Community Health Nursing 1
17
(Individual and Family as Clients)
Florence Puno, RN
FAMILY NURSING PROCESS
OUTLINE
I FAMILY NURSING PROCESS
II FAMILY HEALTH ASSESSMENT
III TYPOLOGY OF NURSING PROBLEMS IN
FAMILY NURSING PRACTICE
IV. SECOND LEVEL ASSESSMENT
V.STEPS IN FAMILY NURSING PROCESS
FAMILY NURSING PROCESS
is the blueprint in the care that the nurse design
to systematically minimize or eliminate the
identified health and family nursing problems
through explicitly formulated outcomes of care
(goals and objectives ) and deliberately chosen set
of interventions , resources , and evaluation
criteria, standards and tools.
FAMILY HEALTH ASSESSMENT
1. Tools for Assessment
IDB (Initial Data Base )
FAMILY STRUCTURE CHARACTERISTICS AND
DYNAMICS
1. Members of the household and relationship
to the head of the family.
2. Demographic data-age, sex, civil status,
position in the family
3. Place of residence of each member-whether
living with the family or elsewhere
4. Type of family structure-e.g. patriarchal,
matriarchal, nuclear or extended
5. Dominant family members in terms of
decision making especially on matters of
health care
6. General family
relationship/dynamicspresence
of any obvious/readily observable
conflict between members; characteristics,
communication / interaction patterns among
members
BSN-2B TRANSCRIBED BY: GROUP 5
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SOCIO-ECONOMIC AND CULTURAL CHARACTERISTICS
1. Income and expenses
• Occupation, place of work and income of
each working member
• Adequacy to meet basic necessities (food,
clothing, shelter)
• Who makes decision about money and
how it is spent
2. Educational Attainment of each Member
3. Ethnic Background and Religious Affiliation
4. Significant others-role (s) they play in family’s
life
5. Relationship of the family to larger
community-nature and extent of participation
of the family in community activities
HOME AND ENVIRONMENT
• information on housing and sanitation
facilities,
kind of neighborhood and availability of social,
health, communication and transportation
facilities
1. Housing
• Adequacy of living space
• Sleeping in arrangement
• Presence of breathing or resting sites of vector
of diseases (e.g. mosquitoes, roaches, flies,
rodents, etc.)
• Presence of accident hazard
• Food storage and cooking facilities
• Water supply-source, ownership, pot
• ability
• Toilet facilities-type, ownership, sanitary
• condition
• Garbage/refuse disposal-type, sanitary
• condition
• Drainage System-type, sanitary condition
2. Kind of Neighborhood, e.g. congested, slum
etc.
3. Social and Health facilities available
4. Communication and transportation facilities
available
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HEALTH STATUS OF EACH OF THE FAMILY MEMBERS
1. Medical Nursing history indicating current or
past significant illnesses or beliefs and
practices conducive to health and illness
2. Nutritional assessment (especially for
vulnerable or at-risk members)
ANTHROPOMETRIC DATA
• measures of nutritional status of children weight,
height, mid-upper arm circumference; risk
assessment measures for obesity: body mass
index (BMI=weight in kgs. divided by height in
meters2), waist circumference (WC: greater than
90 cm. in men and greater than 80 cm. in
women), waist hip ration (WHR=waist
circumference in cm. divided by hip circumference
in cm. Central obesity: WHR is equal to or greater
than 1.0 cm in men and 0.85 in women)
DIETARY HISTORY specifying quality and quantity of
food or nutrient per day
EATING/ FEEDING HABITS/ PRACTICE
3. Developmental assessment of infant,
toddlers and preschoolers- e.g. Metro Manila
Developmental Screening Test (MMDST).
4. Risk factor assessment indicating presence of
major and contributing modifiable risk factors
for specific lifestyle diseases e.g.
hypertension, physical inactivity, sedentary
lifestyle, cigarette/ tobacco smoking, elevated
blood lipids/ cholesterol, obesity, diabetes
mellitus, inadequate fiber intake, stress,
alcohol drinking, and other substance abuse.
5. Physical Assessment indicating presence of
illness state/s (diagnosed or undiagnosed by
medical practitioners)
6. Results of laboratory/diagnostic and other
screening procedures supportive of
assessment findings.
VALUES HEALTH PRACTICES ON HEALTH
PROMOTION, MAINTENANCE AND DISEASE
PREVENTION
1. Immunization status of family members
2. Healthy lifestyle practices.
BSN-2B TRANSCRIBED BY: GROUP 5
3. Specify Adequacy of Rest and sleep
Exercise/activities Use of protective measure
• e.g. adequate footwear in parasite infested
areas; use of bed nets and
protective clothing in malaria and filariasis
endemic areas. Relaxation and other
stress management activities
4. Use of promotive-preventive health services
TYPOLOGY OF NURSING PROBLEMS IN FAMILY
NURSING PRACTICE
FIRST LEVEL ASSESSMENT
Presence of Wellness Condition
• stated as potential or Readiness - a clinical or
nursing judgment about a client in transition
from a specific level of wellness or capability to
a higher level. Wellness potential is a nursing
judgment on wellness state or condition based
on client’s performance, current competencies,
or performance, clinical data or explicit
expression of desire to achieve a higher level of
state or function in a specific area on health
promotion and maintenance.
• Examples of this are the following:
