FCAFormat 2023

HOLY ANGEL UNIVERSITY
SCHOOL OF NURSING AND ALLIED MEDICAL SCIENCES

NCM104RLE / First Semester, SY, 2023 - 2024
Family Case Analysis (FCA) Format

I. Title Page
II. Approval Sheet – to be provided by the clinical instructors.
III. Acknowledgement
IV. Table of Content (with page number)

1. Include the following with pages
i. List of Tables
ii. List of Figures
iii. List of Appendices
V. Objectives
• Refer to Learning Objectives of NCM104 specific with FCA
VI. Introduction (250 - 300 words)

• May discuss what is community health nursing and family nursing practice.
• Include the theoretical / conceptual framework / model utilized in the study.
• May include the activities, roles, and responsibilities of a community health nurse
to a family as a clientele
• May end up introducing the family in the case scenario and the nursing process
that will be undertaken to solve the case.
VII. Nursing Theory

• Explain the nursing theory adopted or utilized in designing the nursing plan and
actions.
VIII. Assessment Data Base (ADB)

1. Family background (Structure, Characteristics, Dynamics & Relationship Pattern)
o Table No. 1 - Present the family background on both table and brief
narrative explanation.
Format:
Table 1. Demographic Profile
Name Age Birth Birthplace Gender Position Civil Educational Occupation Average
(start Date in the Status Attainment Monthly
with the Family Income
index
client),
followed
by the
spouse,
children,
and
extended
family
members
(if
needed)
i. Include the following figures with narrative explanations:

1. Figure 1: Genomap with Relationship Map (refer to your handout
for an example)
1
2. Figure 2: Ecomap (refer to your handout for an example)
2. Socio-economic and cultural characteristics background

i. Include the table below with narrative explanation
1. Table No. 2 – Summary of Household Income and Expenditures
Example:
Table 2. Summary of Household Income and Expenditures
3. Home and environment

o Describe the home structure and environment
o Include adequacy of living space / floor area and present with table (Table
No. 3) and narrative explanation
▪ Recommended space requirement:
▪ Per Adult: 15 m² each
▪ Children: 8.0 m² each
▪ Infant: 0 m²
Interpretation:
• Actual Problem: If client’s Total Floor Area (TFR) < the Total
Space Required (TSR) – it is INADEQUATE
• If client’s Total Floor Area (TFR) =/> the Total Space Required
(TSR) – it is ADEQUATE
• Potential problem = If client’s Total Floor Area (TFR) < / = to
the Total Space Required (TSR) with infant/s.
• What is / are actual and potential health and health – related
problems with your findings?
o Include adequacy of ventilation (Table No.4) and narrative explanation

▪ Formula:
Total Window Opening (TWO) in m² x 100
Total Floor Area in m²
• Interpretation:
o If 19% and below - INADEQUATE Ventilation
o If 20% and above – ADEQUATE Ventilation
o Consider presence of window obstructions too
• What is / are actual and potential health and health – related
problems with your findings?
o Food Sources, Storage & Cooking Facilities
• Where do they buy food? Are these fresh and safe? Do they plant
vegetables &/or fruits?
2
• What cooking utensils they use? Are these safe (e.g., fire
hazard)?
• Do they have a refrigerator? If none or not in use, how do the
family store uncooked and left – over foods?
• Water Supply – is the water source and supply potable / safe for
drinking and personal use? If not, how do the family purify the
drinking water?
• Were the water containers covered and protected from
environmental contaminants?
o Toilet Facility
• How was the toilet facility – describe (with flush, pail system, cat –
hole, etc.)
• How was the sanitary condition?
• Was the water being used in the toilet clean? Was it covered and
protected from any environmental contaminant?
o Social and Health Facilities
• What are the community facilities (presence of health center,
pharmacy, school, hospital, barangay hall, church, public market,
groceries, and variety (sari – sari) stores, recreation such as park,
basketball, or any sports facilities, etc.) and what was the distance
from the residence of the family. Do the family members utilize
these facilities? If not, why?
• Can we describe the condition, distance, and the quality (and
quantity, if applicable) of the facilities identified?
• Do the family participate in various social functions in the
community?
• Was the family identified and acknowledged as permanent or
transient resident of the village (Barangay) based on the record of
the Barangay Hall and RHU?
• Did the family receive any social support or amelioration (food,
medicines, materials, money, PPEs) from the Barangay,
municipality, city, or the national level?
o Communication and Transportation
• Is there a telecommunication (cellular and / or landline) signal
within the area?
• Was there a local post office?
• How are local products being transported to other places?
• Provision for internet access?
• Mode of transportation available (Bus, Jeepney, Tricycle, Pedicab,
Taxi, Calesa, Boat, etc.)
• How as the road condition (rough, asphalted, concrete, muddy,
etc.)
4. Health Status of each Family Member

