FAMILY NURSING ASSESSMENT TOOL

HEAD OF THE FAMILY: Alvin Pandian DATE ASSESSED: February 2, 2018

ADDRESS: Purok 6 – A Panadtalan, Bukidnon Maramag Bukidnon
A. FAMILY STRUCTURE, CHARACTERISTICS AND DYNAMICS
FAMILY STRUCTURE: Extended

RELATIONSHIP TO BIRTHDAY MONTH

MARITAL DECISION MAKER IN TERMS OF HEALTH
FAMILY MEMBER THE HEAD OF THE AGE SEX DYNAMICS
STATUS CARE
FAMILY DAY YEAR
NAME

Albin Pandian Husband 25 M January 23, 1993 Married

Riza Pandian Wife 25 F September 12, 1993 Married

Teresita Pandian Mother 49 F October 15, 1968 Widow

Almira Pandian Sister 16 F December 2, 2002 Single

Aldrea Pandian Daughter 5 F July 27, 2013 Single

Aldrin Pandian Son 1 M April 6, 2016 Single

B. SOCI- ECONOMIC AND CULTURAL CHARACTERISTICS

FAMILY NAMES EDUCATIONAL OCCUPATION RELIGION OR ETHNIC FAMILY PARTICIPATION IN

ATTAINMENT COMMUNITY ACTIVITIES
TYPE OF WORK PLACE INCOME

Albin Pandian High School Graduate Laborer Private Baptist

Riza Pandian High School Level Housewife Home Baptist

Teresita Pandian Elementary Graduate Roman Catholic

Almira Pandian Grade 7 Roman Catholic

Aldrea Pandian Baptist

Aldrin Pandian Baptist

C. HOME AND ENVIRONMENT

1. HOME

a. Ownership: ( ) Owned ( ) Rented ( ) Rent- free

b. Construction Materials: ( ) Light ( ) Mixed ( ) Strong
c. Number of rooms used: 1 Room
d. Lighting facilities: ( ) Electricity ( ) Kerosene ( ) Others : Specify
e. General sanitary condition: Poor
2. DRINKING WATER SUPPLY
Source of water Supply: ( ) Private ( ) Public portability: _______________
Distance the house: ____________________________
Storage: ( ) None (direct from faucet or pipe)
( ) large covered container with faucet
( ) Large uncovered container without faucet
( ) Others, specify _________________________
3. KITCHEN
Cooking facility: ( ) Electric stove ( ) Gas stove ( ) Firewood/charcoal
Sanitary condition: Poor
Drainage facility: ( ) open drainage ( ) Blind drainage ( ) None
4. WASTE DISPOSAL
a. Refuse and garbage container: ( ) Covered ( ) Open ( ) None
Method of disposal: ( ) Hog feeding ( ) Open Burning
( ) Open Dumping ( ) Garbage collection
( ) Burial in pit ( ) Others, Specify: _____________________
( ) Composting
b. Toilet Type: ( ) None ( ) Pail System
( ) Overhug latrine ( ) Antipolo
( ) Open pit privy ( ) Water-sealed latrine
( ) Closed pit privy ( ) Flush type
( ) Bored hole latrine ( ) Others, specify:
Distance from house: 100 meters
Sanitary Condition: Poor
5. DOMESTIC ANIMALS:

KIND NUMBER WHERE KEPT

Piglets 3 Cage

Dogs 2 Everywhere

Chickens 9 Everywhere

6. THE COMMUNITY IN GENERAL

a. General sanitary condition: Poor

b. Housing congestion: ( ) Yes ( ) No
c. Presence of breeding Sites of Vectors of Diseases: ( ) Yes, specify: Fishpond
( ) None
d. Recreational Facilities: None
e. Availability of health care services (describe briefly): Health Center
f. Distance of house from nearest health care facility: 1 kilometer
g. Available transportation and communication facilities: Motor Vehicle, Cellphone
 HEALTH STATUS OF EACH FAMILY MEMBER

NAME OF FAMILY MEMBER HISTORY OF SIGNIFICANT CURRENT SIGNIFICANT PRACTICES CONDUCTIVE TO HEALTH &
PAST ILLNESS ILLNESS ILLNESS

