A CASE STUDY

ILLUSTRATING
THE NURSING
ASSESSMENT

Prepared by: Mark Ebony Sumalinog

Reference:
Nursing Practice in the Community (4th ed.) by Araceli Maglaya
The nursing assessment
described in this PowerPoint
presentation is a deliberate,
systematic process of
gathering and analyzing data
to identify and continuously
validate health and nursing
problems of families.
Note:

• Texts in yellow highlight are important cues/findings     taken from the

first level and second level assessment conducted by the public health
nurse.

• For first and second level assessment, refer to Table 3: Typology of

Nursing Problems in Family Nursing Practice (starting page 68) in the
scanned copy of your Family Nursing Process by Maglaya found in
Microsoft Teams.
Situation:
On an afternoon of a prenatal clinic day, the community health nurse
was going over the record files of the patients seen in the morning. She
cross checked this file with the prenatal appointment book and realized
that Mrs. A, a 37-year-old patient, on her second trimester of her
pregnancy, missed her appointment for that day. The nurse took her
family envelope and went over her record of previous follow-up.
She obtained the following data taken during the patient’s prenatal
check-up done a week ago:
• G8P7
• Age of Gestation (AOG): 21 weeks
• Blood pressure: 140/90 mmHg
• Weight: 118 lbs.
• Abdominal palpation:
• Breech Presentation
• Fundal height: 14 cm.
• Fetal heart tone: 135 bpm; RUQ
• Regular but faint
• Other significant findings: slight pedal edema
• Impression: Pregnancy Uterine, 21 weeks R/O Pre-eclampsia
• Management:
• Low salt diet
• Urinalysis
• To come back next prenatal clinic day
Since the nurse decided to do a home follow-up on the patient, she read
the clinical records of the other members of the family who have gone
to clinic for consultation.

She noted down the following data:

• Rina, 3 years old, got sick of bronchopneumonia three month ago,
weight -10 kgs
• Lita, 4 years old, and Andres, 6 years old, were brought to the clinic a
month ago for scabies; management included personal hygiene and
Benzyl Benzoate in two applications 12 hours apart and followed by a
shower after 12-24 hours.
The Assessment Process
The available data gathered during the first-level assessment reflected
possible health condition or problems:
1. Pre-eclampsia
Cues: 37-year-old mother of seven at 21 weeks AOG, with BP
140/90 mmHg and slight pedal edema; weight 118 lbs.

2. Scabies which may have not been fully cured

Cues: two preschoolers brought to the center for scabies one month
ago
3. Malnutrition which may have not been successfully managed
Cues: 3-year-old daughter weighed 10 kgs, 3 months ago

4. Family size beyond what family resources can adequately provide

Cues: a family with seven children; mother, 37 years old and
currently pregnant
NEXT
STEP
The nurse decided to do a home visit/ follow-up on this family. As part
of her preparation for the home visit, she specified the important points
that are needed to be able to do an in-depth second level assessment on
the possible health condition or problems gathered from the individual
clinical records of the family members.
By going through the following questions, she aims to determine the
family’s ABILITY TO PERFORM THE HEALTH TASKS on the
health conditions or problems identified earlier:
1. Why did Mrs. A fail to go to the clinic for check-up? What does the
family think about Mrs. A’s condition? Does the family recognize a
possible complication of pregnancy? If no, why not? If yes, what is
the family doing about it?

2. How is Rina now? Does the family recognize the existence of

malnutrition in Rina? If no, why now? If yes, what has the family
done about it? Were the solutions effective?
To be able to an adequate assessment on the other aspects of family life,
the nurse decided to also inquire about the following during the home
visit:
1. How are Lita and Andres? What has the family done about the
scabies? Were the solutions effective?
2. How are the 3 family members (Rina, Lita and Andres)? How do the
members relate with or affect each other?
3. What are the goals or plans of the family for its members and/for
itself as a functioning unit?
4. How are the conditions in the home and the community
environment?
NEXT
STEP
The afternoon of the next day, the nurse made her home visit and
obtained the following data:
• The family lives in a two-room house of light materials situated in a
congested urban community about 3 km from the health center.
• Lita and Andres have varying degrees of infected and healed skin
eruptions and scabs on their hands and feet.
• Rina looks pale, lethargic and
apathetic; with scabies, too;
markedly underweight and
undernourished.
• Mrs. A is a fish vendor in the community’s market and earns a profit of
P200/day. Mrs. A verbalized, “with the meager daily income of
P300/day my husband earns, I need to help increase the family’s
income through selling fish.”
• “I am so busy that I cannot find time to have my urine examined. But I did
not have problems during my previous pregnancies and even with my
present pregnancy. That’s why I seldom go for check-up at the clinic.”

• “But just happened that I passed by the health center on my way to my in-
laws last week, so I thought of dropping by the clinic to have a prenatal
check-up. t I actually feel alright.”