POTENTIAL FOR ENHANCED CAPABILITY
FOR:
1. Healthy lifestyle - e.g. nutrition/diet,
exercise/activity
2. Health maintenance/health management
3. Parenting
4. Breastfeeding
5. Spiritual well-being - process of client’s
developing/unfolding of mystery through
harmonious interconnectedness that
comes from inner strength/sacred
source/God (NANDA 2001)
6. Others. Specify
• READINESS FOR ENHANCED
CAPABILITY FOR:
1. Healthy lifestyle
2. Health maintenance/health management
3. Parenting
4. Breastfeeding
5. Spiritual well-being
6. Others Specify
Presence of Health Threats
• conditions that are conducive to disease and
accident or may result to failure to maintain
wellness or realize health potential.
• Examples of this are the following:
1. Presence of risk factors of specific diseases
(e.g. lifestyle diseases, metabolic syndrome)
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 2. Threat of cross infection from communicable
disease case
3. Family size beyond what family resources can
adequately provide
4. Accident hazards specify.
Broken chairs
Pointed /sharp objects, poisons and
medicines improperly kept
Fire hazards
Fall hazards
Others specify
5. Faulty/unhealthful nutritional/eating habits or
feeding techniques/practices. Specify
Inadequate food intake both in quality
and quantity
Excessive intake of certain nutrients
Faulty eating habits
Ineffective breastfeeding
Faulty feeding techniques
6. Stress Provoking Factors. Specify.
Strained marital relationship
Strained parent-sibling relationship
Interpersonal conflicts between family
members
Care-giving burden
7. Poor Home/Environmental
Condition/Sanitation. Specify.
Inadequate living space
Lack of food storage facilities
Polluted water supply
Presence of breeding or resting sights of
vectors of diseases
Improper garbage/refuse disposal
Unsanitary waste disposal
Improper drainage system
Poor lightning and ventilation
Noise pollution
Air pollution
8. H. Unsanitary Food Handling and Preparation
9. . Unhealthy Lifestyle and Personal
Habits/Practices. Specify.
Alcohol drinking
Cigarette/tobacco smoking
Walking barefooted or inadequate
footwear
Eating raw meat or fish
Poor personal hygiene
Self medication/substance abuse
Sexual promiscuity
Engaging in dangerous sports
Inadequate rest or sleep
Lack of /inadequate exercise/physical
activity
Lack of/relaxation activities
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Non use of self-protection measures (e.g.
non use of bed nets in malaria and
filariasis endemic areas).
10. Inherent Personal Characteristics - e.g. poor
impulse control
11. Health History, which may Participate/Induce
the Occurrence of Health Deficit - e.g.
previous history of difficult labor.
12. Inappropriate Role Assumption - e.g. child
assuming mother’s role, father not assuming
his role.
13. Lack of Immunization/Inadequate
Immunization Status Specially of Children
14. N. Family Disunity - e.g.
Self-oriented behavior of member(s)
Unresolved conflicts of member(s)
Intolerable disagreement
Others. Specify.
Presence of health deficits
instances of failure in health maintenance
Examples include:
a) Illness states, regardless of whether it is
diagnosed or undiagnosed by medical
practitioner.
b) Failure to thrive/develop according to normal
rate
c) Disability - whether congenital or arising from
illness; transient/temporary (e.g. aphasia or
temporary paralysis after a CVA) or
permanent (e.g. leg amputation secondary to
diabetes, blindness from measles, lameness
from polio)
Presence of stress points/foreseeable crisis
situations
anticipated periods of unusual demand on the
individual or family in terms of
adjustment/family resources.
Examples of this include:
Marriage
Pregnancy, labor, puerperium
Parenthood
Additional member - e.g. newborn, lodger
Abortion
Entrance at school
Adolescence
Divorce or separation
Menopause
Loss of job
Hospitalization of a family member
Death of a member
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 Resettlement in a new community
Illegitimacy
Others, specify.__
SECOND LEVEL ASSESSMENT
Inability to recognize the presence of the condition
or problem due to:
1) . Lack of or inadequate knowledge
2) Denial about its existence or severity as a result of
fear of consequences of diagnosis of problem,
specifically:
a) Social-stigma, loss of respect of
peer/significant others
b) Economic/cost implications
c) Physical consequences
d) Emotional/psychological issues/concerns
3) Attitude/Philosophy in life, which hinders
recognition/acceptance of a problem
4) Others. Specify
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/condition
3) Feeling of confusion, helplessness and/or
resignation brought about by perceive
magnitude/severity of the situation or problem,
i.e. failure to breakdown problems into
manageable units of attack.
4) Lack of/inadequate knowledge/insight as to
alternative courses of action open to them
5) Inability to decide which action to take from
among a list of alternatives
6) Conflicting opinions among family
members/significant others regarding action to
take.
7) Lack of/inadequate knowledge of community
resources for care
8) Fear of consequences of action, specifically:
a) .Social consequences
b) Economic consequences
c) Physical consequences
d) Emotional/psychological consequences
9) .Negative attitude towards the health condition or
problem-by negative attitude is meant one that
