Appendix A

FAMILY ASSESSMENT FORM

Family Name: Mohamed A. Phone:077000000

Address: Irbid

I. Family Members (10 marks)

A. Persons Living in Household: Household members (names, ages, sex, relationship to

head of household, education, occupation)

Name Age Sex Relationship Education Occupation Marital Status

to head of
household
Mohamed 35 Male Father Secondary Militarily M

Mona 31 Female Mother Secondary Housewife M

Afaf 10 Female Daughter Elementary Student S

Ali 8 Male son Elementary Student S

Leen 5 Female Daughter Pre-school Student S

B. Significant Family Members or others Living outside Household

Name Age Sex Relationship Education Occupation Location Frequency/

to head of duration of contact
household
Ali 65 Male Grandfather Elementary Retired Irbid Weekly
II. Family Characteristics (10 marks)

A. Family Structure and Functions:

1. Structure:

a. Type: Nuclear

b. Role Differentiation Based on Age and Sex

Each one in the family has his or her function depends on their ag.

Mohamed: The Father who works and gets money to support, protect his

family and take-care of them. He in military and visits his family weekly for that he gives most

of daily decision to his wife.

Mona: The mother /Housewife her role to take care of her family

(cook, clean and teach her children) and help her husband to take decision.

Afaf: Student ;(the eldest daughter) her role to help her mother at

housework and study.

Ali: Student; do his homework and support his family if mother needs help

while the father at work.

Leen: Student. the youngest daughter, student, do her homework by

mother help.

Age and Sex appropriate: Yes

No, specify deviations from norms: Each member follow family norm enforcing
 2. Functions (roles/responsibilities; distribution of power and authority):

Function Family Institution Social Shared

Institution Function
(specify) (specify
Institution)
Economic production Father only one who works No No

and gets income .(not enough)

Economic consumption Because very low income No No

almost they don’t get their

needs.

Sexual function Healthy sexual relationship No No

Reproductive function Satisfied and happy for their No No

family member

Nutrient Socialization The mother ;she cooks ,make No No

(primary care of young children) shopping and get her family

food needs.

Education Father (Mohamed)completed No No

only high school.

Mother (Mona) completed High

school

Daughter (Afaf):

Elementary school student

Son:(Ali):

Elementary school student

 Daughter:((Leen):

Pre-school student.

Emotional support The mother is emotional No No

support to all her family.

Status Conferral (place in family as determined by Father: support and protection. No No

family) Mother: help and emotional

support.

Religious Islam ;they follow the Islam No No

roles (Praying and fasting in

Ramadan ).

Recreation From time to time go trip in No No

Fridays.

Social Control (maintain internal order) Father and mother are control . No No

Health No routine health checkup. No No

They have medical insurance.

Father has Diabetic on

medication .
B. Family Cohesion:

- Degree of emotional support given to other members:

Listen. Simply giving space to talk, and listening to how they're feeling, offer

reassurance, encouraging and caring, making them feel valued and important.

- Degree of individual autonomy:

Parents helps children learn and respect about family values, social norms, and

essential rules.

C. Family Adaptation:

Family adaptation is the process by which parents and other family members

adjust, accommodate, or transform their roles and responsibilities to better meet current

demands.

Ability to adapt to change: They encourage their children to help think of new

things can do and adapt to the change to survive in their community.

Coping strategies used: Mother try to be social and be coping by using spiritual

support (praying) because she responsible to take care her family while her husband at his work.

their children playing or watching TV.

 Conflict management skills: Conflict in reality it may be in any house but they

try to cooperate with each other to solve it in proper way in healthy environment.

How decisions are made: In urgent decision the mother make the decision but

The father with mother help made a decision in daily base. Father nature of work to be at home

weekly most of urgent decision rely on (Mona)/mother.

Discipline (type, source, consistency, appropriateness): As Muslim family follow

a middle religious roles and Jordanian culture to raise their children.

D. Family interaction:

Family Member Role observed/ Role perception Role Making (suitability to Congruence

Reported (by individual) individual) (with family

expectations)

Mohamed As a father his Father think His role over for him; he Family respect

Father responsibility for his role only to spends days away from his and satisfied

income and gain and spend family at work. but he is from their

decision maker money for his happy in military. father.

family .and understand

protect his nature of his

family from work.

outside .
 Mona As a mother her Mother Her role suitable to her and Family

Mother role believe that she is happy expected too

responsibility to cooking much from her

take-care her ,prepare the as she is main

family and do all food and teach person to

house work. her children is support them.

her role .

Afaf Student , help She said Suitable Happy and

Daughter her mother “Study hard satisfied .

beside her study. and pass school

” .

