Name: Section: BSN 2A

FAMILY NURSING CARE PLAN

FAMILY FAMILY NURSING OBJECTIVES OF METHODS OF

PROBLEM PROBLEM GOAL OF CARE NURSING CARE NURSING FAMILY-NURSE RESOURCES EVALUATION
INTERVENTIONS CONTACT REQUIRED
Name of the Interviewer: ____________________________________________ Date of Interview: ________________________
Name of the Respondent: ____________________________________________ INITIAL DATA BASE
Name of the Head of the Family: ______________________________________
Address: __________________________________________________________
A. FAMILY STRUCTURE AND CHARACTERISTICS

RELATION TO
EDUCATIONAL ETHNIC
NAME THE HEAD SEX AGE BIRTHDAY CIVIL STATUS OCCUPATION RELIGION
ATTAINMENT BACKGROUND
Describe in paragraph form: Type of Family Structure D. HEALTH ASSESSMENT OF THE MEMBERS OF T HE FAMILY
: Dominant Family Members in terms of Decision Making in matters of
Health Care
: General Family Relationship

B. SOCIO ECONOMIC AND CULTURAL FACTORS E. VALUE PLACED ON PREVENTION OF DISEASE

 4. WASTE DISPOSAL
1. HOME
a. Refuse and Garbage
a. Ownership owned rented rent-free
i. Container covered open none
b. Construction materials used light mixed strong
ii. Method of Disposal hog feeding composting open dumping
c. Number of rooms for sleeping: ____________________________________
Incineration open burning burial in pit
d. Lighting facilities electricity kerosene others (specify)
others (specify): ______________
e. General sanitary condition: ____________________________________
b. Toilet

2. WATER SUPPLY i. Type pail system overhung latrine none

a. Drinking water open pit privy water-sealed latrine flush type

SOURCE: private public
closed pit privy bored-hole latrine others (specify):_________
DISTANCE FROM HOUSE: ________________________________________________
ii. Distance from House:________________________________________________________
STORAGE: none (direct from faucet or pipe)
iii. Sanitary condition:_________________________________________________________
jar or can with faucet
5. DOMESTIC ANIMALS
jar or can without faucet
a. Kind:_____________________________________________________________________
others (specify): __________________________________________
b. Number:__________________________________________________________________

3. KITCHEN c. Where kept: _______________________________________________________________

a. Cooking facility electric stove gas stove firewood/charcoal 6. COMMUNITY IN GENERAL

a. Sanitary condition: _________________________________________________________
b. Sanitary condition: _________________________________________________________ b. Housing congestion: ________________________________________________________
c. Recreational activities: ______________________________________________________
c. Drainage facility none open drainage blind drainage
d. Availability of health care facilities (describe briefly): ______________________________
e. Distance of house from nearest health care facility: _______________________________