• “However, the doctor mentioned that my blood pressure was slightly

elevated. She wanted me to go back to the clinic yesterday for follow-up.
She wants to see the results of my urine examination. But the problem is
that I have plenty things to do especially in the morning. It is indeed
difficult to find time for the urine examination and the regular prenatal
consultation the clinic..”
• “One more thing, the clinic is out of my way when I go the market. But I
don’t think I have to worry because I have had seven pregnancies and they
were all normal. All of them were even home deliveries attended by a
‘hilot’ (traditional birth attendant).”

• “I have a lot of things to attend to as a fish vendor that I could hardly see
the needs of my children. The children are left at home by themselves
everyday, except for Manuel. Pedro and Cita who go to school. Nieves is
the only older child who is left to take care of the three younger ones when
we are not around. But I can’t expect her to everything. That’s the reason
why the scabies of Andres and Lita have not improved. I was able to buy
the medicine prescribed by the doctor. However, it was quite expensive that
I was not able to buy another one when it was consumed. Scabies must also
be caused by the weather. Quite a lot of children in the neighborhood have
this. See, even Rina got it, too.”
• “Rina is really small in built since she was a baby. She is not fond of
eating to.”

• “My husband and I would like to give the children a better future. We
would like them to finish even just a vocational education. With a higher
educational attainment, they would not have experience the kind of life we
have now- meager income despite hard work. We can’t really expect to
earn much since we are just elementary school graduates. We have such a
goal for our children that’s why we don’t want additional children
anymore. We have decided on this since I delivered my 5th child, Andres.
However, we have been hearing a lot of things about the methods of family
planning that cause abortion, cancer or other problems. We can’t decide a
method because of fear of possible side effects. We might have more
problems to worry about due to any of these methods.”
The other members of the family include: Mr. A, 40 years old, a
construction worker; Manuel, 14 years old, in the first year high school;
Pedro, 12 years old, in grade 6; Cita, 10 years old, in grade 4; and
Nieves, 8 years old and not yet in school.

• All the other children help in the household chores after schoolwork.
They fetch water from a public artesian well about half a kilometer
from the house.

• Mrs. A has the major responsibility in so far as the health of the family
is concerned.
The other data that the nurse observed in so far as the conditions or
resources in the home include:
• Dimension of each room is 3x3 meters
• Small screened cabinet for food storage
• One-burner gas stove for cooking purposes
• Earthen jar with cover for drinking water supply
• Dining table with 2 benches
• Lighting: electricity
• Toilet facility: closed pit privy type situated beside the garbage pit; foul
smelling and plenty of flies all over
• Garbage disposal: dumping in open pit situated at the back of the house
two meters away, with plenty of flies
The results of the in-depth second level assessment on the identified
health condition or problems are presented in the following tables. Note
that the problem statements have been defined in specific terms so as to
reflect the family’s inability to perform certain aspects of the health
tasks. Thus, the problems are stated as FAMILY NURSING
PROBLEMS.
 Cues/ Data
• 37-year-old mother of seven at 21 weeks AOG, with BP of 140/90
mmHg and slight pedal edema; weight: 118 lbs.
• Mother verbalized, “…but I did not have problems during my
previous pregnancies and even with my present pregnancy… It just
happened that I passed by the health center on my way to my in-laws
last week, so I thought of dropping by the clinic to have a prenatal
check-up. But I actually feel alright.”
• Busy with work as a fish vendor, hardly has time to go to the center
for follow-up.
• Has major responsibility on health matters
• Health center is 3 kilometers from the house
• Laboratory for urinalysis is 10 kilometers away; not situated within
the community
Blue: First level assessment (may use Nanda or Maglaya)
Green: Second level assessment (only from Maglaya)
Refer to the scanned copy of the Family Nursing Process by Maglaya in Teams.
Family Nursing Problems
A. Possible Complicated Pregnancy
1. Inability to recognize presence of a possible
complications of pregnancy due to lack of
knowledge.
2. Inability to provide adequate nursing care to a
pregnant member due to:
a. Lack of knowledge on the nature and
management of the health condition
b. Lack of knowledge on the nature and extent of
nursing care needed
3. Failure to utilize community resources for health
care due to:
a. Failure to perceive benefits of healthcare
b. Physical inaccessibility of required service
facility for urinalysis, i.e. in terms of distance
from the house.
 Cues/ Data
• Rina, 3 years old, looks pale, lethargic and apathetic; weighs 10 lbs;
markedly underweight and undernourished.
• Mother verbalized, “Rina is really small in built since she was a
baby. She is not fond of eating.”
• Three preschool members usually are left to the care of an 8-year-old
sister (Nieves) when parents are working, and older children are in
school.
• Mother is very busy helping earn a living that she could hardly see/
attend to the needs of the children.
• Family income is P500/day (P300 from father and P200 from Mrs.
A.)
Blue: First level assessment (may use Nanda or Maglaya)
Green: Second level assessment (only from Maglaya)
Refer to the scanned copy of the Family Nursing Process by Maglaya in Teams.
Family Nursing Problems
A. Malnutrition as health deficit
1. Inability to recognize the presence of malnutrition in
dependent member due to lack of knowledge.
2. Inability to decide about taking appropriate health
action due to failure to comprehend the nature,
magnitude and scope of the problem.
3. Inability to provide adequate nursing care to a
member suffering from malnutrition due to:
a. Lack of knowledge about the health condition
b. Lack of knowledge on the nature and extent of
nursing care needed
c. Inadequate resources, i.e. responsible family
member and financial constraints
 Cues/ Data Family Nursing Problems
• The preschoolers have scabies A. Scabies as a health deficit
• Mother verbalized, “I have a lot of things to attend to as a fish
1. Inability to provide adequate nursing care to
vendor that I could hardly see the needs of my children… Nieves is preschoolers with scabies due to:
the only older child who is left to take care of the three younger ones a. Lack of knowledge about the health condition
when we are not around. But I can’t expect her to everything. That’s b. Inadequate knowledge of the nature and extent
the reason why the scabies of Andres and Lita have not improved. I
was able to buy the medicine prescribed by the doctor. However, it of nursing care needed
was quite expensive that I was not able to buy another one when it c. Inadequate family resources for care,
was consumed. Scabies must also be caused by the weather. Quite a specifically:
lot of children in the neighborhood have this. See, even Rina got it,
too.”
• Responsible family member
• Financial resources
• Family income is P500/day • Physical resources: water supply facilities
• Water supply is taken from a public well ½ kilometer from the house
(factor that may affect family hygiene)

