PREGNANT MOTHER

COMMUNITY HEALTH NURSING RLE

PART A. INITIAL DATA BASE

I. CHARACTERS:
A. What is the type of family structure?
/ Nuclear Single - Parent
Extended Others (specify)
B. What is the type of family based on authority?
/ Patriarchal
/ Matriarchal
C. Who makes decisions regarding health care? Mother
D. What is the present family relationship?
With conflicts between members
/ Without conflicts between family members
E. Activities of daily living:
1. Sleeping pattern:
Retiring/getting up hours 8:00pm–
3:00am Nap during the day none
Do members sleep together? Yes
2. Eating pattern
How many meals each day? 3 times a day
Who appears overweight? N/A
Who appears underweight? N/A
3. Leisure time activities
How does each member spend leisure hours? Catching about what happen
to them in the whole day
Is it appropriate for the sex and age group? Yes
What is the effect on the family? Sometimes they’re happy, sometimes not
Any joint activity for leisure? Watching movie in Netflix

II. FAMILY INFORMATION

Head of the family: N. Sandigan
Address: Libis, Valenzuela City
Members of the household:

NAME RELATIONSHIP AGE EDUCATIONAL ATTAINMENT

N. Sandigan Husband 36 High School Graduate
J. Sandigan Wife 34 High School Graduate
T. M. Sandigan Daughter 14 High School ( Second Year)
N. L. Sandigan Son 10 Elementary ( Grade Five)
N. J. Sandigan Son 3

/avg 1
PREGNANT MOTHER

III. SOCIO-ECONOMIC AND CULTURAL FACTORS

A. Income

NAME OCCUPATION PLACE INCOME /

MONTH
N. Sandigan Factory Worker Quezon City 16,000

1. Does the working family member meet the basic necessities?

/ Yes No
2. Who makes decisions regarding money matters?
3. Religious affiliation: Roman Catholic
4. What roles does the family play in the community? Street leader, community member

IV. ENVIRONMENTAL FACTORS

A. Housing
1. Ownership
Owned / Rented Rent-Free Others (specify)
2. Construction materials used
Light Mixed / Strong
3. Living space
/ Adequate Inadequate
4. Sleeping arrangement: The daughter is sleeping in the top of the double deck.
The mother, father and the boys are sleeping in the lower part of the double deck.
5. Adequacy in furniture
/ Adequate Inadequate
6. Water source
/ Private Public
7. Food storage
Refrigerator / Jars/container Others (specify)
8. Cooking facility
Electric stove Firewood Others (specify)
/ Gas Stove Kerosene
9. Drainage facility
/ Open drainage Blind drainage None
10. Toilet facilities/type
Flushed Overhung latrine
/ Water-sealed latrine Bored-hole latrine
Pail system others (specify)
11. Sanitary condition
/ Fair Good Poor

Provide brief description: There’s a little bit dishes in the sink and also their thing are a little bit messy.
12. Neighborhood
/ Congested Slum Other
13. Availability of Health Care Facility
/avg 2
PREGNANT MOTHER
Describe briefly: There are two health care facilities in this community
14. Garbage disposal
/ Dumped at street corner / Picked up by garbage collector
Buried Burned then buried Others (specify)

V. HEALTH MEDICAL HISTORY

NAME PAST ILLNESS DIAGNOSED / ILLNESS STATE HEALTH ACTION TAKEN
UNDIAGNOSED
N.L. Sandigan Fever, cold Diagnosed He’s doing well Check up, Take
medication

VI. VALUE PLACED ON PREVENTION OF

DISEASE Vaccinations

NAME AGE COMPLETE INCOMPLETE

N. Sandigan 36 Covid Vaccine (Fully)
J. Sandigan 34 Covid Vaccine (Fully) Tetanoid toxide
T. M. Sandigan 14 Covid Vaccine (Fully)

N. J. Sandigan 3

Other preventive practices employed by the family: First Aid kit, Proper diet, Taking vitamins
Sources of Health Care:
/ Health Center / Government Hospital
Private Hospital Others (specify)

/avg 3
PREGNANT MOTHER
PART B.

DETERMINE AT LEAST 3 FAMILY HEALTH PROBLEMS. IF NONE, DETERMINE THE FAMILY’S PROMOTIVE OR PREVENTIVE
PRACTICES.
FAMILY HEALTH PROBLEMS. / TYPOLOGY OF HEALTH PROBLEM
(WELLNESS STATE , HEALTH DEFICIT,HEALTH THREAT,
(IF NONE, FAMILY’S PROMOTIVE OR FORESEEABLE CRISIS)
PREVENTIVE PRACTICES.)

1. Proper diet Wellness State

Wellness State
2. Taking vitamins

3. Fever and cold Health threat

PART C.

DO THE SCALING OF THE 3 IDENTIFIED HEALTH PROBLEMS OR PROMOTIVE PRACTICES OF THE FAMILY.

HEALTH PROBLEM 1:

CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION

NATURE OF THE PROBLEM

MODIFIABILITY OF THE
PROBLEM

PREVENTIVE POTENTIAL

SALIENCE

TOTAL

/avg 4
PREGNANT MOTHER

HEALTH PROBLEM 2:

CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION

NATURE OF THE PROBLEM

MODIFIABILITY OF THE
PROBLEM

PREVENTIVE POTENTIAL

SALIENCE

TOTAL

HEALTH PROBLEM 3:

CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION

NATURE OF THE PROBLEM

MODIFIABILITY OF THE
PROBLEM

PREVENTIVE POTENTIAL

SALIENCE

TOTAL
Surveyed by _________________________
Date ______________________________

/avg 5