ASSESSMENT DATA BASE IN FAMILY NURSING PRACTICE

8 CASTROVILLE
ADDRESS: ________________________ Sta. Maria Zamboanga CIty
__________________________ _____ _1_____ 06547521
FAMILY NUMBER: _______________
Street / Road Barangay Zone

A. FAMILY STRUCTURE, CHARACTERISTICS , & DYNAMICS/RELATIONAL PATTERNS

1. Members of the Household
Birthdate Relationship to the Head of the
Name of Family Member Age Sex Civil Status Position in the Family
Month Year Family
Kevin bryan ojey T. 21 08 2000 M SINGLE MOTHER SIDE COUSIN IN MOTHER
John rhainer T. 25 05 1994 M MARRIED BROTHER BROTHER

2. Socio-demographic data of members not currently living in the household but with major role in resource generation and use

Highest Relationship to Head of the

Name of Family Birthdate Marital Occupation
Age Sex Educational Family
Member Status
Month Year Attainment Type of Work Place
200 PASOBOLON
Jennie 18 06 M SINGLE COLLEGE STUDENT 2ND CHILDREN
5 G Z.C

3. Length of residency: 10 YEARS

4. Type of Family Structure and Form NUCLEAR FAMILY

 Based on Composition Based on Locus of Power Based on Place of Residency
Nuclear Family Stepfamily/Blended Patrifocal / Patriarchal Patrilocal

Extended Single Matrifocal / Matriarchal Matrilocal

Beanpole Same-sex/Homosexual Egalitarian Bilocal

Single-Parent Cohabiting/Communal Matricentric

5. Family Dynamics, Communication Pattern/s, Interaction Processes and Interpersonal Relationships.

Criteria Status Additional Information

B. SOCIO-ECONOMIC & CULTURAL CHARACTERISTICS

Highest Educational Occupation

Name of Family Member Ethnic Background Religion Income
Attainment Nature of Work Place of Work
MARIA MIKAELLA C. CHAVACANO/BISAYA ROMAN CATHOLIC COLLEGE GRADUATE BUSINESSWOMEN ZAMBOANGA CITY 7-15,17,500
ROEL C. TAGALOG/BISAYA ROMAN CATHOLIC COLLEGE GRADUATE BUINESSMAN METRO MANILA 9-20-25,000

Legend for Monthly Family Income

1 – Below 2,500 3 – above 5,000 to 7,500 5 – above 10,000 to 12,500 7 – above 15,000 to 17,500 9 – above 20,000 to 25,000
2 – 2,500 to 5,000 4 – above 7,500 to 10,000 6 – above 12,500 to 15,000 8 – above 17,500 to 20,000 10 – above 25,000
1. Income & Expenses
a. Adequacy to Meet Basic Necessities
In the family group we spend more on foods and health vitamins, and the others is the responsiblities in household expenses
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________

2. Family Traditions, events or practices affecting member’s health or family functioning

In family the ordinary traditions that always do is eating together.
__________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
____________________________

3. Significant Others – role(s) they play in family’s life

Name Role & Relation to Family
Mikaella mercedes C. Third children in the family
Wyio C. First children in the family

4. Relationship of the Family to Larger Community – Nature and extent of participation of the family in community activities
a. Awareness of existing organization Yes Name ________________________________ No
b. Membership in an organization Yes Name No Why? _________________________
c. Involvement in an organization Yes Name ________________________________ No Why? _________________________
d. Potential or Existing leaders _____________________________________________________________________________________________________
C. HOME AND ENVIRONMENT
1. Home
Ownership: owned rented free Constructional material used: light mixed strong
Lighting facilities: electricity kerosene others (specify) ________________________
Number of rooms used for sleeping & sleeping arrangement: __________________________________________________________________________
One room
2. Water Supply
Drinking: Source private public Potability: specify is safe for drinking Safe Unsafe
 Storage direct from faucet or pipe covered container with faucet large uncovered without faucet
Other (specify) __________________