Ali Student ,his He think “help Suitable Family

Son responsibility his mother at expectation too

support and help home and much and

his parents support beside happy.

beside his school study hard

while his father

away ”

Leen Student ,her Study and do Suitable Happy and

Daughter responsibility to her homework. satisfied

study
E. Role conflict and/or Negotiation (Specify): No conflict among the family. The mother seeks

good to her children and be advocate.

F. Social integration:

- Literacy (ability to read and write): All family able to read and write. Parents

encourage their children to study hard.

- Describe degree of social connection with neighbors, friends, other families,

religious and social affiliations (external sources of emotional, social, and

financial support and medical care):

Family is connected with neighbors most of their neighbors are from their

relative, the mother very sociable. She used to share her relatives and neighbors

with all occasions.

- Knowledge of external resources: Available

- Availability of external resources: Available

III. Developmental Assessment (10 marks)

a. Developmental stage of family:

Children are all in good health, they have good gap between each child youngest 5

years old and eldest daughter 10 years old.

b. Recent additions or loss of members:

No recent loss of member.

c. Individual family members' developmental tasks met? Tasks that need to be

accomplished:

Mother, son and daughters met their role. The father /Mohamed his role very limited as

he not involves with his family in daily basis due to his job.

c. Effects of individual development on family health:

None of the family member their health effected, the father has Diabetic.
 d. Major normative transitions and non-normative life events (changes) occurring

now:

No major normative and non-normative change occur.

e. Family's perception of current normative and non-normative life events:

Nothing.

IV. Socioeconomic and Cultural Factors: (10 marks)

A. Family income:

Amount: 450JD

Source: From father’s work

Income enough to meet expenses: Yes

B. Cultural/Nationality Background:

Jordanian family, Muslim & Arabic culture.

C. Religious Affiliation and Commitment:

Family is Muslim they pray and fast. They are following Islamic rules.
D. Family Life Style and Value System:

i. Life Style:

Coping and operating patterns:

Parents in different situations show different psychological function to cope and face

financial stress issues and has the coping strategy to solve it.

Accommodation of family and individual Needs:

They have their own house. The house with three rooms, living room and kitchen and 2

bathrooms. The house suitable and met the family needs.

ii. Value System:

Human Relationships: As a family they respect other culture and value.

Family as a unit: every one parents and children support each other they are cooperative.

Parenting: The father and mother have good relationship.

Education: The family aim to their children to have university degree.

Material Resources: Depends on their income some resources can’t offered.

Values, attitudes, and beliefs about:

- Spirituality: It’s important to their life.

 - Rituals (holidays, celebrations): The family has their own rituals by

celebrating in Eids and holidays with their relative. Usual the father took his family to make Eid

Prayer.

- Customs: The father in special occasions wears Jordanian customs. And the

mother and children wear decent clothe.

- Health: Father has Diabetic on medication but not follow his doctor instruction

on other hand his wife and his children follow healthy style.

- Folk diseases, folk medicine, cultural healers:

Mother believes of folk medicine and always said she took herbs before visited

the doctors.

- Care of ill family members: They take care of each other during sickness

- Role of spiritual leader in care of an ill family member:

They believe in God to cure their sickness but depends on level of sickness,

most of their time used to go to government hospital.

Importance of these identified values to the family: Very important for them. Values give

family an outlook on life and influence their behavior and parenting style.

Are there any value conflicts evident within the family itself? No value conflicts

evidence within the family.

How do these family values affect the family’s health status or level of functioning:
Having a positive family environment support good mental and emotional health, which in turn

lead to better physical health. Family relationships marked by open communication, honesty,

humor, and reassurance effects all family members mental and emotional well-being.

V. Environmental Factors: (10 marks)

A. Housing:

Type: house

Rent: No

Condition of residence/hazards: (stairs, structurally safe, number of rooms,

sleeping arrangements, bathrooms, cooking and refrigeration, storage of

medications and cleaning agents, loose rugs, smoke alarms, emergency

numbers,).

Good house, second floor, safe stair with stair railing. three bed rooms two

bathroom, kitchen (has cooker and Refrigerator). No smoke alarm. They have safe

place to store medications.

B. Family Neighborhood:

a. Location (urban, rural): Rural area

b. Safety (traffic patterns, lighting, security): Yes

 c. Density (noise, crowding, poverty, crime): Good no noise not crowded

no crime, safe place in village. there are few family’s poor in neighborhood.

d. Other environmental hazards: (air, pollution problems). No pollution,

Rural area.

e. Modes of transportation. Public transportation.

f. Resources (access to water, sewer, and garbage services). Because they

live in rural area in a village the family has government access to water,

sewage and garbage.

