about the client’s status and progress.
 c. Interpreting and summarizing findings

Using evidence, the nurse makes judgement about the client’s condition. To develop

clinical judgement, match the result of evaluative measures with expected outcomes to determine if the
client’s status is improving or not.

Examine the goal attainment to determine the exact client behavior or response.

Assess the client for the presence of that behavior or response.

Compare the established outcome criteria with the behavior or response.

Judge the degree of agreement between outcome criteria and the behavior or response.

If there is no agreement between outcome criteria and response or behavior, identify the barriers.

d. Documenting findings

Documentation and reporting are important parts of evaluation like written nursing process notes,
assessment flow sheets and endorsement among nurses regarding the client’s progress towards meeting
expected outcome.

e. Care Plans Revision

Evaluate expected outcomes and determine the goals of care have been met.

Then decide the need to adjust to the plan of care. If goal met successfully discontinue that
portion of care plan.

Components of Evaluation

1. Collecting the data related to the desired outcomes

2. Comparing the data with outcomes
3. Relating nursing activities to outcomes
4. Drawing conclusion about problem status
5. Continuing, modifying, or terminating the nursing care plan

Collecting the data

The nurse collects the data so that conclusion can be drawn about whether goals have been met. It is
usually necessary to collect both subjective & objective data. Data must be recorded concisely and
accurately to facilitate the next part of the evaluating process.

Comparing the data with outcomes

If the first part of the evaluation process has been carried out effectively , it is relatively simple to
determine whether a desired outcome has been met. Both the nurse and client play an active role in
comparing the client’s actual responses with the desired outcomes.

Relating nursing activities to outcomes

The third aspect of the evaluating process is whether the nursing activities had any relation to the
outcome.

Drawing conclusion about problem status

The nurse uses the judgement about goal achievement to determine whether the care plan was effective
in resolving, reducing or preventing client problems.
 When goals have been met the nurse can draw one of the following conclusions about the status of
the client’s problem.

The actual problem stated in the nursing diagnosis has been resolved, or the potential problem is being
prevented and the risk factors no longer exist. In these instances, the nurse documents that the goals
have been met and discontinues the care for the problem.

The potential problem is being prevented, but the risk factors are still present. In this case, the nurse
keeps the problem on the care plan.

The actual problem still exists even though some goals are being met. In this case the nursing
interventions must be continued.

Continuing, modifying, or terminating the nursing care plan

After drawing a conclusion about the status of the client’s problems, the nurse modifies the care plan as
indicated. Whether or not goals were met, a number of decisions need to be made about continuing,
modifying or terminating nursing care for each problem.

Before making individual modifications, the nurse must first determine why the plan as a whole was not
completely effective. This requires a review of the entire plan.

Factors Affecting Goal Attainment

1. Family Members
2. Health Team Members
3. Nurse

Evaluation Skill Required for Nurses

1. Nurses must know the hospital policies, procedure and protocols of interventions and recording.
2. Nurses must have up to date knowledge and information of many subject.
3. Nurses must have intellectual and technical skill to monitor the effectiveness of nursing
interventions.
4. Nurses must have knowledge and skill of collecting subjective data and objective data.

Purposes of evaluation

1. Determine client’s behavioral response to nursing interventions.

2. Compare the client’s response with predetermined outcome criteria.
3. Appraise the extent to which client’s goals were attained.
4. Assess the collaboration of client and health care team members.
5. Identify the errors in the plan of care.
6. Monitor the quality of nursing care.

