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ARELLANO UNIVERSITY-PASIG
Andres Bonifacio Campus
Pag-asa St., Caniogan, Pasig City

COMMUNITY HEALTH NURSING

INITIAL DATA FOR FAMILY ASSESSMENT

PART I. Identification Information

Date:____11-13-23__________
Name of Person Interviewed:___Totong Santos___________________________________________________
Address: House No.:_K117__________, Street:__Kabutihan st.._DELA
PAZ________________________________________
City:___Pasig City__________________________________________________________________

Family Members Profile:

No. Name Relation Gende Age Birth Civil Highest Occupatio Employmen
to head r Date Status Education n t Status
Completed
JUN 2
1.(Head Elberto The Male 56 1969 Marrie College N/A Unemployed
of the Discaya Provider d
Family
FEB 18
2. Ginna Nurturing Female 54 1967 Marrie High N/A Unemployed
Spouse Discaya Mother d School
JAN 16
3. CJohn Eldest Male 30 1993 Separat Highschool N/A Unemployed
Childre Edil child ed/Ann
n Discaya ulled

2nd child Male AUG Single Pizza

4. Jordan 29 21 College Maker Employed
Discaya 1994
5. Jobert 3rd child Male 27 OCT Single Vocational Contractor Employed
Discaya 29 Electrician
1996
6. Jeric 4th child Male 26 DEC Single Vocational Machine Employed
Discaya 18 Operator
1997
7. Ma. 5th child Female 22 NOV Single College N/A Unemployed
Edina 22,
Discaya 2000
8. Joseph Youngest Male 20 AUG Single Senior N/A Unemployed
Discaya child 25, High
2003 School
Other 1.Jhoan Grand Female 11 MAY Single Elementary N/A N/A
membe na Daughter 04
rs of Discaya 2012
the
family/
living
in the
house

2. George Grand Male 08 JAN 30 Single Pre School N/A N/A

Discaya Son 2015
3. Sophia Grand Female 06 JUL 27 Single Pre School N/A N/A
Marie Daughter 2017
Discaya
4. Lovely Partner Female 28 Novem Single Highschool Sales Lady Employed
Asosiat of the ber 2
ion 2nd 1995
child
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5. Jamaica Grand female 04 Oct 12 Single N/A N/A N/A

Discaya Daughter 2019

6. Autnu Grand female 02 Aug 12 Single N/A N/A N/A

m Kath daughter 2021
Discaya
7. Jennie Grand female 4m Jul 05 Single N/A N/A N/A
Mae daughter nts/ 2023
Discaya old

Type of Family Structure:

Dominant Family Members in Terms of decision making: The head of the family was always the center when it
comes on decision making.
General family relationship/ dynamics:
The connection became scattered because of lack of communication between the head of the family and the spouse.

Total Monthly Income of Household:

[ ] below 1,000/month [ ] Php 1,000-3,000/month
[ ] Php 3,000-5,000/month [ ] Php 5,000-10,000/month [ ] above 10,000/month

Total Monthly Expenses

[ ] below 1,000/month [ ] Php 1,000-3,000/month

[ ] Php 3,000-5,000/month [ ] Php 5,000-10,000/month [ ] above 10,000/month

PART II. Environmental Factors of the House

Home Ownership:
[ ] owned [ ] shared [ ]rental

Housing: Adequacy of living space:

Number of rooms: [ ] 1 room [ ] 2 rooms [ ] 3 rooms [ ️] 4 rooms

Number of person/s per room: ______5______(specify)

Housing Structure:
[ ] concrete (strong material [ ] mixed (combination of wood and concrete)
[✔ ] light (wood, bamboo, nipa)

Lightning Facilities:
[ ]electric bulb [ ] used of kerosene lamp [ ] others________

Sources of Electricity:
[ ] owned [ ] shared

Environment proximal to the house:

[ ] near factories [ ] near dumpsite
[ ] near creek/river [ ] near the fields

Toilet Facility:
[ ] water-sealed [ ] flush-type [ ] open pit-hole privy
[ ] over-hung lantrine [ ] antipolo-type [ ] closed pit-hole privy

Garbage Disposal:
[ ] thrown/open dumping [ ✔] collected (frequency)_____3____ X a week
[ ] open burning [ ] composting
[ ] burial pit

Kind of neighborhood:
[ ] slum [ ️] congested

Drainage:
[ ] close drainage [✔ ] open drainage [ ] none
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Infestation of Insect and Rodents:

Are insect and rodents present in the house:
[ ] yes [ ] no

Presence of Domestic animals: None

Kind of Animal Number Where kept:
[ ] dogs ____6__ [ ] loose [ ] tied/kept in backyard
[ ] cats ______ [ ] loose [ ] tied/kept in backyard
[ ] cow ______ [ ] loose [ ] tied/kept in backyard
[ ] carabao ______ [ ] loose [ ] tied/kept in backyard
[ ] pigs ______ [ ] loose [ ] tied/kept in backyard
[ ] chicken __10____ [ ] loose [ ] tied/kept in backyard
[ ] others ______ [ ] loose [ ] tied/kept in backyard

If with dogs, are they vaccinated or not?