interferes with rational decision-making.
10) In accessibility of appropriate resources for care,
specifically:
a) Physical Inaccessibility
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b) Costs constraints or economic/financial
inaccessibility
11) Lack of trust/confidence in the health
personnel/agency
12) Misconceptions or erroneous information about
proposed course(s) of action
13) Others specify._
Inability to provide adequate nursing care to the sick,
disabled, dependent or vulnerable/at risk member of
the family due to:
1) A. Lack of/inadequate knowledge about the
disease/health condition (nature, severity,
complications, prognosis and management)
2) Lack of/inadequate knowledge about child
development and care
3) Lack of/inadequate knowledge of the nature or
extent of nursing care needed
4) Lack of the necessary facilities, equipment and
supplies of care
5) Lack of/inadequate knowledge or skill in carrying
out the necessary intervention or
treatment/procedure of care (i.e., complex
therapeutic regimen or healthy lifestyle program).
6) F. Inadequate family resources of care specifically:
a) Absence of responsible member
b). Financial constraints
c) Limitation of luck/lack of physical resources
7) Significant persons unexpressed feelings (e.g.
hostility/anger, guilt, fear/anxiety, despair,
rejection) which his/her capacities to provide
care.
8) Philosophy in life which negates/hinder caring for
the sick, disabled, dependent, vulnerable/at risk
member
9) Member’s preoccupation with on
concerns/interests
10) Prolonged disease or disabilities, which exhaust
supportive capacity of family members.
11) K. Altered role performance, specify.
a) Role denials or ambivalence
b) Role strain
c) Role dissatisfaction
d) Role conflict
e) Role confusion
f) Role overload
g) Others. Specify
Inability to provide a home environment conducive
to health maintenance and personal development
due to:
1) A. Inadequate family resources specifically:
a) Financial constraints/limited financial
resources
b) Limited physical resources - e.i. lack of space
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to construct facility measuring status of the family
2) Failure to see benefits (specifically long term
ones) of investments in home environment ability to maintain itself
improvement ability to maintain wellness
3) Lack of/inadequate knowledge of importance of
prevent, control and resolve problems
hygiene and sanitation
4) Lack of/inadequate knowledge of preventive data are compared with the norms and
measures standards
5) Lack of skill in carrying out measures to improve
home environment STEPS IN FAMILY NURSING PROCESS
6) Ineffective communication pattern within the
1. Data Collection (for first level assessment)
family
• Involves gathering of five types of data
7) lack of supportive relationship among family
which will generate the categories of
members
health conditions or problems of the
8) Negative attitudes/philosophy in life which is not
family. These data include:
conducive to health maintenance and personal
o Family structure, characteristics, and
development
dynamics
9) Lack of/inadequate competencies in relating to
o Socio economic and cultural characteristics
each other for mutual growth and maturation
o Home and environment
(e.g. reduced ability to meet the physical and
o Health status of each member
psychological needs of other members as a result
o Values and practices on health promotion/
of family’s preoccupation with current problem or
maintenance and disease prevention
condition.
• METHODS ON COLLECTION:
10) Others specify
o Observation
o Physical examination
Failure to utilize community resources for health
o Interview
care due to:
o Record review
1) A. Lack of/inadequate knowledge of community
o Lab/diagnostic tests
resources for health care
2) Failure to perceive the benefits of health
care/services
2. Data Analysis
3) Lack of trust/confidence in the agency/personnel
• Sub steps:
4) Previous unpleasant experience with health
o Sort data
worker
o Cluster/group related data
5) Fear of consequences of action (preventive,
o Distinguish relevant from irrelevant data
diagnostic, therapeutic, rehabilitative) specifically:
o Identify patterns – functions, behavior,
Physical/psychological consequences
lifestyle
Financial consequences
o Compare patterns with norms or standards
Social consequences o Interpret results
6) F. Unavailability of required care/services o Make inferences or conclusion
7) Inaccessibility of required services due to:
a) Cost constraints 3. Problem Definition or Nursing Diagnosis
b) Physical inaccessibility • Levels of assessment:
8) H. Lack of or inadequate family resources, o First level – identifying potential and existing
specifically problems
a) Manpower resources, e.g. baby sitter ▪ Presence of well condition
b) Financial resources, cost of medicines ▪ Presence of health threat
prescribe ▪ Presence of health deficits
9) Feeling of alienation to/lack of support from the ▪ Presence of stress points/foreseeable
community, e.g. stigma due to mental illness, crisis
AIDS, etc. • Second level – problems encountered by the
10) Negative attitude/ philosophy in life which family in performing health tasks with the
hinders effective/maximum utilization of given health condition or problem
community resources for health care
11) Others, specify
ASSESSMENT