Blue: First level assessment (may use Nanda or Maglaya)

Green: Second level assessment (only from Maglaya)
Refer to the scanned copy of the Family Nursing Process by Maglaya in Teams.
 Cues/ Data
• Rina contracted the scabies of the two older sibling
• Mother believes that scabies is due to weather condition
• Family lives in a two-room house; each room has a dimension of 3x3
meters (small space may not allow proper isolation of family
members with scabies)
• Water supply comes from a public well ½ kilometers from the house
Blue: First level assessment (may use Nanda or Maglaya)
Green: Second level assessment (only from Maglaya)
Refer to the scanned copy of the Family Nursing Process by Maglaya in Teams.
Family Nursing Problems
A. Threat of cross-contamination from a communicable
disease
1. Inability to recognize the presence of malnutrition in
dependent member due to lack of knowledge.
2. Inability to make decisions with respect to taking
appropriate health action on the threat due to failure
to comprehend the nature of the problem.
3. Inability to provide a home environment conducive
to health maintenance and personal development due
to:
a. Ignorance of preventive measures
b. Inadequate family resources, specifically:
• Financial resources
• Physical facilities: living space and water
supply
 Cues/ Data Family Nursing Problems
• Family has nine members (7 children + couple) with a gross income A. Family size beyond what family resources can
of P500 a day and three children are still studying
adequately provide
• Mother is still child-bearing; she’s very busy earning a living that she 1. Inability to make decisions with respect to taking
cannot take care of the children appropriate health actions due to lack of knowledge
as to alternative courses of action open to the family.
• Mother verbalized, “My husband and I would like to give the
children a better future. We would like them to finish even just a
vocational education… We have such a goal for our children that’s
why we don’t want additional children anymore. We have decided on
this since I delivered my 5th child, Andres. However, we have been
hearing a lot of things about the methods of family planning that
cause abortion, cancer or other problems. We can’t decide a method
because of fear of possible side effects. We might have more
problems to worry about due to any of these methods.”

Blue: First level assessment (may use Nanda or Maglaya)

Green: Second level assessment (only from Maglaya)
Refer to the scanned copy of the Family Nursing Process by Maglaya in Teams.
The results of the nurse’s first level assessment on the home and
environmental conditions are presented on the next slide.

Second level assessment on these health condition or problems will be

done as soon as she gets the opportunity to determine how the
family is able to perform the health tasks on all of these.
 Cues/ Data Family Nursing Problems
• Nine members stay in a two-room house; each room with a A. Inadequate living space
dimension of 3x3 meters

• Family income is P500 a day

• Garbage disposal is dumping in an open pit situated at the back of B. Improper garbage disposal
the house, two meters away, with plenty of flies all over

• Type of toilet facility is closed pit privy, foul smelling and with
plenty of flies, situated at the back of the house
C. Unsanitary waste disposal

Blue: First level assessment (may use Nanda or Maglaya)

Green: Second level assessment (only from Maglaya)
Refer to the scanned copy of the Family Nursing Process by Maglaya in Teams.
Effective nursing of clients depends on the accurate description of each
health and nursing problem.

The assessment process offers the nurse the opportunity to strengthen her
skill at making sound judgment using data based on EVIDENCE.

It challenges her mind to evaluate assumptions and arrive at valid

conclusions.