[ ] vaccinated [ ] unvaccinated
Food storage and cooking facilities:
Where do you cook your food?
[ ] gas range [ ] woods [ ]charcoal [ ] pugon
[️ ] electric stove [ ] others

How do you store your food?

[✔️] stored in the refrigerator [ ] sealed or covered [ ] no seal or cover at all

Water Supply:
Source of Drinking Water:
[ ] NAWASA [✔️] Water station
[ ] deep well [ ] Own water purifier/filter
[ ] artesian well

PART III. Health Assessment of Each Member

Medical History

Family History of Disease

[ ] Diabetes [ ] Tuberculosis [ ] Heart Disease
[ ] Hypertension [ ] Hepatitis B/C [ ] Mental Illness
[ ] Asthma [ ] Food Allergy [ ] Hemophilia
[ ] Cancer [ ] Skin Allergy/Skin Disease [ ] Abnormalities

Present Illness (starting January 2023)

[️ ] Diabetes [ ] Tuberculosis [ ] Heart Disease
[ ] Hypertension [ ] Hepatitis A [ ] Pneumonia
[ ] Fracture [ ] Hepatitis B [ ] Migraine
[ ] Asthma [ ] Food Allergy [ ] Diarrhea (more than 3 days)
[ ] Cancer [ ] Skin Allergy [ ] Respiratory Illness (cough more than 1 week)
[ ] Typhoid Fever [ ] Bleeding [ ] Dengue Fever
[ ] Anemia [ ] Malnutrition [ ] others:________________

Chronic Illness
[] Diabetes [ ] Tuberculosis ] Heart Disease
[ ] Hypertension [ ] Hepatitis B/C [ ] Cancer

Sources of Health Care of Family: (frequently used service)

[✔ ] Health Center [ ] Private Clinics [ ] Traditional Doctor
[ ️] Private Hospital [ ] Government Hospital [ ] Others_________(specify)

Source of Health Insurance:

[ ] SSS [ ] Philhealth [ ] Private Health Card []
OthersPAGIBIG_________(specify)

Vaccination against:
[ ] Influenza [ ] Hepatitis B
[ ] Cervical cancer/HPV
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Vices: (None)
[ ] smoking ___________(note number of sticks per day)
[ ] alcoholism _____2____(note number of bottles per day)
[ ] prohibited drugs_______(specify)

Beliefs and Practices in case of emergency medical problem:

[ ] consult medical practitioner
[ ️] use herbal medicine
[ ] consult hilot, albularyo and espiritista
[ ] self medication/self-treatment
[ ] traditional therapy such as reflexology, acupressure, acupuncture
[ ] others

For Females:
Do you conduct or submit yourself for the following procedure:
[ ] Monthly self-breast examination
[ ] yearly Pap Smear
[ ] annual physical examination
[ ] others

For Males:
Do you conduct or submit yourself for the following procedure:
[ ] Testicular Examination
[ ] annual physical examination
[ ] others

Nutritional Assessment

Typical Diet per day:

[ ] vegetarian [ ] carnivorous [ ] mixed

Food Preference when cooked:

[ ] inihaw/grilled [ ] nilaga/boiled or blanch [ ] ginisa/sautéed

Quantity of meal per day:

[ ]6 x a day [ ] 5x a day [ ]4x a day [️ ]3 x a day [ ]2 x a day [ ] 1 x a day

Hospitalized member of the family (since January 2023 up to the present):

Name Age Gender Date Admitted Diagnosis Medical /Surgical
in Hospital Management

Deaths from January 2023 up to present

Name Age Gender Date Died Cause of Death Relationship

Additional Questions

1. Do they still practice the COVID-19 Protocol of Physical distancing, wearing of masks and face shields, not being
allowed to go out because they belong to the most vulnerable (the Senior Citizens) groups to contact the disease).

YES NO

2. At present, do they still feel fear of contacting COVID-19? YES NO

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3. What are their plans when someone in the family gets CODID-19?

II. List down at least 2 wellness or health conditions from the information gathered in the
IDB.
1. House is overcrowded, with barely enough room for all family members due to unplanned
pregnancies.

Criteria Computation Actual Score Justification

The family's
Nature of the Problem: 1/3×1 0.33 simultaneous
Foreseeable
unexpected
Crisis/Stress point
pregnancy caused the
house to fill up quickly
and become too small
for the entire family.

Together with the

Modifiability of the
Problem:
Partially Modifiable
1/2× 2 1 help of health centers
there is a hope for the
mothers or the spouse
in the family to
acknowledge the
existence of family
planning.

Preventive Potential: 3/3×1 1 Because of the

High willingness of the
family to prevent the
stated problem, it has
a high chance to
prevent the problem

Salience: 2/2×1 1 Unplanned pregnancy

became number one
Problem needing
immediate attention
reason of poverty in a
family, I there for
conclude that this
case needed
immediate attention.

