College of Nursing

FAMILY NURSING CARE PLAN

PATIO TIRONA HEALTH CENTER

PRESENTED TO: MR. LEON L. FOJAS, RN, MAN

CLINICAL INSTRUCTOR

PRESENTED BY: MS. CATHERINE DE LA REA

BSN 32 GROUP 4
 FAMILY NURSING CARE PLAN

HEAD OF THE FAMILY: _________________________

FAMILY MEMBER: ____________________________
ADDRESS: ___________________________________
FAMILY STRUCTURE: __________________________
PLACE OF ORIGIN: ____________________________
RELIGION: __________________________________
ETHNIC GROUP: _________________________________

I. Assessment of Family Structures and Dynamics/ Socio – Economic and Cultural Characteristics: A.
Family Structure/Socio Economic
Family Member Relation to Head Sex Birthdate Civil Highest Educ. Occupation Monthly Remarks
Status Completed earning

No. Name Month Year Age Type of Place

Work
 a.1 Dominant Family Members in terms of decision making especially on the aspect of health care: __________________________________
a.2. Presence of any obvious /readily observable conflict between members of the family: ( ) yes ( ) No
a.3 Adequacy to meet basic necessities (foods, clothing, shelter etc.) ( ) yes ( ) No
a.4 Who makes decisions about money: ________________________
a.5. Membership in an Organization: ( ) yes ( ) No Name of
the organization: ________________________________
Nature of Organization: __________________________________
Position in the organization: ______________________________
B. Home and Environment
Date Assessed__________________________________
1. Home
a. Ownership: ( ) Owned ( ) Rented ( ) Rent – free
b. Construction Materials used: ( ) Light ( ) Mixed ( ) Strong
c. Number of rooms used for sleeping: ____________________
d. Lighting facilities: ( ) Electricity ( ) Kerosene ( ) others. Specify: _________________
e. Ventilation: ( ) good ( ) poor
f. General Sanitary Condition (Overall surroundings of house and environment):
____________________________________________________________________________________________________________
_______________________________________________________________
2. Drinking Water Supply
Source: ( ) Private ( ) Public Potability: ________________________________
Distance from house: _____________________________________
Storage: ( ) None (Direct from faucet or pipe)
( ) Large covered container with faucet
( ) Large uncovered container without faucet
 ( ) Others, Specify: __________________________
3. Kitchen
Cooking facility: ( ) electric stove ( ) gas stove ( ) firewood/charcoal
Sanitary condition: ____________________________________
Drainage Facility: ( ) open drainage ( ) blind drainage ( ) none
4. Waste Disposal
a. Refuse and garbage
Container: ( ) covered ( ) open ( ) none
Method of disposal:
( ) hog feeding ( ) composting
( ) open dumping ( ) open burning
( ) burial in pit ( ) others, specify ____________________

b. Toilet Type
( ) None ( ) Pail system
( ) overhang latrine ( ) Antipolo
( ) open pit privy ( ) water sealed latrine
( ) closed pit privy ( ) flushed type
( ) bore hole latrine
( ) others, specify: _________________________-
Distance from house: ______________________
Sanitary Condition: _______________________________________________

5. Domestic Animals

Kind Number Where kept

6. Nutrition
a. Food preferences (general/day)
( ) vegetables ( ) pork ( ) beef ( ) chicken ( ) fish
Number of glasses consumed/day:
Juice: ____________________
Water: ___________________
Softdrinks: ________________
Number of meals/day: _____________________
Number of snacks/day: ____________________
b. Ways and means of food preparation (Most of the time)
( ) prepared at house ( ) instant meals ( ) others, specify: _____________________
7. The Community in General
a. General Sanitary Condition: _______________________________________
b. Housing Congestion: ( ) YES ( )NO
c. Recreational Facilities: ___________________________________________
d. Availability of health care services (Describe briefly): _____________________________________________________________
e. Distance of house from the nearest health care facility: __________________________________________________________
8. Other Information
a. Personal Habits (15 years old and above)
Name: _______________________________
 ( ) Smoking number of packs/day: ____________________
( ) Drinking alcoholic beverages
( ) Prohibited drugs
b. Family Planning
( ) Acceptor ( ) defaulter ( ) Non acceptor
Method: _____________________________