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FAMILY HEALTH TASK
EIGH FAMILY TASKS (DUVAL AND NILLER)
1. PHYSICAL MAINTENANCE
• Provides food, shelter, clothing and health
care to its members being certain that a
family has ample resources to provide
2. SOCIALIZATION OF FAMILY
• Involves preparation of children to live in
the community and interact with people
outside the family
3. ALLOCATION OF RESOURCES
• Determines which family needs will be
met and their order of priority
4. MAINTENANCE OF ORDER
• Task includes opening an effective means
of communication between family
members, integrating family values and
enforcing common regulations for all
family members
5. DIVISION OF LABOR
• Who will fulfill certain roles
o Family provider, home manager, children’s
caregiver
6. REPRODUCTION, RECRUITMENT, AND
RELEASE OF FAMILY MEMBER
7. PLACEMENT OF MEMBERS INTO LARGAR
SOCIETY
• Consists of selecting community activities,
such as church, school, politics that
correlate with the family beliefs and
values
8. MAINTENANCE OF MOTIVATION AND
MORALE
• Created when members serve as support
people
Purpose: to provide a basis for estimating the nursing
needs of a particular family
• HEALTH CARE NEED
• A family health care need is present when:
• Family has a health problem with which they
are unable to cope
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• A reasonable likelihood that nursing will make
a difference in the family’s ability to cope
*note: relation to coping nursing need:
COPING may be defined as dealing w/ problems
associated w/ health care w/ reasonable success.
COPING DEFICIT – when family is unable to cope with
or another aspect of health care
• Direction for scaling
o 2 parts of coping index:
▪ A point on the scale
▪ A justification statement
• The scale enables you to place the family in
relation to their ability to cope with 9 areas
of family nursing at the time observed and as
you would expect it to be in 3 months or at
the time of discharge if nursing care were
provided
• Coping capacity is rated from 1 (totally unable
to manage this aspect of family nursing care)
to 5 (able to handle this aspect of care
without the help from community sources)
• Justification consists of brief statement of
phrases that explain why you have rated the
family as you have
• GENERAL CONSIDERATIONS:
o It is the coping capacity and not the
underlying problem that is being
rated
o It is the family and not the individual
that is being rated
o Rating should be done after 2-3 home
visits when the nurse is more
acquainted with the family
o Justification – should be expressed in
terms of behavior of observable facts
o Terminal rating is done at the end of
the given period of time. To see
progress the family has made in their
competence; whether the prognosis
was reasonable; and whether the
family needs further nursing service
and where emphasis should be
placed
• SCALING CUES
o ff. descriptive statements are cues to help
you as you rate family coping. Limited to
three points
▪ 1 or no competence
▪ 3 for moderate competence
▪ 5 for complete competence
AREAS TO BE ASSESSED:
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• PHYSICAL INDEPENDENCE
• concerned w/ the ability to move about to
get out of bed, take care of daily
grooming, walking and other things on
daily activities
• THERAPEUTIC COMPETENCE
• procedures or treatment prescribed for
the care of ill – giving medication,
dressings, exercise, relaxation and special
diets
• KNOWLEDGE OF HEALTH CONDITION
• concerned with the particular health
condition that is the occasion of care
• APPLICATION OF THE PRINCIPLES OF
GENERAL HYGIENE
• concerned with the family action in
maintaining family nutrition, securing
adequate rest and relaxation for family
members, carrying out accepted
preventive measures (immunization)
• HEALTH ATTITUDES
• the way the family feels about health care
in general, including preventive services,
care of illness and public health measures
• EMOTIONAL COMPETENCE
• maturity and integrity with which the
members of the family are able to meet
the usual stresses and problems of life,
and plan for happy and fruitful living
• FAMILY LIVING
- Concerned largely w/ the interpersonal with
the group aspects of family life
- How well the members get along with one
another
- Ways in which they take decisions affecting
the family as a whole
• PHYSICAL ENVIRONMENT
• Home, the community and the work
environment as it affects family health
• USE OF COMMUNITY FACILITIES
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• Generally keeps appointments
• Follows through referrals
• Tell others about health dept services
2. Family Data Analysis
• Socio-economic and cultural
characteristics
• Home environment
• Family health status
• Family values and health practices
FAMILY NURSING DIAGNOSIS
Health Problem
• Situation or condition which
interferes the promotion and/or
maintenance of health and recovery
from illness or injury & which is
subject to change/modification
through Nursing intervention
Family Nursing Problem
• Stated as the family’s failure to
perform adequately specific health
tasks for a particular problem
• Nursing diagnosis in family nursing
practice
FORMULATING FAMILY NURSING CARE PLAN
Priority Setting
Priority Health Problems
a. Nature of the Problem - wellness state, hx
deficit, health threat and stress point/ foreseeable
crisis
b. Modifiability of the Problem - probability of
success in enhancing wellness state, improving
condition minimizing, alleviating or totally
eradicating the problem.
Factors in Determining Modifiability of the
Problem
• Current knowledge, technology and
interventions
• Resources of the family
• Resources of the nurse
• Resource of the community
c. Preventive Potential - nature or magnitude of
the problem than can be minimize or totally
eradicated.
Scoring Preventative Potential
• Gravity or severity of the problem
• Duration of the problem
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 • Current Management
• Exposure of high risk groups
d. Salience - 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

