PILAR COLLEGE OF ZAMBOANGA CITY, INC.

R.T. Lim Boulevard, Zamboanga City

Nursing Program

FAMILY
ASSESSMENT
GUIDE

In partial fulfilment of the requirement in

Related Learning Experience

Submitted by:
Benaro, Christine Lindsey P.
Butlangan, Whyzel Yvonne
Jupakkal, Refaina B.
Jordan, Angelyn

Submitted to:
Jasmin Ong, RN
Clinical Instructor
 PILAR COLLEGE OF ZAMBOANGA CITY, INC.
R.T. Lim Boulevard, Zamboanga City
Nursing Program

FAMILY ASSESSMENT GUIDE

I. Family Name: ____________________________ Address: __________________________

I. Demographic Data
Household No.: _______ Barangay House No. : ______

II. Family Data

Length of residency: ______
Place of origin: __________________
___________________
Family size: __________________
Religion: Husband - _______________
Wife - _______________

Family Member’s Chart

Family Members Age Sex Civil Position Relationsh Education Occupation

Status in the ip to al
Family Family Attainmen
Head t

1.

2.

3.

4.

5.

III. Family Characteristics

Type of Family Structure
a. Extended d. Nuclear _____
b. Matriarchal ____ e. Patriarchal ____
c. Dominant Family Member _____

General Family Relationship/Dynamics

CRITERIA STATUS ADDITIONAL INFORMATION

Observable conflicts between family

members

Characteristics of communication
Interaction patterns among members

Family Dietary Habits

What did you eat yesterday? (24 hours dietary recall)

Breakfast: Coffee

Lunch: Rice, vegetables, fish

Supper: Rice, Chicken, vegetables

Monthly Family Income Source

Husband: __________________

Wife: NONE

Others: ___________________

Monthly Family Income Source

Total (Check Bracket)

Below P5, 000 20,000 to 25,000 _______

5,000 to 10,000 ________ 25,000 to 30,000 _______

10,000 to 15,000 _______ 30,000 to 35,000 _______

15,000 to 20,000 _______ more than P35, 000 _____

Family Health Status/ Health History

Father: NONE

Mother: Hypertension

Children: NONE

Felt Family Needs (Identify and rank according to priority)

1. Source of income 5. Security

2. Food 6. Health Medications
3. Shelter 7.
4. Utilities (water, electricity) 8.

IV. Home and Environment

A. Is your lot owned? Yes ______ No

B. Is your house owned? Yes No ______

C. Type of housing materials

Wood Mixed _____ _____ others, specify __________

 Concrete _____ Makeshift ______

D. Is the living space adequate? Yes ______ No ______

E. What are the appliances owned by the family?

____________________________________________________________________

F. Type of garbage disposal?

Collected _____ burning

Waste Segregation ______ burying ______
Feeding to animals ______ throw in the river/sewer ______
Open dumping _____ others, specify __________

G. Type of waste disposal

Flush _____ Water sealed ______

Wrap and throw _____ Pit privy _______
_____ others, specify __________

H. Type of drainage system

Open _______ Closed

I. Source of water supply

Owned ______ shared ______

Bought _____ others specify __________

J. Drinking water storage

Refrigerated _____ covered ______

Uncovered _____

K. Containers used

Plastic pitchers ______ jars, clay pots _____

Bottles others, specify Mineral gallons, Ice Chest

L. Food storage/ cooking facilities

Covered uncovered ______ cabinet ______

Refrigerator ______ stove ______ pots, pans, etc. ______

M. Common household pets found at home

Cat and rabbit
N. Are there breeding sites of insects, rodents, etc. present? Yes None _____
O. Pets or animals kept in the yard /home
Chicken
P. Are there accident hazards present? Yes None _____

V. Health and health practices

A. Common illnesses encountered for the last 6 months, and the treatment applied.
_________________________________________________________________
_________________________________________________________________

B. Whom do you consult for health-related problems?

Manghihilot _____ Albularyo ______
 Midwife _____ Nurse ______
Doctor _____ Health Center ______
Barangay Health Worker _____ _____ others, specify __________

C. For problems other than health, whom do you consult?

Family members’ _______ Relatives ______
Friends’ ______ Barangay officials’ _______
Priest ______ _____ others, specify __________

D. Immunization status of family members

All fully vaccinated with booster

E. Have you had adequate?

1. Rest and sleep? Yes ______ No

2. Exercise? Yes ______ No
3. Relaxation activities Yes No ______
4. Stress management activities Yes No ______

VI. Environment

1. Kind of neighborhood

2. Social and health facilities

available

3. Communication and
transportation facilities

VII. Awareness of community organization

A. Are you aware of existing organizations in the community?

Yes ______ No ______

B. Name all the organization/s you know.

_______________________________________________________________

C. Are you a member of any of these organizations?

Yes ______ No ______

D. Are you aware of its activities and projects?

Yes ______ No ______

E. How are you involved in its activities?

Attend meetings ______ Give donations ______
Planning _____ Evaluation ______
Implementation ______ _____ others, specify __________

F. Name 3 formal or non-formal leaders of the community whom you think can lead the
people.
1.
2.
3.

II. List down the health problems recognized in the family you have interviewed. Compute the score of
each problem, justify scores given and rank problems according to priority.
 List of Problem Nature of Problem

Presence of breeding site for vector of disease Health Threat

Hypertension Health deficit

UTI Health deficit

III. Encircle the actual standard scores and the scores that apply to the problems of the family
interviewed. Justify the scores you gave in the indicated column. Compute for the sum of all the actual
scores you have encircled and write them on the space provided.

Problem: ____________________________

Criteria Standard Scor Weight Actual Justification

e Score
1.Nature of the Wellness State 0 The problem is a
problem Health Deficit 3/ 1 1/ health threat as it can
Health Threat 2 2/3 threaten the life of the
Foreseeable Crisis 1 1/3 family with various
diseases like dengue.
2.Modiafiablity Removable 2 2 It is removable since
of the problem Partially Modifiable 1/ 2 1/ there are alternative
Not Modifiable 0 0 ways on elminitaing
this
3.Preventive High 3/ 1/
potential Moderate 2 1 2/3
Low 1 1/3
4.Salience of Needs immediate attention 2/ 1/ It need immediate
the problem Does not need immediate 1 1 ½ attention because it
attention 0 0 can put the life of the
Not a problem family at risk.
Total Score:

IV. Determine the root cause of the family health problems as well as their family nursing problems.

Health Problems Family Nursing Problems

First Level Assessment Second Level Assessment

Problem 1: Hypertension Poor diet and unhealthy practices Inability to recognize the presence of
the conditions of problem due to lack
of in adequate knowledge and lack of
financial resources.

Problem 2: Presence of breeding Poor home Inability to provide home environment

site for vector diseases Poor Environment condition/ condusive to health maintenance and
sanitation personal development due to lack of
inadequate knowledge og hygiene,
sanitation and prevention measures.
V. Formulate a family health care plan for the family you have assessed.

Health Family Nursing Goals Objectives Intervention Methods of Resources Required Evaluation
Problems Problems Methods Nursing
Family
Contact
Home visit Material resources for
Presence of Inability to make the handouts.
breeding decision about taking
sites of appropriate actions Human Resources. Both
mosquitos due to failure to of the students and family
recognize the nature time and effort
of the dengue
diseases and its Financial Resources for
accompanied the transportation, snacks
problem. and handouts.