Total: 3.33
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2. Near ️a ️creek ️that ️might ️be ️problematic ️after ️heavy ️rains ️and ️storms ️due ️to ️flooding.
Criteria Computation Actual Score Justification

Nature of the Problem: 2/3×1 0.67 Because of the area's

Health Threat inadequate
infrastructure—a very
low elevation and a
partially cement street—
the house was
vulnerable to natural
disasters or flooding
during periods of heavy
rain. And there are some
diseases like
leptospirosis can be
taken from rats or
mouse that could be
present in flood.

Modifiability of the 1/2*2 1 The risk associated

Problem: with the mentioned
Partially Modifiable issue might be a
modifiable by finding
out the locations of
potential evacuation
centers.

Preventive Potential: 2/3×1 1 They don't want to

Moderate leave their things
behind or escape due
to the spouse's
comment since they
are afraid they might
be stolen that why the
preventive potential
might be low.

Salience: Not 1/2×1 0.5 Because of the

needing Immediate programs and
attention
evacuation center that
provided in the place
this issue or case need
a solution but doesn’t
need immediate
attention

Total: 3.17
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3. Unvaccinated tied dogs that can accidentally transmit serious rabies to any family member.

Criteria Computation Actual Score Justification

Nature of the Problem: 2/3×1 0.67 Due to the family had a

Health Threat lot of dogs, so some of
them may have carried
the rabies virus, which
would put the family in
grave danger.

Modifiability of the 1/2*2 1 There is a chance that

Problem: this issue could be
Partially resolved if the family
cooperates with the
community and gets
their dog vaccinated
against rabies.

Preventive Potential: 1/3×1 0.33 Due to the family

Low believes it's a waste of
money and prefers to
wait for the
community to provide
free anti-rabies
vaccinations for dogs
instead of pursuing
the anti-rabies
vaccination.

Salience: 2/2×1 1 Because of the

Immediate dangerous effect of
attention
the rabies to the
human it can be a
threat to any
members in the family
so it should be given a
immediate action.

Total: 3
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III. Prioritize the health condition using the scale of prioritizing to determine which of the two
health conditions is ranked 1.
Listed Health Problems:
1. House is overcrowded, with barely enough room for all family members due to
unplanned pregnancies.= 3.33 (Rank 1)
2. Near a creek that might be problematic after heavy rains and storms due to flooding.=
3.17

3. Unvaccinated tied dogs that can accidentally transmit serious rabies to any family
member.=3

FNCP House is overcrowded, with barely enough room for all family members due to
unplanned pregnancies.= 3.33 (Rank 1)

Health Problem Family Nursing Problem Goal of Care Objectives of Care Intervention Plan
Nursing Intervention Methods Resources
of Nurse Required
Client
Contact
House is Can't guarantee a Following the After doing the nursing A.Discuss the Materials and
overcrowded, sufficient nursing intervention the family benefits of family Home supplies
with barely population within intervention, the will: planning, such as Visit
enough room the house because family should health, financial Teaching
for all family of: understand the a. Consult with a security, emotional Aids:
members due importance of family Healthcare Professional support, and family Whiteboards
to unplanned A. The family was planning and And Schedule a visit with communication. and Markers:
pregnancies. not practicing population control, a healthcare provider to Visual aids
family planning, as well as the discuss family planning B. Informing the /printed
which resulted in disadvantages of not options. family about the materials for
several unplanned choosing family various types of explaining
pregnancies and a planning. B. Can Educate contraception and concepts.
lack of planning for Themselves about methods. Charts and
the intervals different family planning Posters:
between methods, including C. Teaching the Display
pregnancies. contraceptives, fertility family how to use important
B.Because of the awareness methods, and contraception information
population in the other options. Reliable correctly and for easy
house, the sources of information effectively. reference.
monthly income include healthcare Explaining the side
cannot support the providers, reputable effects of Human
entire family. websites, and educational contraception or Resources:
materials. birth control. And Cooperation
C. Because of how effective and and
"rumors" that it C. Communicate with safe is it collaboration
can impair fertility family and their partners between the
and harm the planning together ensures D. Teaching them family and
uterus, the spouse that both partners are on the importance of the nurse
and partner of the the same page and can family planning
second child are provide support for each consultations and Financial:
afraid to use birth other's choices. informing them Funds for the
control pills or any about the materials and
birth control D. Consider Personal and programs offered supplies
method. Financial Factors and by nearby health needed for
Reflect on personal and centers. the process.
financial considerations
when planning the size of
the family. Factors such as
career goals, financial
stability, and the well-
being of existing children
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may play a role in

decision-making.

E. Can a contraceptive
method that suits the
mother's preferences and
health needs. Options
include birth control pills,
patches, injections,
intrauterine devices
(IUDs), condoms, and
more. Including
monitoring of menstrual
cycle.after nursing
intervention the family
will:

DOCUMENTATION