SCORING
1. Decide on a score for each of the criteria
2. Decide the score by the highest possible score
and multiply by the weight
Score
--- X Weight
- Highest score
3. Sum up the scores for all the criteria. The
highest score is 5, equivalent to the total
weight
Goal:
4. The higher the score (near 5 and above) of a
given problem, the more likely it is taken as a • A general statement of the condition or state
priority to brought about by specific course of action
(e.g. to improve nutrition status of the family)
CARDINAL PRINCIPLE IN GOAL SETTING
• Goal must be set jointly with family
Barriers to Joint Setting of Goals
1. Failure to perceive the problem
2. Realize the problem but too busy at the
moment
3. Do not see the problem as serious enough to
be solved.

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 4. The problem that need to take action:
• Fear of consequences
• Respect for tradition
• Failure to perceive the benefits REFERENCES
• Failure to relate actions with family’
goal “PROF’S PPT ON QUIPPER AND LECTURE”
1. Failure to develop working relationship from both
nurses and family

OBJECTIVES
• Refers to a more specific statements of the
desired results or outcomes of care
• The more specific the objectives, the easier is
the evaluation of their attainment

Family Health Assessment Form

• is a guide in date collection, as a
means to record pertinent
information about the family that will
assist the nurse in working with family

Genogram
• helps the nurse outline the family’s
structure. It is a way to diagram the
family.
• Three generations of family members
are included with symbols denoting
genealogy.

Ecomap
• a classic tool is used to depict a
family’s linkages to its suprasystem
• Portrays an overview of the family in
their situation;
• It depicts the important nurturant of a
conflict laden connection between
the family and the world.
• It demonstrates the flow of resources
or the lacks and deprivation
• A mapping procedure that highlights
the nature of the interferences and
points to conflicts to be mediated,
bridges to built, and resources to be
sought and mobilized.

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