By going through the process of data collection and analysis, she learns that
the client have varied views of life, that they hold different aspirations and
that they respond to situations or problems in unique ways. It’s the nurse’s
way of learning about the families’ way of knowing.
DEVELOPING
THE NURSING
CARE PLAN
Araceli S. Maglaya
Family Care Plan (FCP)
The blueprint of the care that the nurse designs
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, methods and tools.
 The FCP focuses on actions (approaches,
strategies, activities, methods and materials)
which are designed to solve of minimize
existing problems.

Features The FCP is a product of deliberate

systematic process. The planning process is
characterized by logical analysis of data that
are put together to arrive at rational decisions.
The interventions the nurse decides to
implement are chosen from alternatives after
careful analysis and weighing of available
options.
3. The FCP relates to the future. It utilizes events in the past and what is
happening in the present to determine patterns. It also projects the future scenario
if the current situation is not corrected.

4. The FCP is based upon identified health and family nursing problems.

5. The FCP is a means to an end, not an end itself. The goal in planning is to
deliver the most appropriate care to the client by eliminating barriers to family
health development.
6. The FCP is a continuous process, not a one-shot deal. The result
of the evaluation of the plan’s effectiveness trigger another cycle of
the planning process until the health and nursing problems are
eliminated.
Desirable Qualities of an FCP
1. BASED ON CLEAR, EXPLICIT DEFINITION OF THE
PROBLEM(S).
• A goof FCP is based on comprehensive analysis of the problem situation.
Contributory causes of the health condition or family nursing problem should
be identified.

2. A GOOD PLAN IS REALISTIC.

• Can be implemented with a reasonable chance of success.
• Determined by the quantity and quality of resources required in the
implementation.
3. THE FCP IS PREPARED JOINTLY WITH THE FAMILY.
• Involves the family in determining health needs and problems, in establishing
priorities , in selecting appropriate course of action, implementing and
evaluating them. The nurse makes the family feel that the health of its
members is a family responsibility.

4. THE FCP IS MOST USEFUL IN WRITTEN FORM.

• It is means of communication not only among nurses but also with the other
members of the healthcare team.
• It is impossible to keep many nursing plans in her mind and remember the
salient points of care
• It also serves as a useful administrative device for evaluating staff
performance and the quality of care provided to clients.
 1. They individualize care to clients.
2. Helps in setting priorities by providing
information about the client as well as the
nature of the problems.
3. Promotes systematic communication among
Importance of 4.
those involved in the health care effort.
Continuity of care is facilitated. Gaps and
Planning Care duplication of services (due to frequent staff
turn-over) are minimized.
5. Facilitates the coordination of care by
making known to other members of the
health team what the nurse is doing.
STEPS IN
DEVELOPING A
FAMILY NURSING
CARE PLAN
 PRIORITIZE THE HEALTH DEVELOP THE EVALUATION PLAN
PROBLEMS BASED ON: Specify:
• Nature of condition or problem • Criteria/ Outcomes based on objectives of care
• Modifiability (quantitative or qualitative)
• Preventive potential • Methods/ Tools
• Salience

DEVELOP THE INTERVENTION PLAN

DEFINE GOALS AND OBJECTIVES OF
CARE
Formulate:
• Expected outcomes
• Conditions to be observed to show problem
is prevented, controlled, resolved or
eliminated
• Client response/s or behavior
• Specific, Measured, Client-centered
statements/ competencies
• Decide on:
• Measures to help family eliminate:
• Barriers to performance of health tasks
• Underlying cause/s of non-performance of
health tasks
• Family centered alternatives to recognize/
detect, monitor, control or manage health
conditions or problems
• Determine the methods of Nurse-Family contact
(Home Visit, Clinic Visit, etc.)
• Specific resources needed
 Prioritizing Health Problems

Bailon and Maglaya (1990)

devised a tool called SCALE
OF RANKING OF HEALTH This tool aims to objectivize
CONDITIONS AND PRIORITY SETTING.
PROBLEMS ACCORDING
TO PRIORITIES.
 SCALE OF RANKING HEALTH CONDITIONS AND PROBLEMS ACCORDING TO PRIORITIES

CRITERIA WEIGHT SCORE JUSTIFICATION

A. Nature of the condition or problem

presented
• Wellness state 3
• Health Deficit 3 x1
• Health Threat 2
• Foreseeable crisis 1

B. Modifiability of the condition or problem

• Easily modifiable
• Partially modifiable 2
• Not modifiable 1 x2
0
 CRITERIA WEIGHT SCORE JUSTIFICATION

C. Preventive Potential
• High 3
• Moderate 2 x1
• Low 1

D. Salience
• A condition or problem needing immediate
attention 2
• A condition or problem not needing x1
immediate attention 1
• Not perceived as a problem or condition
needing change 0