C. Accessibility of Services:

Service Type Yes No Comments

Health Services (Pharmacy, clinics, hospitals) Yes

Emergency (fire, police) Yes

Grocery shopping Yes

Social Yes

Educational Yes

Religious Yes

Recreational Yes
VI. Family Health Status: (20 marks)

A. Family Health Promotion Practices

a. Immunizations: All family had their necessary immunization and follow

government program.

b. Health screening practices: All family do their routine screening.

c. Use of safety devices: Yes

d. Family planning (need for, type used, effectiveness): Use effectively

contraceptive bills.

e. Risk behaviors: None

f. Family dietary patterns (amount, food preferences, preparation, adequacy,

special needs): No preference food, eat regular amount and cooked food.

g. Hygiene practices: Family very clean and tidy. House clean.

h. Use of substances (alcohol, tobacco, other drugs): No

i. Use of prescription and nonprescription medications: Use only Prescription

medication

j. Rest and exercise patterns: Yes

k. Typical daily activities: children go to school while the mother do her house

work and father in his job.

l. Leisure time/recreational activities: Children play games on computer. And

parents watching TV.

m. Health hazards associated with leisure pursuits: None

n. Occupational health hazards: None

o. Home environment conducive to health promotion and individual

development: House is clean, safe and organized.

p. Knowledge and attitude of the family about health: Family well known

about their health and father takes his Diabetics medication on time. And seek

medical advice if they need.

 q. Stress management: (Ability to handle usual strains of everyday life,

Stressful situations:

Mother can’t cope with everyday stress; she took full responsibility. Mohamed; the

father can manage and support his wife.

B. Source and Adequacy of Health Care Financing

a. Sources of health care (medical, dental) (primary care and institutional;

last appointment): All medical care covered in military hospitals.

Explain
Yes
No

Job provides complete health coverage Yes

In-hospital coverage Yes

Adequate and covers all aspects including vision, dental, Yes

and obstetrics

If not insured do own finances meet the needs? Full cover medical

insurance

b. Barriers to obtaining health care: No barriers, family has full cover medical

insurance from father’s work.

 c. Use of other health care resources/services: Sometimes; they use private

medical sections.

d. Appropriate decisions concerning utilization of health care: Yes, Parents try

to use alternative care.

e. Management of health and non-health crises: Yes

f. Provision of care for sick, disabled, or dependent members: no disability,

only father has Diabetic.

C. Family History (Past medical illness and/or accident of family members):

Father / Mohamed: No past surgery, has diabetic.

Mother/Mona and her children: No past medical history or accident.

 D. Family Health Needs (for each member)

Any current physical & mental health status;

Name
Health history – significant illnesses, surgeries; recent surgeries or

hospitalizations, supportive assessment data (physical, emotional, cognitive)

Ahmed No any physical and mental problems ,has Diabetic on medication .No previous

/Mohamed surgeries.

Mother No medical problem. History of hospitalization for delivery babies

Mona

Daughter No medical or surgery history .fit and healthy

Afaf

Son No medical or surgery history .fit and healthy

Ali

Daughter No medical or surgery history .fit and healthy

Leen
VII. Summary of Family Data: (20 marks)

Family Strengths

Perceived by Family Perceived by Nurse

Mother has the big role of the house. The father supports his Financial and medical insurance

family mentally and financially. the main strength of the family

beside the healthy children .

Family Stress

Family's Perception of Current Sources of Stress Nurse's Perception of Current

Family Sources of Stress

Father not sharing his wife responsibility, Overload of Financial issues low income.

mother responsibility.
Family Needs

Identified by the Family Identified by the Nurse

Needs support from relative while Needs more sources of income. Father need to follow medical

the father in his work. advice to maintain his glucose level within normal and prevent

complications.

VIII Primary nursing diagnoses: (10 marks)

1. Deficient knowledge of the father related to lack of information of his diabetic as evidenced

by inaccurate of instruction and verbalized inaccurate information.

2. Readiness for enhanced family coping related to inadequate family support as evidenced by

increased stress.

3. Ineffective financial family anxiety as evidenced by inability to increase income.

Family expectations of graduate student/nurse:

The family expectation from graduate nurse to have knowledge and help them by giving them

advice related to their assessment.

Reflect on the whole process of family assessment:

After completing my family assessment, I think, it was very valuable experience. I started taking

information about the family structure, it was the most necessary part of my assignment. I been

with them in more detailed information of the family structure ad relationship within the family.

The family providing information to observe the external and internal factors that cause stress or

support for the family. And I assessed strength and weakness of the family and role of each one.

During my assessment I have noticed that the family even they have low income and father

comes to his family weekly they have very strong relationship, and the mother even in stress

from the big responsibility.

Finally, I believe community nurse assessment and be involve with family life details is

essential for better life and healthy community.