Additional CHN Lectures

1. ENVIRONMENTAL SANITATION
- refers to all factors available in the environment affecting the health of the individual or
population
 - regulated by PD 856: Comprehensive Sanitation Code of the Philippines
ENVIRONMENTAL HEALTH SERVICE (EHS) OF DOH IS RESPONSIBLE FOR
2. Promotion of healthy environmental conditions & prevention of environmental related
diseases through appropriate sanitation strategies
3. Promotion & implementation of sanitation programs through the Department of Health
Field Health Units
4. Conceptualization of new programs/projects to contend with emerging environmentally
related health problems
COMPONENTS:
5. Water Supply Sanitation Program
6. Proper Excreta and Sewage Disposal Program
7. Insect and Rodent Control
8. Food and Sanitation Program
9. Hospital Waste Management Program
1. WATER SUPPLY SANITATION PROGRAM
- Potable
- Free from any particles that might cause illness to an individual
Ways to make Water Potable:
10. Boiling: minimum of 3 minutes to maximum of 10 minutes for drinking
11. Sterilization: 30 minutes after the water starts to boil
12. Filtration: makes use of filter paper or cotton cloth to separate solid particle from liquid
if water comes from river
13. Coagulation/Flocculation: uses aluminum crystal (tawas) that collects or absorbs
particles from liquid part & becomes slimy
- In 1 gallon of water, drop tawas (the size of magic cubes) & allow to stand for 6-8 hours
- Initially, water appears to be cloudy then after 6-8 hours of standing, the water becomes
clear
14. Chlorination: uses 100% pure concentrated chlorine bought from botika or given free by
health centers
- To prepare stock solution (SS): in 1 liter drinking water, add 1 tablespoon of
concentrated chlorine which is potent for 3-4 months
- To prepare the chlorinated water: in 2 ½ gallons of drinking water (10,000 ml=10 liters),
add 1 tablespoon from the prepared stock solution & let it stand for 30 minutes to react
with water
15. Fluoridation: adding fluoride to prevent dental caries (primary significance) & whitens
enamel of teeth ( 2nd significance)
 16. Aeration: exposing drinking water in air to strengthen taste within 24 hours which is
usually used in uphill areas where there’s less or no pollution
3 Types of Approved Water Supply and Facilities
a. Level I
- Point Source
- A protected well or a developed spring with an outlet but without a distribution system
for rural areas where houses are thinly scattered.
b. Level II
- Communal faucet system or stand posts
- A system composed of a source, a reservoir, a piped distribution network and communal
faucets, located at not more than 25 meters from the farthest house in rural areas
where houses are clustered densely.
c. Level III
- Waterworks system or individual house connections
- A system with a source, a reservoir, a piped distributor network and household taps that
is suited for densely populated urban areas.
2. PROPER EXCRETA AND SEWAGE DISPOSAL SYSTEM
3 Types of Approved Toilet Facilities
a. Level 1
- Non-water carriage toilet facility:
1. Pit latrines
2. Reed Odorless Earth Closet
3. Bored-hole
4. Compost
- Toilets requiring small amount of water to wash waste into receiving space
1. Pour flush
2. Aqua privies
- Pit latrines
a. most commonly observed in rural area
b. has three components: the pit, a squatting plate and the super-structure
c. types of pit include
c.1. “Antipolo type”, a pit type of toilet provided with concrete floor and an elevated seat with a
cover
c.2. Ventilated Improved Pit or VIP, pit with a vent pipe
c.3. Reed Odorless Earth Closet or ROEC, a pit completely displaced from the superstructure and
connected to the squatting plate by a curved chute.
- Bored Hole Latrine
d. consists of relatively deep holes bored into the earth by mechanical or manual earth-
boring equipment
e. holes are about 10-18 inches in diameter and usually 15-35 feet deep. The hole is
provided to facilitate squatting.
f. Two types of bored-hole latrines are:
c.1. Wet Type - when the hole penetrates ground water table or other strata.
c.2. Dry Type - when he hole does not reach ground water table; fills up at a faster rate then
than the wet type.
b. Level 2
- On site toilet facilities of the water carriage type with water sealed and flushed type
with septic vault/tank disposal facilities.
c. Level 3
- Water carriage types of toilet facilities connected to septic tanks an/or to sewerage
system to treatment plant.
Things to Consider in Constructing a Toilet Facility:
17. At least 25 meters away from water sources at a lower elevation
18. It should be within your financial capability
19. It should be approved by the local health authorities
Care and Maintenance of Toilet Facility:
20. Water must be provided at all times.
21. Use toilet paper
22. Use lysol once a month for odor removal
23. Clean the bowl by muriatic acid to remove the stains.
24. Avoid depositing solid objects on the bowl to prevent clogging
25. Always check your toilet if it’s clean
26. Use plunger when clogging occurs. Don’t use sticks or rods to avoid the breakage of the
trap or the bowl.
3. PROPER SOLID WASTE MANAGEMENT
- refers to satisfactory methods of storage, collection and final disposal of solid wastes
Sources of Solid Waste:
27. Household Waste - these are wastes generated in or discharged from household
including shops but excluding commercial activities
 28. Commercial Waste - restaurants, stationery shops, grocery shops or any commercial
activity are the main sources of commercial waste.
29. Market Waste - only refers to waste generated in or discharged from markets both for
whole sale and retailing
30. Institutional Waste - these are wastes generated in government, state enterprise and
private firm office.
31. Street Sweeping Waste - these are wastes generated by the street sweeping cleansing
service.
32. River Waste - includes all the wastes generated by the river and creek cleansing
33. Medical Waste - these are wastes generated in hospitals.
Components of Solid Waste
34. Garbage refers to left over vegetable, animal and fish material from kitchen and food
establishments. These materials have the tendency to decay giving off foul odors and
sometimes serve as food for flies and rats.

