Lourdes College

Nursing Program Cagayan de Oro City

QUESTIONNAIRE DATA HEALTH RECORD

HOUSEHOLD
4 3 2 1 B P

FP

ST

SU

HI

Name of Family:_______________________________________________ Address (Barangay & Zone): ___________________________________ _____________________________________________________________ House no.: _____________________________________________ Household no.: _____________________________________________ Interviewee: _____________________________________________ Date: _____________________________________________ Interviewer: _____________________________________________ CI Signature: _____________________________________________

Green Safe (Complete) Yellow Intermediate (incomplete) Red None (Danger) Blue Not Applicable (Not Known)

NURSING ASSESSMENT: QUESTIONAIRE AND DATA SHEET

A. FAMILY STRUCTURE AND CHARACTERISTISTICS Head of Family

Last Name Address

First Name

M.I.

Age

Members of the Family Name 1. 2. 3. 4. 5. 6. 7. 8. 9. 10 B. BIOLOGICAL AND SOCIO-CULTURAL FACTORS 1. What is the familys source of income? (Specify the daily income and the daily expenses) 2. What is their ethnic background? Their religious affiliation? 3. Who are the familys significant others? What roles do they play in the familys life? 4. Do the family participate in the activities of the community? If yes, what are these activities? If no, what are the reasons why they dont participate? C. ENVIROMENTAL FACTORS 1. Housing a. Is the familys living space adequate for their number? b. Is their furniture adequate for them? Is it enough for their needs? c. Are there insects and rodents in their house? d. Are there accident hazards and fire hazards around the house? If yes, please enumerate. e. What are their cooking utensils? What is their food storage? f. What is their water supply? Where is their source? Is it potable? g. What is their toilet facility? What is its condition? Is it sanitary? h. What is the type of their garbage and refuse disposal system? Is it sanitary? Age Sex Civil Status Position in the Family Relationship to the Head of the Family Place of Residence

i. Describe their drainage system. Is it sanitary? 2. What type of neighborhood does the family belong? Please describe. 3. Are there social and health facilities available in the neighborhood? If yes, please enumerate and describe each. 4. What is the familys means of communication and transportation? D. HEALTH AND MEDICAL HISTORY 1. Medical history of each family member 2. Value placed on disease prevention a. Are there children immunized? What is their immunization status? b. Does the family utilize other preventive actions? If yes, what are they? 3. What are the familys source of medical care? Is it the same for each individual? To whom does the family turn for help in time of illness or crisis? 4. What is their perception of the role of the health professional and their services? What are their expectations of the services of the community health nurse? 5. Do they have previous experience with the health professionals? If yes, were they satisfied with the result? Type of Family Structure Patriarchal Matriarchal Nuclear Extended Single Parent Alternate Family Dominant family member/s in terms of decision making, especially in health care: Describe the general family relationship: Activities for daily living: A. Sleeping Pattern 1. Are there regular hours for retiring and getting up? Or is it dependent on the whim of each individual? 2. Do the family nap during the day? 3. Do the members sleep together? B. Eating Pattern 1. How many meals do the family have each day? 2. Does anyone of the family appear overweight or underweight? Who are they? C. Leisure Time Activities 1. How does each member spend his leisure hours? Is the leisure time appropriate for the sex and age group of the individual? 2. Does any member have an all-consuming hobby? If yes, what affects does this have on the family? 3. Does the family have any joint activity for leisure? What is it? How often do they do this leisure activity?

SCALE FOR RANKING FAMILY HEALTH PROBLEMS ACCORDING TO PRIORITIES:

Nature 1. Nature 2. Modifiability of the Problem 3. Preventive Potential 4. Salience

Computation

Actual Weight

Justifications

RESULT OF THE IN-DEPTH SECOND LEVEL ASSESSMENT ON THE IDENTIFIED HEALTH PROBLEM

CUES / DATA

FAMILY NURSING PROBLEM

CUES / DATA

FAMILY NURSING PROBLEM

CUES / DATA

FAMILY NURSING PROBLEM