3. Food storage
Cooking facility: electric gas stove firewood/charcoal
Sanitary condition: ___________________________________________________________________________________________________________
The sanitary condition is very poor.
Drainage facility: open drainage blind drainage none
4. Water Disposal
a. Refuse and Garbage
 Container covered open none
 Method of disposal: hog feeding open dumping burial in pit composting open burning garbage collection
Other (specify) _________________________________________
b. Toilet
 Type: none overhung latrine open pit privy closed pit privy bored- hole latrine pail system
antipolo type water-sealed latrine flush type other (specify) _____________________________________________
 Distance from the house: ______________________________________
Five meters
 Sanitary Condition: ___________________________________________________________________________________________________
It is fairly clean and does not smell foul, they also have an open drainage.
5. Domestic Animals

Kind Number Where Kept

6. The Community in General

a. General sanitary condition: __________________________________________________________________________________________________
_______________________________________________________
b. Housing congestion: ________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________
 c. Presence of breeding or resting sites of vectors of disease: _________________________________________________________________________
_________________________

d. Recreational Facility: _______________________________________________________________________________________________________

e. Availability of health care services: ___________________________________________
f. Distance of house from nearest health care facility: ____________________________________________
g. Communication & Transportation Facilities available :

D. HEALTH STATUS OF EACH FAMILY MEMBER

1. Medical & Nursing History
a. Medical History of the Family Members

Family Member Health Status / Health History Family Member Health Status / Health History

b. Obstetric Data
Date BP PR Temp. Wt. H FH FHT

2. Nutritional Assessment
a. Anthropometric Data: Measure of Nutritional Status of the Family Members

Name of Family Member Weight Height Mid-Arm Circumference

 b. Dietary History specifying quality & quantity of food/nutrient intake per day

____________________________________________________

c. Eating/Feeding habits/practices
__________________________________
3. Risk factor assessment indicating presence of major & contributing modifiable risk factors for specific lifestyle diseases ______________________________
_______________________________________________________________________________________________________________________________
4. Result of laboratory/diagnostic & other screening procedures supportive of assessment findings ________________________________________________
N/A

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

1. Immunization status of family member

Name of Child Immunization Status Remarks

2. Healthy lifestyle practices ______________________________________________________________________

3. Adequacy of:
a. Rest & Sleep Yes No
b. Exercise/Activities Yes specify: _______________________________________________
c. Use of Protective Measures Yes _________________________________ No Why ___________________________________________
d. Relaxation & other stress management activities Yes _______________________________________ No
e. Opportunities which enhance feelings of self-worth, self-efficacy and sense of connectedness to self, others and a higher power, essence of
meaningfulness
Yes specify: _______________________________________________________________________ No
4. Use of promotive – preventive health services Yes specify: _________________________________________________________________________
No Why ________________________
5. Use of Family Planning Methods
a. Type
Natural
Abstinence Lactational Amenorrhea Method Basal Body Temperature Cervical Mucus Method
Symptothermal Method Standard Days Method Others: specify ___________________________________________

Artificial
Hormonal
Oral Contraceptives Specify: Progesterone – Only Oral Contraceptive Low- Dose Combined Oral Contraceptive
Injectable depot medroxyprogesterone acetate / Depo-Provera (DMPA)

Norplant Implants
Barrier
Intrauterine Devices Condom Diaphragm Cervical Cap Others: specify __________________________

Permanent

Tubal Ligation Vasectomy

None Are you willing to practice Family Planning Method? Yes No

What hinders you from practicing Family Planning Method? Biological Psychological Social Cultural
Religion Others, specify; _____________________
b. Who taught you about Family Planning Method?
PHN/PHM BHW Friend Neighbor Print/Visual Ads Student Nurse Others; specify ______________________
c. Is your husband aware of your usage of Family Planning Method Yes No
d. Do you know side effects of family planning method as a result of its use? Yes No
Changes in menstrual bleeding headache nausea weight gain moodiness
Delayed return of fertility dizziness acne in women nervousness change in appetite
Enlargement of ovaries/ovarian cyst hair loss breast tenderness others; specify _________________________________________
e. Do you have misconceptions about Family Planning Methods? Yes No
Some FP Methods cause abortion Using Contraceptives will render couples sterile Using contraceptives methods will result to loss sexual
desire
Others; specify _________________________________________________________________________