i. Use Tables and number them accordingly
ii. Include medical history (if available) of each family member
iii. Include diagnostic results (if available) and date taken
iv. Each family member should have his / her own table of nursing
assessment
v. Include obstetrical history of adult women with / without child/ren or
history of previous and current pregnancy.
vi. Use head – to – toe chronology on the table
Example:
Table ___. Physical Assessment Result for Mrs. Juana Dela Cruz
3
PAST MEDICAL HISTORY
DIAGNOSTIC REPORTS Laboratory:
X-ray:
Others:
ANTHROPOMETRICS Height:
Weight:
BMI:
VITAL SIGNS HR:
T:
RR:
BP:
PREGNANCY INFORMATION Number of pregnancies:
Trimester:
OB Score:
LMP:
Fundic Height:
HEAD Symmetry:
Facial movement:
Symmetry
Deformities:
Others:
HAIR Scalp:
Infestation:
Texture:
Color:
Distribution:
Others:
EYES Eyebrows:
Eyelashes:
Eyelids:
Jaundice:
Bulbar conjunctiva:
Palpebral conjunctiva:
Cornea and Iris:
Pupils:
Sclera:
Extraocular muscle test
Eyes movement:
Alignment:
Visual Acuity
Snellen’s test
Vision:
Others:
EARS Auricles:
Color:
Symmetry:
Position:
Watch Tick test:
Others:
4
NOSE Symmetry:
Discharge:
Nasal patency:
Others:
MOUTH Gums:
Texture of lips:
Color of teeth:
Number of teeth:
Decay
Dentures:
Odor:
Tongue color & texture:
Frenulum:
Dental caries:
Others:
NECK Neck movement:
Presence of Jugular vein:
Lymph nodes:
Trachea:
Swallowing:
Others:
THORAX (HEART & LUNGS) Inspection
Shape and symmetry:
Spinal alignment:
Use of accessory muscle:
Palpation
Skin integrity:
Bulge:
Tenderness:
Bilateral fremitus:
Resonant:
Auscultation:
Cough:
Hemoptysis:
Wheezing:
Palpitations:
Syncope:
Orthopnea:
Others:
ABDOMINAL & GI Inspection
Skin color:
Appearance of the abdomen:
Over-all contour:
Lesion:
Rashes:
Distended:
Color of stool:
Auscultation
Bowel sound: Normal
Passing stools:
Palpation (Leopold’s Maneuver, if
applicable)
Fetal buttocks:
Fetal head on left maternal side:
Fetal extremities:
Fetal position:
5
Palpation
Character of the abdomen:
Nausea:
Vomiting:
Dysphagia:
Heartburn:
Diarrhea:
Constipation:
Rectal bleeding:
Others:
PELVIS & GU TRACT Dysuria:
Discharge:
Others:
UPPER & LOWER EXTREMITIES Inspection
Skin color:
Distribution of hair:
Edema & masses:
Lesion:
Varicose veins:
Nailbed:
Rashes:
Pulse:
Sores:
Capillary test:
Light touch testing:
Palpation
Tenderness:
Skin:
Others:
INTEGUMENTARY Inspection
Skin:
Rashes:
Sores:
Lesions:
changes in color:
Muscle pain:
Nails appearance:
Nails color:
Palpation
Capillary Refill Time:
Others:
SENSORY SYSTEM Light touch testing:
Sensation:
Others:
REFLEX Knee-jerk reflex:
Gag reflex:
Corneal reflex:
Others:
5. Values and practices on health promotion / maintenance and disease prevention

• Were family members utilizing the local health care facilities?
• What health practices are being performed to maintain their health and
prevent illness?
o Diet, exercise, practice on personal hygiene including
handwashing, use of PPEs during the pandemic, hobbies or past
6
time, rest and sleep including number of hours, house cleaning
and sanitation, etc.
o Do the family members regularly take vitamins and other
supplemental nutrition? If yes, what are these?
o Do a family member uses alternative medications and treatment
such as acupuncture, acupressure, herbal medicines (especially
those that are not recommended by the DOH), yoga, etc.
o What religious or cultural belief do the family practices that affects
their health?
6. Include Family Coping Index