Scoring:
1. Decide on a score for each criteria.
2. Divide the score by the highest possible score and multiply by the height (Score/Highest score) x Weight
Ex. Modifiability: You gave a score 2. So (2/3) x 2 = 1.33 (2 decimal places)
3. Sum up the scores for all the criteria (A+B+C+D). The highest score is 5.
LET US DISSECT THE
TOOL
 There are four
criteria for A. Nature of the condition or
determining problem
priorities among B. Modifiability
C. Preventive potential
health
D. Salience
conditions or
problems.
A. Nature of the condition or problem
Categorized into (1) wellness state/ potential, (2) health threat, (3)
health deficit, and (4) foreseeable crisis.
1. Wellness state- Stated as Potential or Readiness- a client transition
from a specific level of wellness or capability to a higher level
(NANDA, 2011)
• Wellness potential is a nursing judgment on wellness state or condition based
on client’s performance, current competencies, or clinical data but no explicit
expression of client desire. (see scanned copy under 1st level assessment)
• Readiness for enhanced wellness state is a is a nursing judgment on wellness
state or condition based on client’s performance, current competencies, or
clinical data and explicit expression or desire to achieve a higher level of state
or function in a specific area on health promotion and maintenance. (see
scanned copy under 1st level of assessment)
2. Health Deficit- Instances or failure in health maintenance. Examples
include:
A. Illness states, whether diagnosed or undiagnosed
B. Failure to develop/ thrive according to normal state
C. Disability- whether congenital or arising from illness

(See scanned copy under 1st level assessment)

3. Health Threat- Conditions that conducive to disease and accident, or
may result to failure to maintain wellness or realize health potential.

Examples are the following:

A. Presence of risk factor of specific diseases
B. Threat to cross infection from a communicable disease case
C. Family size beyond what the family resources can adequately provide
D. Accident hazards
E. Faulty/ Unhealthy/ nutritional eating habits or feeding techniques practices
F. Stress provoking factors
G. Poor home and environmental condition/ sanitation
H. Poor home and environmental condition/ sanitation
I. Unsanitary food handling and preparation
J. Unhealthful lifestyle and personal habits/ practices
K. Inherent personal characteristics
L. Health history which may induce the occurrence of a health deficit
M. Inappropriate role assumption
N. Lack of immunization
O. Family disunity
P. Others (specify)

(See scanned copy under 1st level assessment)

4. Presence of stress points or Foreseeable crisis- anticipated periods of
unusual demand on the individual or family in terms of adjustments/
family resources.

Examples are the following:

A. Marriage
B. Pregnancy
C. Parenthood
D. Additional member (newborn, lodger)
E. Abortion
F. Entrance at school
G. Adolescence
H. Divorce or separation
I. Menopause
J. Loss of Job
K. Hospitalization of a family member
L. Death of a member
M. Resettlement in a new community (relocation)
N. Illegitimacy
O. Others (specify)

(See scanned copy under 1st level assessment)

B. Modifiability of the condition or problem
Refers to the probability of success in enhancing the wellness state,
improving the condition, minimizing, alleviating or totally eradicating
the problem through intervention.

The nurse considers the availability of the following factors in

determining the modifiability of the health condition of problem:
1. Current knowledge, technology and interventions to manage problem
2. Resources of the family (physical, financial and manpower)
3. Resources of the nurse
4. Resources of the community
C. Preventive Potential
Refers to the nature and magnitude of future problems that can be
minimized or totally prevented if intervention is done on the condition
or problem under consideration

To decide on the score, the following factors are considered:

• Gravity or severity of the problem: extent of damage to the patient or family;
the more severe the or advance the problem, the lower the preventive
potential.
• Duration of the problem: length of time the problem has been existing.
Duration has direct relationship to gravity.
• Current management: presence of appropriate intervention instituted to
enhance the wellness state or remedy the problem.
• Exposure of any vulnerable or high-risk group
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.

Family’s felt needs and readiness increase the score on salience.

LET US NOW
APPLY THE
TOOL TO THE
CASE OF MRS. A
Problem A: POSSIBLE PRE-ECLAMPSIA
CRITERIA WEIGHT SCORE JUSTIFICATION
A. Nature of the condition or problem presented The problem is a health deficit and
• Wellness state 3 requires more immediate
• Health Deficit 3 x1 intervention.
• Health Threat 2
1
• Foreseeable crisis 1

B. Modifiability of the condition or problem The resources and interventions

• Easily modifiable 2 needed to solve the problem are
• Partially modifiable 1 x2 2 available to the family.
• Not modifiable 0

C. Preventive Potential The possibility of complications during

• High 3 labor and delivery and occurrences of
• Moderate 2 x1 1 abnormalities in the infant are prevented if
pre-eclampsia is eliminated as early as
• Low 1 possible.
D. Salience The family does not recognize the
• A condition or problem needing immediate attention 2 existence of the problem.
• A condition or problem not needing immediate attention
• Not perceived as a problem or condition needing change 1 x1 0
0

TOTAL 4
Problem B: MALNUTRITION
CRITERIA WEIGHT SCORE JUSTIFICATION
A. Nature of the condition or problem presented It is a health deficit that requires immediate
• Wellness state 3 management to eliminate untoward consequence.
• Health Deficit 3 x1 1
• Health Threat 2
• Foreseeable crisis 1
B. Modifiability of the condition or problem The problem is easily modifiable since the nurse’s
• Easily modifiable 2 resources are available; she can help the family on
• Partially modifiable 1 x2 effective budgeting of money and scheduling of time;
• Not modifiable 0 2 she can develop the skills of other members to achieve
good nutrition, proper food selection and preparation
and feeding practices.