35. Rubbish refers to waste materials such as bottles, broken glass, tin can, waste papers,
discarded textile materials, porcelain wares, pieces of metal and other wrapping
materials.
36. Ashes are left over from burning of wood and coal. Ashes may become a nuisance
because of the dust associated with them.
37. Stable manure is animal manure collected from stables.
38. Dead animals like dead dogs, cats, rats, pigs, and chickens that are killed by cars and
trucks on streets and public highways. They include small and large animals that died
from disease.
39. Street sweeping includes dust, manure, leaves, cigarette butts, waste papers and other
materials that are swept from streets.
40. Night soil is human waste normally wrapped and thrown into sidewalks and streets. This
also includes human waste from pail system of toilets.
41. Yard cuttings includes leaves, branches, grass and other
Sanitary Ways of Treating Garbage:
42. Segregation-separating biodegradable from non biodegradable
43. Collection-adherence to the proper collection time
Ways of Disposal
1. Household
○ Burial
► Deposited in 1m x 1m deep pits covered with
soil, located 25 m. away from water supply
○ Open burning
o Animal feeding
o Composting
o Grinding and disposal sewer
2. Community
○ Sanitary landfill or controlled tipping
► Excavation of soil deposition of refuse and compacting
with a solid cover of 2 feet
○ Incineration
Ecological Solid Waste Management: RA 9003- the use of incinerator approved in 2000
but was implemented in 2003 because of lack of funding to purchase
Hospital Waste Management
RA 4226-Hospital Licensure Act monitors the hospital license & proper management of
wastes as well as renewal of license to operate.
GOAL:
To prevent the risk of contraction contracting nosocomial infection from type disposal of
infectious, pathological and other wastes from hospital
COLOR CODING OF BIN TO KEEP WASTE:
Green : wet waste
Black : dry waste
Yellow: infectious/pathological waste like blood, sputum, urine, feces & gauze
Orange: toxic/hazardous waste

FOOD SANITATION PROGRAM POLICIES:

44. Food establishment are subject to inspection (approved of all food sources containers
and transport vehicles)
45. Comply with sanitary permit requirement
46. Comply with updated health certificates for food handlers, helpers, cooks
 47. All ambulant vendors must submit a health certificate to determine present of intestinal
parasite and bacterial infection
3 POINTS OF CONTAMINATION
48. Place of production processing and source of supply
49. Transportation and storage
50. Retail and distribution points
FIELD HEALTH SERVICE INFORMATION SYSTEM (FHSIS)
- It is a network of information
- It is intended to address the short term needs of DOH and LGU staff with managerial or
supervisory functions in facilities and program areas.
- It monitors health service delivery nationwide.
OBJECTIVES OF FHSIS
51. To provide summary data on health service delivery and selected program
accomplishment indicators at the barangay, municipality/ city, and district, provincial,
regional and national levels.
52. To provide data which when combined with data from other sources, can be used for
program monitoring and evaluation purposes.
53. To provide a standardized, facility-level data base that can be accessed for more in-
depth studies.
54. To minimize the recording and reporting burden at the service delivery level in order to
allow more time for patient care and promote activities.
IMPORTANCE OF FHSIS
55. Helps local government determine public health priorities.
56. Basis for monitoring and evaluating health program implementation.
57. Basis for planning, budgeting, logistics and decision making at all levels.
58. Source of data to detect unusual occurrence of a disease.
59. Needed to monitor health status of the community.
60. Helps midwives in following up clients.
61. Documentation of RHM/PHN day to day activities.
COMPONENTS OF FHSIS
1. Individual Treatment Record (ITR)
2. Target Client List (TCL)
3. Summary Table
4. The Monthly Consolidation Table (MCT)
INDIVIDUAL TREATMENT RECORD (ITR)
- The fundamental building block or foundation of the Field Health Service Information
System is the INDIVIDUAL TREATMENT RECORD.
- This is a document, form or piece of paper upon which is recorded the date, name,
address of patient, presenting symptoms or complaint of the patient on consultation
and the diagnosis (if available), treatment and date of treatment.
TARGET CLIENT LIST (TCL)
- The Target Client Lists constitute the second “building block” of the FHSIS and are
intended to serve several purposes
1. First is to plan and carry out patient care and service delivery. Such lists will be of
considerable value to midwives/nurses in monitoring service delivery to clients in
general and in particular to groups of patients identified as “targets” or “eligibles” for
one or another program of the Department
2. The second purpose of Target Client Lists is to facilitate the monitoring and supervision
of service delivery activities.
3. The third purpose is to report services delivered.
4. The fourth purpose of the Target Client Lists is to provide a clinic-level data base which
can be accessed for further studies
TARGET CLIENT LISTS TO BE MAINTAINED IN THE FHSIS
1. Target Client List for Prenatal Care
2. Target Client List for Post-Partum Care
3. Target Client List of Under 1 Year Old Children
4. Target Client List for Family Planning
5. Target Client List for Sick Children
6. NTP TB Register
7. National Leprosy Control Program Form 2-Central Registration
Form
SUMMARY TABLE
- The Summary Tables is a form with 12-month columns retained at the facility (BHS)
where the midwife records monthly all relevant data. The Summary Table is composed
of:
62. Health Program Accomplishment this can serve as proof of accomplishments to show
LGU officials whenever they visit the facility.
 63. Morbidity Diseases the source of ten leading causes of morbidity for the
municipality/city. This summary table will help the nurse and MHO to get the monthly
trend of diseases
THE MONTHLY CONSOLIDATION TABLE (MCT)
- The Consolidation Table is an essential form in the FHSIS where the nurse at the RHU
records the reported data per indicator by each BHS or midwife.
- This is the source document of the nurse for the Quarterly Form.
- The Consolidation Table shall serve as the Output Table of the RHU as it already contains
listing of BHS per indicator.
FHSIS REPORTING
- These are summary data that are transmitted or submitted on a monthly, quarterly and
on annual basis to higher level. The source of data for this component is dependent on
the records.
THE MONTHLY FORM
64. Program Report (M1)
- The Monthly Form contains selected indicators categorized as maternal care, child care,
family planning and disease control.
65. Morbidity Report (M2)
- The Monthly Morbidity Disease Report contains a list of all diseases by age and sex. The
Midwife uses the form for the monthly consolidation report of Morbidity Diseases and is
submitted to the PHN for quarterly consolidation.
THE QUARTERLY FORM
66. Program Report (Q1)
- The Quarterly Form is the municipality/city health report and contains the three-month
total of indicators categorized as maternal care, family planning, child care, dental
health and disease control
67. Morbidity Report (Q2)
- The PHN uses the form for the Quarterly Consolidation Report of Morbidity Diseases to
consolidate the Monthly Morbidity Diseases taken from the Summary Table.
THE ANNUAL FORMS (A-BHS, A1, A2 & A3)
- ABHS Form is the report of midwife which contains data on demographic,
environmental and natality.
- The report of nurse at the RHU/MHC are the Annual Form 1 which is the report on vital
statistics: demographic, environmental, natality and mortality.
- Annual Form 2 is the report that lists all diseases and their occurrence in the
municipality/city. The report is broken down by age and sex.
 - Annual Form 3 is the report of all deaths occurred in the municipality/city. The report is
also broken down by age and sex.
FLOW OF REPORTSON RECORDING
OFFICE PERSON RECORDING FORMS FREQUENCY SCHEDULE OF
TOOLS SUBMISION
BHS Midwife - ITR Monthly Form Monthly Every 2nd week of
- TCL (M1 & M2) the
- ST succeeding month

A-BHS Form Every 2nd week of

Annually January
RHU PHN - ST Quarterly Quarterly Every 3rd week of
- MCT Form the 1st
(Q1 & Q2) month of
succeeding
quarter

Every 3rd week of

Annual Forms January
- A1
- A2
- A3