Albin Pandian

Riza Pandian

Teresita Pandian

Almira Pandian

Aldrea Pandian

Aldrin Pandian
NAME:
PAST MEDICAL HISTORY
General health status: __________________________________
________________________________________________________
Past medical problems: _________________________________
________________________________________________________
Hospitalization and surgery: ____________________________
________________________________________________________
Immunizations: ________________________________________
General survey
Physical appearance (height and weight appropriate for body build,
grooming, hygiene): ______________________________
________________________________________________________
Mental status (affect, mood, orientation, recall): _________
________________________________________________________
Mobility (gait ease of movement, agility): ________________
________________________________________________________
REMARKS AND VERBALIZATION FROM THE CLIENT:
________________________________________________________
NAME:
PAST MEDICAL HISTORY
General health status: __________________________________
________________________________________________________
Past medical problems: _________________________________
________________________________________________________
Hospitalization and surgery: ____________________________
________________________________________________________
Immunizations: ________________________________________
General survey
Physical appearance (height and weight appropriate for body build,
grooming, hygiene): ______________________________
________________________________________________________
Mental status (affect, mood, orientation, recall): _________
________________________________________________________
Mobility (gait ease of movement, agility): ________________
________________________________________________________
REMARKS AND VERBALIZATION FROM THE CLIENT:
________________________________________________________
NAME:
PAST MEDICAL HISTORY
General health status: __________________________________
________________________________________________________
Past medical problems: _________________________________
________________________________________________________
Hospitalization and surgery: ____________________________
________________________________________________________
Immunizations: ________________________________________
General survey
Physical appearance (height and weight appropriate for body build,
grooming, hygiene): ______________________________
________________________________________________________
Mental status (affect, mood, orientation, recall): _________
________________________________________________________
Mobility (gait ease of movement, agility): ________________
________________________________________________________
REMARKS AND VERBALIZATION FROM THE CLIENT:
________________________________________________________
NAME:
PAST MEDICAL HISTORY
General health status: __________________________________
________________________________________________________
Past medical problems: _________________________________
________________________________________________________
Hospitalization and surgery: ____________________________
________________________________________________________
Immunizations: ________________________________________
General survey
Physical appearance (height and weight appropriate for body build,
grooming, hygiene): ______________________________
________________________________________________________
Mental status (affect, mood, orientation, recall): _________
________________________________________________________
Mobility (gait ease of movement, agility): ________________
________________________________________________________
REMARKS AND VERBALIZATION FROM THE CLIENT:
________________________________________________________
NAME:
PAST MEDICAL HISTORY
General health status: __________________________________
________________________________________________________
Past medical problems: _________________________________
________________________________________________________
Hospitalization and surgery: ____________________________
________________________________________________________
Immunizations: ________________________________________
General survey
Physical appearance (height and weight appropriate for body build,
grooming, hygiene): ______________________________
________________________________________________________
Mental status (affect, mood, orientation, recall): _________
________________________________________________________
Mobility (gait ease of movement, agility): ________________
________________________________________________________
REMARKS AND VERBALIZATION FROM THE CLIENT:
________________________________________________________
NAME:
PAST MEDICAL HISTORY
General health status: __________________________________
________________________________________________________
Past medical problems: _________________________________
________________________________________________________
Hospitalization and surgery: ____________________________
________________________________________________________
Immunizations: ________________________________________
General survey
Physical appearance (height and weight appropriate for body build,
grooming, hygiene): ______________________________
________________________________________________________
Mental status (affect, mood, orientation, recall): _________
________________________________________________________
Mobility (gait ease of movement, agility): ________________
________________________________________________________
REMARKS AND VERBALIZATION FROM THE CLIENT:
________________________________________________________
NAME:
PAST MEDICAL HISTORY
General health status: __________________________________
________________________________________________________
Past medical problems: _________________________________
________________________________________________________
Hospitalization and surgery: ____________________________
________________________________________________________
Immunizations: ________________________________________
General survey
Physical appearance (height and weight appropriate for body build,
grooming, hygiene): ______________________________
________________________________________________________
Mental status (affect, mood, orientation, recall): _________
________________________________________________________
Mobility (gait ease of movement, agility): ________________
________________________________________________________
REMARKS AND VERBALIZATION FROM THE CLIENT:
________________________________________________________
NAME:
PAST MEDICAL HISTORY
General health status: __________________________________
________________________________________________________
Past medical problems: _________________________________
________________________________________________________
Hospitalization and surgery: ____________________________
________________________________________________________
Immunizations: ________________________________________
General survey
Physical appearance (height and weight appropriate for body build,
grooming, hygiene): ______________________________
________________________________________________________
Mental status (affect, mood, orientation, recall): _________
________________________________________________________
Mobility (gait ease of movement, agility): ________________
________________________________________________________
REMARKS AND VERBALIZATION FROM THE CLIENT:
________________________________________________________
 NUTRITIONAL ASSESSMENT