C. Preventive Potential Susceptibility to other diseases and infections can

• High 3 be prevented if malnutrition is eliminated; normal
• Moderate 2 x1 1 growth and develop can thus be achieved.
• Low 1
D. Salience It is not a felt problem.
• A condition or problem needing immediate attention 2
• A condition or problem not needing immediate attention
• Not perceived as a problem or condition needing change 1 x1 0
0

TOTAL 4
Problem C: SCABIES AS A HEALTH DEFICIT
CRITERIA WEIGHT SCORE JUSTIFICATION
A. Nature of the condition or problem presented It is a health deficit that requires immediate
• Wellness state 3 attention and adequate management to reduce
• Health Deficit 3 x1 likelihood of transfer of the disease to the rest of
• Health Threat 2 1 the family members.
• Foreseeable crisis 1

B. Modifiability of the condition or problem The family does not have adequate resources to
• Easily modifiable 2 solve the problem. Inadequacy of living space and
• Partially modifiable 1 x2 1 water supply are barriers to achieve god hygiene.
• Not modifiable 0

C. Preventive Potential Transferability of scabies to other family members

• High 3 is reduced or eliminated if the problem is managed
• Moderate 2 x1 1 adequately as soon as possible.
• Low 1

D. Salience The family recognizes it as a problem. Mrs. A

• A condition or problem needing immediate attention 2 consulted the health personnel a month ago.
• A condition or problem not needing immediate attention However, she does not see the problem as needing
immediate attention.
• Not perceived as a problem or condition needing change 1 x1 1
0

TOTAL 4
Problem D: FAMILY SIZE BEYOND WHAT FAMILY RESOURCES CAN ADEQUATELY PROVIDE
CRITERIA WEIGHT SCORE JUSTIFICATION
A. Nature of the condition or problem presented It is a health threat since family income is not
• Wellness state 3 adequate for a family of 9. This can lead to
• Health Deficit 3 x1 future problems if not given attention.
• Health Threat 2
0.67
• Foreseeable crisis 1

B. Modifiability of the condition or problem Current knowledge, interventions and resources

• Easily modifiable 2 are available to solve the problem.
• Partially modifiable 1 x2 2
• Not modifiable 0

C. Preventive Potential The possibility of increasing family size is

• High 3 reduced; the available family resources can be
• Moderate 2 x1 1 utilized to encourage growth promoting
experiences for members.
• Low 1

D. Salience The family perceives it as a serious problem

• A condition or problem needing immediate attention 2 needing attention to ensure that her fifth
• A condition or problem not needing immediate attention pregnancy was the last one.
• Not perceived as a problem or condition needing change 1 x1 1
0

TOTAL 4.67
GIVEN WE ARE DONE COMPUTING,
LET US NOW COMPARE THE TOTAL
SCORES FROM EACH FAMILY
NURSING PROBLEM.
The prioritized health problems
The list of health conditions or problems ranked according to priorities
is presented:
Family Nursing Problem Score Rank
Family size beyond family resources 4.67 1
Possible pre-eclampsia 4 2
Malnutrition 4 2
Scabies as threat and deficit 4 2
Improper garbage disposal* 3.67 3
Unsanitary waste disposal* 3.67 3
Inadequate living space* 2.67 4

Note: (*)- assuming we are done computing for their individual scores.
WE ARE NOW READY TO
DEVELOP THE GOALS
AND OBJECTIVES
GOAL
• Is a general statement of the condition or state to be brought about by
specific course of action.

• Cardinal principle: Goal setting states that goals must be set jointly
with the family to ensure commitment. The nurse must ascertain
family’s recognition and acceptance of existing health needs and
problems.
Barriers to joint goal setting between the
nurse and the family

1. Failure on the part of the family to perceive the existence of the

problem.
2. The family may realize the existence of the problem BUT is too
busy at the moment with other concerns.
3. Sometimes the perceives the existence of a problem but does not see
it as serious enough to warrant attention.
4. The family may perceive the presence of the problem and the need
to take action; however, refuse to face and do something about it
because:
a) Fear of consequence of taking action (ex. Diagnosis of a disease may mean
expenses for the family or stigma against them)
b) Respect for tradition
c) Failure to perceive the benefits of action proposed (this could be a result of
previous experiences with health workers and their services)
d) Failure to relate the proposed action to the family’s goals

5. Failure to develop a working relationship

OBJECTIVE
• Refers to more specific statements of the desired results or outcome of
care.
• They specify the criteria by which the degree of effectiveness of care
to be measured.
• Goals tell where the family is going; objectives are the milestones to
reach the destination
• The more specific the objectives, the easier is the evaluation of their
attainment.
Objectives vary according to time span required for their realization.
• Short-term or immediate objectives
• Formulated for problem needing immediate attention
• Results observed in a relatively short period of time
• Accomplished with few nurse-family contact
• Use of relatively less resources

• Long-term or ultimate objectives

• Require several nurse-family contact
• Investment of more resources
• Requires more time to demonstrate
• Behavior change is often the object of nursing intervention
• Medium-term or intermediate objectives
• Those that are not immediately achieved and are required to attain the long
term ones.

Examples of short-, medium- and long-term objectives:

• Short term: the sick members will take the drugs accurately as to dose, frequency,
duration, and drug combination. All members will use self-protection measures at
night till early morning when biting time of malaria vector is expected.
• Medium-term: all members will have medical check-up and laboratory
confirmation (i.e. blood smear) to diagnose malaria.
• Long-term: all members will carry out mosquito vector control measures.

Note: Be S-M-A-R-T in making the objectives. Action verbs must be used since the
nurse wants to OBSERVE changes.
 DEVELOPING THE
INTERVENTION PLAN
Click to add text
• This involves selection of appropriate nursing interventions based on
the formulated goals and objectives.

• The nurse selects from a set of alternatives, specifying the most

effective or efficient method of nurse-family contact (home visit,
clinic visit, telephone calls, etc.)

• The resources which include material or human must be specified in

the plan to ensure that necessary preparations, coordination and
collaboration are done before the implementation phase.
General directions can guide you in selecting
appropriate nursing interventions:
1. Analyze with the family the current situation and determine the choices and
possibilities based on lived experience of means and concerns.

2. Develop/ Enhance cognition, volition and emotion (Thinker, Doer and Feeler)
• Thinker: make information readily available and accessible for ease of and confidence in
understanding current situations in health and illness.
• Doer: developing and maximizing the skills and communication competencies; enhance
confidence in carrying out the needed interventions to initiate and sustain change for health
promotion and maintenance and accurate disease management.
• Feeler: develop or strengthen its affective competencies in order to acknowledge and
understand emotions generated by family life or health and illness situation (fear, anger,
anxiety, etc)
3. Focus on interventions to help the family perform the health tasks
a. Help the family recognize the problem
b. Guide the family on how to decide on appropriate health actions to take
c. Develop the ability and commitment to provide nursing care to its members
d. Enhance the capability of the family to provide a home environment conducive to health
maintenance and personal development
e. Facilitate the family’s capability to utilize community resources for health care.

Contracting is a creative intervention that can maximize opportunities to develop the ability
and commitment of the family to provide nursing care to its members. The nurse creates a situation
in order that the client learns to achieve specific health-related behavior through sequentially
arranged explicit steps and conditions or elements jointly identified by both parties.
This intervention uses reinforcement contracts on a variety of health-related behavior requiring
complex behavioral changes. Such complex changes requires positive reinforcement.
4. Catalyze behavior through motivation and support
To catalyze the change, support is needed so that an otherwise insecure, threatened or
anxious client who is faced with the stresses of the change process can experience stability to
sustain actions and complete the behavior change.

HEALTH FAMILY NURSING
PROBLEM PROBLEMS
3. Malnutrition 1. Inability to recognize the
presence of malnutrition in
dependent member due to
lack of knowledge.
2. Inability to decide about
taking appropriate health
action due to failure to
comprehend the nature,
magnitude and scope of the
problem.
3. Inability to provide
adequate nursing care to a
member suffering from
malnutrition due to:
4. Lack of knowledge about
the health condition
5. Lack of knowledge on the
nature and extent of nursing
care needed
6. Inadequate resources, i.e.
responsible family member
and financial constraints
INTERVENTION PLAN
OBJECTIVES OF METHOD OF
GOAL OF CARE
CARE NURSE- RESOURCES
NURSING INTERVENTIONS
FAMILY REQUIRED
CONTACT
After nursing After nursing 1. Discuss: Home visit Material resources:
intervention, Rina’s intervention, the family a. The implications of the • Visual aids
nutritional status will will: signs and symptoms of • Kitchen stuff for
improve from second a. Avail itself of food malnutrition observed demonstrating
degree malnutrition to at supplements in Rina preparation of low-
least first degree in six provided by health b. The consequences of cost menus
months time. and related agencies malnutrition
for pre-school 2. Discuss with the family the Time and effort of the
malnourished reasons for Rina’s malnutrition; nurse and family
children inquire about and observe the members
b. Be able to plan and family’s food selection and
prepare balanced preparation and the eating Expenses for teaching
Click tomeals
addwhich
text are habits/ practices of Rina. aids and transportation of
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within family’s 3. Discuss with the family the the nurse
budget. courses of action open to them,
c. Feed Rina according specifically:
to agreed upon a. Explore the possibility
quantity and quality of arranging the
of food and manner schedule of all members
of feeding such that responsible
d. Make Rina’s weight ones take turns in
increase by at least 1 seeing to the needs of
pound per month the younger ones when
Mrs. A is not around
 INTERVENTION PLAN
HEALTH FAMILY NURSING OBJECTIVES OF METHOD OF
GOAL OF CARE
PROBLEM PROBLEMS CARE NURSE- RESOURCES
NURSING INTERVENTIONS
FAMILY REQUIRED
CONTACT
c. Use of, ‘contracting’ as
motivational strategy to
encourage family
members to participate
in providing care to
Rina

4. Develop the skills of family

members on proper food
selection and preparation and
feeding practices utilizing low-
cost menus and food
supplements provided by health
agencies and community
resources.

5. Guide the family in using

“contracting” as motivational
strategy

6. Make proper referral to existing

agencies on nutrition so that the
family can avail itself of food
supplements for Rina.
 INTERVENTION PLAN
HEALTH FAMILY NURSING OBJECTIVES OF METHOD OF
GOAL OF CARE
PROBLEM PROBLEMS CARE NURSE- RESOURCES
NURSING INTERVENTIONS
FAMILY REQUIRED
CONTACT
4a. Scabies as a 1. Inability to provide After nursing After nursing 1. Involve all the children, Home visit Material resources:
health deficit adequate nursing care to intervention, the scabies intervention, the family including the preschoolers, in • Visual aids
preschoolers with scabies of the 3 preschoolers will will be able to apply discussing about the nature of • Low-cost supplies that
due to: heal in 3 months times. therapeutic measures, scabies, its signs and symptoms treat scabies
a. Lack of knowledge include skin care, to and the proper care needed.
about the health manage the scabies of 3 2. Discuss the possible ways of Time and effort of the
condition members. providing adequate treatment nurse and the family
b. Inadequate of scabies utilizing less
knowledge of the expensive drugs and supplies Expenses for teaching
nature and extent of like sulfur soap. aids and transportation to
nursing care needed 3. Demonstrate to the mother and the nurse.
c. Inadequate family other members the preparation
resources for care, of Kalatsutsi bark (Plumera
specifically: acuminate) or Makabuhay
• Responsible family (Tinospora rumphii) cooked in
member coconut oil and its application
• Financial resources to the affected skin.
• Physical resources: 4. Emphasize the importance of
water supply personal hygiene and proper
facilities washing of clothes and
beddings.
5. Explore with the family ways
of implementing measures to
eliminate mite that causes
Scabies.

HEALTH FAMILY NURSING
PROBLEM PROBLEMS
4b. Scabies as a 1. Inability to recognize the
health threat to presence of malnutrition in
the rest of the dependent member due to
family lack of knowledge.
2. Inability to make decisions
with respect to taking
appropriate health action on
the threat due to failure to
comprehend the nature of
the problem.
3. Inability to provide a home
environment conducive to
health maintenance and
personal development due
to:
a. Ignorance of
preventive measures
b. Inadequate family
resources,
specifically:
c. Financial resources
d. Physical facilities:
living space and
water supply
INTERVENTION PLAN
OBJECTIVES OF METHOD OF
GOAL OF CARE
CARE NURSE- RESOURCES
NURSING INTERVENTIONS
FAMILY REQUIRED
CONTACT
After nursing After nursing 1. Discuss with the family the Home visit Material resources:
intervention, the intervention, the family nature, cause, signs and • Visual aids
possibility of cross- will: symptoms of scabies, and the • Materials for personal
contamination of scabies 1. Correct its wrong consequences if proper hygiene and home
will be minimized or notions about the management is not done. sanitation (specify)
prevented. cause of scabies 2. Explore with the family ways
2. Implement the agreed of implementing measures to Time and effort of the
upon measures to maintain personal hygiene nurse and family
improve personal especially among dependent
hygiene of family members. Expenses for the
members and home 3. Explore with the family ways transportation of the
sanitation of implementing sanitation nurse.
3. Recognize beginning measures (e.g. management of
cases of scabies and used clothing and bedding/
apply immediate linen) maximizing resources.
therapeutic measures.
 AFTER THE NURSE HAS
CONSTRUCTED HER FAMILY
NURSING CARE PLAN, SHE NOW
PROCEEDS TO MAKING HER
TEACHING AND HOME VISIT
PLAN.
LATER, DEVELOPS TEACHING
MATERIALS TO BE USED DURING
THE HOME VISIT.
A CASE STUDY
ILLUSTRATING
THE NURSING
ASSESSMENT
Prepared by: Mark Ebony Sumalinog

Reference:
Nursing Practice in the Community (4th ed.) by Araceli Maglaya