• Table __. Family Coping Index
Area Score Justification

1. Physical Independence
2. Therapeutic Competence
3. Knowledge of Health Condition
4. Application of the Principles of

General Hygiene
5. Health Attitudes
6. Emotional Competence
7. Family Living
8. Physical Environment
9. Use of Community Facilities
IX. Management
1. Medical management (if provided)
• Previous and current medical management provided to each family
member
• Any surgical (minor or major) procedure/s performed.
• Previous and current medications and therapies (of any form).
• Diagnostic procedure prescribed but nor performed.
• Medications prescribed but not being taken.
• Use of mechanical aids to assist a family member to perform ADL
(eyeglasses, contact lenses, crutches, cane, walker, wheelchair, etc.), rest
and sleep (oxygen, CPAP, tongue aide / guards, orthopedic bed, etc.).
• Others, specify
2. Nursing Management
i. Problem List with Rank and Score
ii. Tables for Priority Setting (each problem should have its own table)
1. Scale Ranking of Health Conditions & Problem
7
Example:
Table ___. (Rank no. ____ & state the problem here)
CRITERIA WEIGHTS SCORE JUSTIFICATION

Nature of the Condition of the Problem
Scale:
• Wellness State 3 1
• Health Deficit 3
• Health Threat 2
• Foreseeable Crisis 1
Modifiability of the Condition or Problem
Scale:
• Easily Modifiable 2 2
• Partially Modifiable 1
• Not Modifiable 0
Preventive Potential
Scale:
• High 3 1
• Moderate 2
• Low 1
Salience
Scale:
• A condition or problem needing immediate 2 1
attention
• A condition or problem not needing 1
immediate attention
• Not perceived as a problem or condition 0
needing change
Total Score
iii. Family Nursing Care Plans

1. ADPIE
2. Include referrals in the nursing interventions
3. Each set of nursing interventions (or problem) should contain at a
minimum of 3 new / current EBP (include citation)
4. Include health teachings / educations
Family Nursing Care Plan Format
Assessment Family Plan of Care Nursing Rationale Method Resources Evaluation Resources
Nursing Interventions of Nurse / Materials Criteria / Materials
Diagnosis – Family Needed Needed
Contact
S: P.E.S format Goal: Include the Each Example: Note: Were all
(Use Second following: intervention Home PHN Bag is objectives
Level should have visit always and goals
O: Assessment) Objectives: Independent its own necessary has required
& rationale for home criteria for
Short – Term Collaborative visit. Goal Met,
Goal
8
Medium – nursing Partially
Term actions Met, and
Long - Term Goal
Health Unmet?
teachings
Are these
Home realistic and
instructions measurable?
Referral/s
X. FDAR
XI. SBAR
XII. References
• Use APA 7 format for referencing
XIII. Appendices
1. Informed Consent (for actual client)
2. Referral Letters
3. Health Education Materials
XIV. Photo documentation

• Insert group photo of every group meetings with the client (for actual) and with the
clinical instructor (for virtual). If the meeting was held without the CI, the team leader is in
charge to carry out all objectives and activities for the day.
• Team leader should be in – charge of the photo documentation
• Each photo should have a narrative explanation that contains the objectives for the
meeting, date, attendees, and achievement for the day.
XV. Individual Reflection

Consider the following:
• Meeting the learning objectives in making family case analysis
• Meeting the HAU Core Values
• Experiential / empirical learning and development
• Working with the team / group and clinical instructor/s
XVI. Curriculum Vitae (individual with picture)
Prepared by NCM104RLE Instructors

First Semester, SY 2023 – 2024

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HOLY ANGEL UNIVERSITY

SCHOOL OF NURSING AND ALLIED MEDICAL SCIENCES

Family Case Analysis (FCA) Format

II. Approval Sheet – to be provided by the clinical instructors.

IV. Table of Content (with page number)

VI. Introduction (250 - 300 words)

VII. Nursing Theory

VIII. Assessment Data Base (ADB)

i. Include the following figures with narrative explanations:

2. Socio-economic and cultural characteristics background

3. Home and environment

o Include adequacy of ventilation (Table No.4) and narrative explanation

4. Health Status of each Family Member

DIAGNOSTIC REPORTS Laboratory:

5. Values and practices on health promotion / maintenance and disease prevention

6. Include Family Coping Index

Area Score Justification

3. Knowledge of Health Condition

4. Application of the Principles of

9. Use of Community Facilities

CRITERIA WEIGHTS SCORE JUSTIFICATION

iii. Family Nursing Care Plans

XIV. Photo documentation

XV. Individual Reflection

XVI. Curriculum Vitae (individual with picture)

Prepared by NCM104RLE Instructors

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