(especially for vulnerable or at-risk members)

NAME OF ANTHROPOMETRIC DATA QUANTITY & QUALITY EATING/FEEDING

THE OF FOOD INTAKE/DAY PRACTICES
Height Weight Circumference
FAMILY BMI
(cm) (kg) Chest Abdomen Lower Upper
MEMBER
(cm) (cm) extremities (cm) extremities (cm)

Albin
Pandian

Riza
Pandian

Teresita
Pandian

Almira
Pandian

Aldrea
Pandian

Aldrin
Pandian
Name: __________________________________________
Weight: _________________________________________
Weight gain: ____________________________________
Appetite description:
Good ( )
Fair ( )
Poor ( )
Food intolerance: _______________________________
Dietary restriction: _____________________________
Usual food intake: ______________________________
Fluid intake: ___________________________________
Food dislike: ___________________________________
Problems:
Nausea: ____________________________________
Vomiting: ___________________________________
Swallowing: _________________________________
Chewing: ___________________________________
Digestion: ___________________________________
REMARKS AND VERBALIZATION FROM THECLIENT:
___________________________________________________
Name: __________________________________________
Weight: _________________________________________
Weight gain: ____________________________________
Appetite description:
Good ( )
Fair ( )
Poor ( )
Food intolerance: _______________________________
Dietary restriction: _____________________________
Usual food intake: ______________________________
Fluid intake: ___________________________________
Food dislike: ___________________________________
Problems:
Nausea: ____________________________________
Vomiting: ___________________________________
Swallowing: _________________________________
Chewing: ___________________________________
Digestion: ___________________________________
REMARKS AND VERBALIZATION FROM THECLIENT:
_________________________________________________
Name: __________________________________________
Weight: _________________________________________
Weight gain: ____________________________________
Appetite description:
Good ( )
Fair ( )
Poor ( )
Food intolerance: _______________________________
Dietary restriction: _____________________________
Usual food intake: ______________________________
Fluid intake: ___________________________________
Food dislike: ___________________________________
Problems:
Nausea: ____________________________________
Vomiting: ___________________________________
Swallowing: _________________________________
Chewing: ___________________________________
Digestion: ___________________________________
REMARKS AND VERBALIZATION FROM THECLIENT:
___________________________________________________
Name: __________________________________________
Weight: _________________________________________
Weight gain: ____________________________________
Appetite description:
Good ( )
Fair ( )
Poor ( )
Food intolerance: _______________________________
Dietary restriction: _____________________________
Usual food intake: ______________________________
Fluid intake: ___________________________________
Food dislike: ___________________________________
Problems:
Nausea: ____________________________________
Vomiting: ___________________________________
Swallowing: _________________________________
Chewing: ___________________________________
Digestion: ___________________________________
REMARKS AND VERBALIZATION FROM THECLIENT:
_________________________________________________
Name: __________________________________________
Weight: _________________________________________
Weight gain: ____________________________________
Appetite description:
Good ( )
Fair ( )
Poor ( )
Food intolerance: _______________________________
Dietary restriction: _____________________________
Usual food intake: ______________________________
Fluid intake: ___________________________________
Food dislike: ___________________________________
Problems:
Nausea: ____________________________________
Vomiting: ___________________________________
Swallowing: _________________________________
Chewing: ___________________________________
Digestion: ___________________________________
REMARKS AND VERBALIZATION FROM THECLIENT:
___________________________________________________
Name: __________________________________________
Weight: _________________________________________
Weight gain: ____________________________________
Appetite description:
Good ( )
Fair ( )
Poor ( )
Food intolerance: _______________________________
Dietary restriction: _____________________________
Usual food intake: ______________________________
Fluid intake: ___________________________________
Food dislike: ___________________________________
Problems:
Nausea: ____________________________________
Vomiting: ___________________________________
Swallowing: _________________________________
Chewing: ___________________________________
Digestion: ___________________________________
REMARKS AND VERBALIZATION FROM THECLIENT:
_________________________________________________
 GORDON FUNCTIONAL ASSESSTMENT

Description Assessment

Health perception and health
management
Perceived level of health and wellbeing, and
practices for maintaining health. Habits that may
be detrimental to health are also evaluated,
including smoking and use of alcohol or other
drugs.

