FAMILY NURSING PRACTICE- CHN 1

A. FAMILY STRUCTURE, CHARACTERISTICS AND DYNAMICS

Head Of The family Relation to AGE CIVIL STATUS HIGHEST LEVEL OF Position in (1st, 2nd, 3rdetc) Place of Residence of each
Household Head 1-male (18 Y/O AND ABOVE) SCHOOL ATTENDED member of the Family
______E.B.J_________ 1-head of the household
(initials only) 2-spouse 2-female 1- single 0 – No grade 1- Living with the family
3-son/daughter 2- Completed 2- Living elsewhere
4- father/mother 1 – elementary
Type of Family Structure: 5-grandchildren 2 – high school
6-grand parents 3 – college
7-other relatives 4 – post graduate
8-non-relatives married
____1. Patriarchal 3- widow/widower 5 – vocational
4-divorced/ separated 6 – no formal
Education
____2. Matriarchal

__/__ 3. Nuclear

____ 4. Extended

Members of the Family(Initials only)

1. E.B.J 1 66 1 2 3 1 1

2. E.C.J 2 68 2 2 3 2 1

3. MR.C.J 3 40 1 2 3 3 2

4. MA.C.J 3 39 1 2 3 4 2

5. J.C.J 3 38 1 2 3 5 2

6. J.C.J 3 34 1 2 3 6 1

7. KA.C.J 3 18 2 1 2 7 1

1
Dominant Family Member/s in terms of decision-making in health care: FATHER AND MOTHER

General Family Relationship/dynamics:

Presence of (obvious) conflict between family members: ________YES
____/____ NO

Characteristic Communication Among Family Members: ___/_______ 1. Direct (face to face)

_____/_____ 2. Indirect (Emails, Cellphones and social networking sites)

B. SOCIO-ECONOMIC AND CULTURAL CHARACTERISTICS

A. Income and Expenses of Working Family Members:

Occupation Place of Work Monthly Income Monthly Expenses

BUSINESSMAN PANGASINAN 30k —----

NURSE SAUDI ARABIA 70k —---

NURSE QATAR 150k —---

CONTRACTOR PANGASINAN 20k —----

CRYPTOMINER BINMALEY, PANGASINAN 10k —----

B. Adequate basic necessities:

Food: _____/____ YES Clothing: ___/_____ YES Shelter: ____/_____ YES
_________ NO _________ NO _________ NO

C. Ethnic Background of Family members: ASIAN-HISPANIC-FILIPIN

D. Religious Affiliations of Family Members: ROMAN CATHOLIC

E. Relationship of the Family to a Larger Community: _____/______1. Participative

___________ 2. Non-Participative

2
C. HOME AND ENVIRONMENT
1. Housing
A. Measurement of Housing Space (in terms of square meters (LxW) _______800_____________

B. Sleeping Arrangement:
___/____ 1. family members are sleeping inside the bedroom/s
________ 2. some family members are sleeping in the living room
________ 3. family members are sleeping in the kitchen

C. Presence of Breeding (vectors)Sites: ____/_____ 1. YES

_________ 2. NO

D. Presence of Accident Hazards: _________1. Yes I. Drainage System: _________ 1. Not available
_________2. No _________ 2. Open
____/______3. Blind
E. Food Storage: 2. Kind of Neighborhood
___/_____1. Cabinet
________2. Open shelves _________ lower class
___/_____3. Refrigerator ____/_____ middle class
________4. Others: _________ higher class
 F. Type of cooking fuel source primarily used: 3. Health and Social Facilities
________1. Collected woods
________ 2. Purchased wood or sawdust ____/____1. Government Hospital
____/_____2. Private Hospital
________ 3. Purchased charcoal _________ 3. Barangay Health Center
________ 4. Kerosene gas _________ 4. Private Clinic
____/____ 5. Liquefied Petroleum Gas (LPG) ____/_____ 5. Grocery/Mini –Market
_____/___ 6. Electricity _________ 6. Park
_____/____ 7. Gym/Basketball Court
_________ 8. Others: ______________________
G. Water Supply: 4. Transportation Available:
________1. Dug well
________2. Commercial water
________3. Shared tube/pipe ____/_____1. Tricycle

________4. Own use tube/ pipe _________2. Jeepney

________5. Shared faucet, community water system ____/_____3. Car

____/____6. Owned use faucet, community water system _________4. Others; ____________
________ 7. Others: ___________
3

H. Toilet facilities
Owned: ____/_____YES _______NO
_______1. Open pit
_______2. Closed pit
_______3. Water-sealed, shared with other households
_______4. Flush toilet
____/____5. Water-sealed, used exclusively by the household

D. HEALTH STATUS OF FAMILY MEMBERS

 1. Medical and Nursing History of Past or Present Illness: HYPERTENSION, ASTHMA, ANEMIA

Practices/Beliefs in Health (including Covid 19 prevention & Treatment)

Practices/Beliefs in Illness
Make Immune System Stronger
Take Vitamins Over the counter medicine
Eat Healthy Foods Drink water
Drink a lot of water
Sleep early

2. Nutritional Assessment (5 years and below, 60 years old and above)

a. Anthropometric Data (WEIGHT, HEIGHT, WAIST CICUMFERENCE, HIP CIRCUMFERENCE)

For children, compute for BMI (weight in kgs/height in meters)

For the elderly,c ompute for Waist Hip Ratio (Waist circumference in cm/Hip circumference in cm)

4
 b. Dietary History
b.1 Food intake: ____/____ 1. Fruits ____/____ 5.Beef
___/_____ 2. Vegetables ____/____ 6.Chicken
___/_____ 3. Rice/Corn ___/_____ 7. Pork
___/____ 4. Fish ____/____ 8. Shellfoods

b.2 Beverages: ___/_____ 1. Milk ___/___ 4.Tea

___/_____ 2.Coffee ___/_____ 5. Softdrinks
____/____ 3. Chocodrinks ___/_____ 6. Fruitjuice

c. Eating Practices
____/_____ eats 3 full meals a day
_________ eats 2 full meals a day
_________ eats 1 full meal a day

3. Developmental Assessment (of Infants Only)

Newborn Screening ____/______YES
__________ NO

4. Risk Factor Assessment (for adult family members)

____/____1. Hypertension
________2. Sedentary lifestyle
___/_____3. Cigarette/Vape/Tobacco smoking
________4. Inadequate Fiber intake
____/____5. Stress
____/____6. alcohol drinking
________7. elevated blood lipids
________8. others;________________

5. Physical Assessment (permission must be given by family member) to a part of the body indicating presence of illness

NONE

5
 6. Results of laboratory/diagnostic and other screening procedures supportive of assessment findings

NONE

E. VALUES, HABITS, PRACTICES ON HEALTH PROMOTION, MAINTENANCE AND DISEASE PREVENTION

1. Immunization Status of Family Members

A. Vaccines Received by Adult Family Members: ______COVID VACCINE AND ANTI RABIES_______________________________________________

B. Children Immunizations (for children 0-18 months only)

C. Type of Immunizations

Initials AGE BCG POLIO DPT HEPA

(OPV) B

2. Healthy Lifestyle Practices

_______/_______ 1. Exercises Daily
______/________ 2. Eats healthy foods
_______/________ 3. Takes supplements/ Vitamins
______/_________ 4. Sleeps atleast 7-8 hours/night
______/________ 5. Drinks 6-8 glasses of liquids/day
______/_________ 6. Protects self from vectors
_______________7. Others;_______________________