C. Health Status of Each Family Member

i. Nursing history indicating:
1. Present and past significant illnesses or beliefs and practices conducive to heath and illness.
2. Dietary History (quality, quantity of food intake per day.
3. Eating and feeding habits and practices.
ii. Developmental Assessment for infants, toddlers and preschooler (MMDST)s: iii. PHYSICAL ASSESSMENT/RESULT OF
LABORATORY/DIAGNOSTIC EXAM. (PREVIUS OR LATEST) OF ALL FAMILY MEMEBERS
SYSTEM ROS P.E.
General/ Overall Health Status
SHEENT
CHEST/LUNG
CARDIO
ABDOMEN
GUT
EXTREMITIES

D. Values, Habits. Practices on Health Promotion, Maintenance and Disease Prevention

1. Immunization status of Family members
 Name Age BCG HEPA B OPV DPT Vit. M Remarks
VAC A Vac
1 2 3 1 2 3 1 2 3

2. Healthy Lifestyle Practices: ( ) yes ( ) No

Specify; _______________________________________________
3. Adequacy of rest and sleep: ( ) yes ( )No How many hours: ________________

4. Relaxation/ Stress management: ( ) Yes ( ) No

Specify: ______________________
5. Use of Protective measures:
( ) Mosquito net ( ) footwear (protective clothing () others, specify:
___________________________________ II.
PROBLEM SHEET
Health Conditions and Problems Cues/Data Family Nursing Problems
III. Prioritization of Nursing Problem

A. SCALE FOR RANKING HEALTH CONDITIONS AND PROBLEMS ACORDING TO PRIORITES

SCALE FOR RANKING HEALTH CONDITIONS AND PROBLEMS ACORDING TO PRIORITES
CRITERIA WEIGHT
1.NATURE OF THE CONDITION OR PROBLEM PRESENTED 1
A. WELLNESS STATE 3
B. HEALTH DEFECIT 3
C. HEALTH THREAT 2
D. FORSEABLE CRISIS 1
 2. MODIFIABILTY OF THE CONDITION OR PROBLEM 2
A. EASILY MODIFIABLE 2
B. PARTIALLY MODIFIABLE 1
C. NOT MODIFIABLE 0
3. PREVENTIVE POTENTIAL 1
A. HIGH 3
B. MODERATE 2
C. LOW 1
4. SALIENCE 1
A. A CONDITION OF THE PROBLEM NEEDING 2
IMMEDIATE ATTENTION.
B. A CONDITION OF THR PROBLEM NOT NEEDING 1
IMMEDAITE ATTENTION
C. NOT PERCEIVED AS A PROBLEM OR CONDITION 0
NEEDING CHANGE.
SCORING:
1. DECIDE ON A SCORE FOR EACH OF THE CRITERIA.
2. DIVE THE SCORE BY THE HIGHEST POSSIBLE SCORE AND MULTIPLY BY THE WEIGHT. (SCORE/HIGHEST SCOREX WEIGHT)
3. SUM UP THE SCORE FOR ALL THE CRITERIA. THE HIGHEST SCORE IS 5 EQUIVALENT TO THE TOTAL WEIGHT.
MAGLAYA, A.S 2003. NURSING PRACTICE IN THE COMMUNITY. ARGONAUTA CORP. PHILIPPINES
B. CASE ILLUSTRATION ON PRIORITY SETTING
 (PROBLEM)
CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION

NATURE OF THE PROBLEM

MODIFIABILITY OF THE PROBLEM

PREVENTIVE POTENTIAL

SALIENCE

TOTAL SCORE

IV. FAMILY NURSING CARE PLAN

HEALTH FAMILY NURSING OBJECTIVES OF PLAN OF INTERVENTION EVALUATION PLAN
PROBLEM PROBLEMS CARE
NURSING METHODS OR RESOURCES OUTCOME
INTERVENTIONS TOOLS REQUIRED CRITERIA/INDICATORS

V. SUMMARY OF LAST DAY OF HOME VISIT

PHOTO DOCUMENTATION