Nutrition and metabolism Pattern of food and fluid intake relative to

metabolic needs. The adequacy of local nutrients
supplies is evaluated.

Elimination pattern Excretory pattern (GI, GU and Skin).

Incontinence, constipation, diarrhea, and urinary
retention may be identified.

Activity and exercise Activities of Daily Living (ADLs) requiring energy

expenditure including self-care activities. Assess
major body system involved with the activity and
exercise including respiratory, cardiovascular,
and musculoskeletal systems.
 Description Assessment

Cognitive and perception Ability to comprehend and use information.

Assess sensory functions. Sensory experience
such as pain and altered sensory input may be
identified and evaluated.

Sleep and rest Sleep, rest and relaxation practices.

Dysfunctional sleep patterns and fatigue may be
identified.

Self-perception and self-concept Attitudes towards self, including identity, body

image, and sense of self-worth. Level of self-
esteem and response to threats of self-concept.

Roles and relation Roles in the world and other relationships.

Satisfaction with roles, role strain, or
dysfunctional relationship may be further
evaluated.

Sexuality and reproduction Satisfaction/dissatisfaction with sexual patterns

and reproductive functions. Concerns with
sexuality may be identified.
 Description Assessment

Coping and stress tolerance Perception of stress and coping strategies.

Support systems are evaluated, and symptoms of
stress are noted. Effectiveness of coping
strategies in terms of stress tolerance may be
evaluated.

Values and belief Values, belief, and goals that may be guide
choices or decisions.
 VALUES, HABITS, PRACTICES ON HEALTH PROMOTION, MAINTENANCE AND DISEASE PREVENTION

NAME IMMUNIZATION REST AND EXERCISE USE OF STRESS USE OF PROMOTIVE-

HEALTHY
OF FAMILY SLEEP ACTIVITIES PROTECTIVE MANAGEMENT PREVENTIVE HELATH
LIFESTYLE
MEMBER MEASURE ACTIVITIES SERVICES
PRACTICES

Albin Pandian

Riza Pandian

Teresita
Pandian

Almira
Pandian

Aldrea
Pandian

Aldrin
Pandian
 HEALTH CONDITION AND PROBLEM

HEALTH CONDITIONS AND NURSING PROBLEMS SUPPORTING DATA/CUES DATE

PROBLEMS (OBJECTIVE OR SUBJECTIVE
IDENTIFIED RESOLVED
DATA)
 SCALE FOR RANKING HEALTH CONDITIONS

PROBLEM 1:

CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION

NATURE OF THE PROBLEM

MODIFIABILITY OF THE PROBLEM

PREVENTIVE POTENTIAL

SALIENCE OF THE PROBLEM

TOTAL SCORE
PROBLEM 2:

CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION

NATURE OF THE PROBLEM

MODIFIABILITY OF THE PROBLEM

PREVENTIVE POTENTIAL

SALIENCE OF THE PROBLEM

TOTAL SCORE
PROBLEM 3:

CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION

NATURE OF THE PROBLEM

MODIFIABILITY OF THE PROBLEM

PREVENTIVE POTENTIAL

SALIENCE OF THE PROBLEM

TOTAL SCORE
PROBLEM 4:

CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION

NATURE OF THE PROBLEM

MODIFIABILITY OF THE PROBLEM

PREVENTIVE POTENTIAL

SALIENCE OF THE PROBLEM

TOTAL SCORE
PROBLEM 5:

CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION

NATURE OF THE PROBLEM

MODIFIABILITY OF THE PROBLEM

PREVENTIVE POTENTIAL

SALIENCE OF THE PROBLEM

TOTAL SCORE
 SUMMARY

PROBLEM TOTAL SCORE

PROBLEM 1:

PROBLEM 2:

PROBLEM 3:

PROBLEM 4:

PROBLEM 5:
 FAMILY NURSING CARE PLAN

Intervention Plan
Health Problem Family Nursing Care Goal of Care Objectives of Method of Nurse-Family
Problems Care Nursing Intervention Contact Resources Required
 EVALUATION

PROBLEM INDETIFIED EVALUATION

PROBLEM 1:

PROBLEM 2:

PROBLEM 3:

PROBLEM 4:

PROBLEM 5: