FAMILY NURSING PRACTICE- CHN 1

A. FAMILY STRUCTURE, CHARACTERISTICS AND DYNAMICS

Head Of The family Relation To AGE SEX CIVIL STATUS( 18 Y/O HIGHEST LEVEL OF Position in the Family Place of Residence of each member
Household Head 1-male AND ABOVE) SCHOOL ATTENDED (1st, 2nd, 3rd etc) 1- Living with the family
_______________ 1-head of the 2-female 1- single 0 – No grade 2- Living elsewhere
(initials only) household 2- married Completed
2-spouse 3- widow/widower 1 – elementary
3-son/daughter 4-divorced/ separated 2 – high school
Type of Family Structure: 4- father/mother 3 – college
____1. Patriarchal 5-grandchildren 4 – post graduate
____2. Matriarchal 6-grandparents 5 – vocational
7-other relatives 6 – no formal
____ 3. Nuclear 8-non-relatives Education
____ 4. Extended

Members of the Family

(Initials only)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.

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Dominant Family Member/s in terms of decision-making in health care:____________________
____________________

General Family Relationship/dynamics:

Presence of (obvious) conflict between family members : ________YES
________ NO

Characteristic Communication Among Family Members: __________ 1. Direct (face to face)

__________ 2. Indirect (Emails, Cellphones and social networking sites)

B. SOCIO-ECONOMIC AND CULTURAL CHARACTERISTICS

A. Income and Expenses of Working Family Members:

Occupation Place of Work Monthly Income Monthly Expenses

B. Adequate basic necessities:

Food: _________ YES Clothing: _________ YES Shelter: _________ YES
_________ NO _________ NO _________ NO

C. Ethnic Background of Family members: __________________

D. Religious Affiliations of Family Members:________________________

E. Relationship of the Family to a Larger Community: ___________1. Participative

___________ 2. Non-Participative

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 C. HOME AND ENVIRONMENT

1. Housing
A. Measurement of Housing Space (in terms of square meters (LxW) ____________________

B. Sleeping Arrangement:
________ 1. family members are sleeping inside the bedroom/s
________ 2. some family members are sleeping in the living room
________ 3. family members are sleeping in the kitchen

C. Presence of Breeding (vectors)Sites: _________ 1. YES

_________ 2. NO

D. Presence of Accident Hazards: _________1. Yes I. Drainage System: _________ 1. Not available
_________2. No _________ 2. Open
__________3. Blind
E. Food Storage: 2. Kind of Neighborhood
________1. Cabinet
________2. Open shelves _________ lower class
________3. Refrigerator _________ middle class
________4. Others: ________________ _________ higher class

F. Type of cooking fuel source primarily used: 3. Health and Social Facilities
________1. Collected woods
________ 2. Purchased wood or sawdust _________1. Government Hospital
_________2. Private Hospital
________ 3. Purchased charcoal _________ 3. Barangay Health Center
________ 4. Kerosene gas _________ 4. Private Clinic
________ 5. Liquefied Petroleum Gas (LPG) _________ 5. Grocery/Mini –Market
________ 6. Electricity _________ 6. Park
_________ 7. Gym/Basketball Court
_________ 8. Others: ______________________
G. Water Supply:
________1. Dug well
________2. Commercial water 4. Transportation Available:
________3. Shared tube/pipe _________1. Tricycle
________4. Own use tube/ pipe _________2. Jeepney
________5. Shared faucet, community water system _________3. Car
________6. Owned use faucet, community water system _________4. Others; ____________
________ 7. Others: ___________
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H. Toilet facilities
Owned: _________YES _______NO
_______1. Open pit
_______2. Closed pit
_______3. Water-sealed, shared with other households
_______4. Flush toilet
________5. Water-sealed, used exclusively by the household

D. HEALTH STATUS OF FAMILY MEMBERS

1. Medical and Nursing History of Past or Present Illness:__________________________

Practices/Beliefs in Health (including Covid 19 prevention & Treatment) Practices/Beliefs in Illness

2. Nutritional Assessment (5 years and below, 60 years old and above)

a. Anthropometric Data (WEIGHT, HEIGHT, WAIST CICUMFERENCE, HIP CIRCUMFERENCE)

For children, compute for BMI ( weight in kgs/height in meters)

For the elderly,c ompute for Waist Hip Ratio (Waist circumference in cm/Hip circumference in cm)

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 b. Dietary History
b.1 Food intake: ________ 1. Fruits
________ 2. Vegetables
________ 3. Rice/Corn
________ 4. Fish
________ 5.Beef
________ 6.Chicken
________ 7. Pork
________ 8. Shellfoods

b.2 Beverages: ________ 1. Milk ________ 4.Tea

________ 2.Coffee ________ 5. Softdrinks
________ 3. Chocodrinks ________ 6. Fruitjuice

c. Eating Practices
_________ eats 3 full meals a day
_________ eats 2 full meals a day
_________ eats 1 full meal a day

3. Developmental Assessment (of Infants Only)

Newborn Screening __________YES
__________ NO

4. Risk Factor Assessment (for adult family members)

________1. Hypertension ________6. alcohol drinking
________2. Sedentary lifestyle ________7. elevated blood lipids
________3. Cigarette/Vape/Tobacco smoking ________8. others;________________
________4. Inadequate Fiber intake
________5. Stress

5. Physical Assessment (permission must be given by family member )to a part of the body indicating presence of illness

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 6. Results of laboratory/diagnostic and other screening procedures supportive of assessment findings

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

1. Immunization Status of Family Members

A. Vaccines Received by Adult Family Members: _____________________________________________________

B. Children Immunizations (for children 0-18 months only)

C. Type of Immunizations
Initials AGE BCG POLIO DPT HEPA MMR
(OPV) B

2. Healthy Lifestyle Practices

______________ 1. Exercises Daily
______________ 2. Eats healthy foods
_______________ 3. Takes supplements/ Vitamins
_______________ 4. Sleeps atleast 7-8 hours/night
_______________ 5. Drinks 6-8 glasses of liquids/day
_______________ 6. Protects self from vectors
_______________7. Others;_______________________

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