ASSESSMENT DATA BASE IN FAMILY NURSING PRACTICE

Address: Lumiyap Road, Cabrera drive Divisoria FAMILY NUMBER: 5

Street/Road Barangay Zone

A. FAMILY STRUCTURE, CHARACTERISTICS, & DYNAMICS/RELATIONAL PATTERN

1. Members of the household

Birthdate
Members of the family Age Sex Civil status Position in the family Relationship to the head of the Family
Month Year
Kristoff Lim 56 January 1966 F Married Head of the family -
Elsa Lim 54 March 1968 M Married Mother Husband
Rey Lim 20 December 2002 F Single Daughter Father
JB Lim 32 February 1990 M Married Son Father
Mae Lim 31 April 1991 Married Wife Father-in-law

2. Socio-demographic data of members not currently living in the household but with major role in resource generation and use

Birthdate Highest Occupation

Relationship to the
Name of Family Member Age Sex Marital Status Educational
Month Year Type of Work Place head of the family
Attainment

3. Lenghth of Residency: 20 years

4. Type of family structure and form

Based on Composition Based on locus power Based on place of residency
 Nuclear family Stepfamily/blended Patrifocal Patrifocal

Extended Single Matrifocal Matrifocal

Beanpole Same sex/Homosexual Egalitarian Bilocal

Single Parent Cohabiting Matricentric

5. Family dynamics, Communication patterns, interaction processes and interpersonal relationships.

Criteria Status Additional information

Observable conflicts between family members Observed No financial difficulties

Characteristics of communication Observed With respect and empathy

Interaction patterns Observed Always there for each other and open minded

Others

B. SOCIO ECONOMIC & CULTURAL CHARACTERISTICS

Name of Family member Ethnic background Religion Highest educational Occupation Income
attainment
Nature of work Place of work

Kristoff Lim Caucasian Christian College graduate Businessman Zamboanga Above 25000
Elsa Lim Caucasian Christian College graduate Doctor Zamboanga Above 25000

Legend for monthly income

1- Below 2500 3. Above 5000 to 7500 5- above 10000 to 12500 7- above 15000 to 17500 9-above 20000 to 25000
2- 2500 to 5000 4- above 7500 to 10000 6-above 12500 to 15000 8-above 17500 to 20000 10- above 25000

Income & Expenses

 a. Adequacy to meet basic Necessities
The basic need includes the food & water, shelter, clothing, sanitation, education and healthcare. They see to it that their home is running smoothly and
their monthly family earnings are adequate to support and provide for the whole family.

2. Significant others – role(s) they play in family’s life

Name Relation the family

N/A

3. Relationship of the family to the larger community- nature and extent of participation of the family in community activities

a. Awareness of existing organization Yes Name ___________________________ No

b. Membership in an organization Yes Name ____________________________ No

c. Involvement in an organization Yes Name _____________________________ No Why? Too busy with work

d. Potential or Existing leaders __________________________________________________________________________________________________

C. HOME AND ENVIRONMENT

1. Home
Ownership: owned rented free Constructional material used: light mixed strong
Lighting facilities: electricity kerosene others (specify) ____________________________________
Number of rooms used for sleeping and sleeping arrangement: __________________________________________________
2. Water Supply
Drinking: Source: private public Potability: Specify if safe for drinking safe unsafe
Storage direct from pipe covered container with faucet large uncovered without faucet

Other (specify): ____________________________

3. Food storage & cooking facilities

Cooking facility: electric gas stove firewood

Sanitary condition ______________________________________________________________________________________________

 Drainage facility : Open drainage blind drainage None

4. Waste disposal
a. Refuse and Garbage
- Container: Covered Open None

- Method of disposal : Hog feeding open dumping burial in pit composing Open burning

Garbage collection Other (specify) ______________________________________

b. Toilet
- Type none Overhung latrine open pit privy Closed pit privy Bored hole latrine

Pail system antipolo system water sealed latrine flush type Others

- Distance from the house_________________________________________________________________________________________

- Sanitary condition: Due to blind drainage and good environmental sanitation, the breeding sites for insects and cockroaches are rarely seen.

5. Domestic animal

Kind Number Where kept

N/A

6. Community in general
a. General sanitary condition: Clean/good sanitation
b. Housing congestion Urban
c. Presence of breeding or resting sites of vectors of disease
d. Recreational activity Basketball court and covered court
e. Availability of health care services Barangay Health center
f. Distance of house from nearest health care facility 1.118 miles away
g. Communication & transportation facilities available barangay health services, private service, taxi, tricycle
D. Health status of each family member
1. Medical history and nursing history
 Family member Health status Family member Health status
Kristoff Lim Hyperlipidemia and Type 2 diabetes Father
JD Lim Diarrhea Son

2. Nutritional assessment
a. Anthropometric Data : Measure of Nutritional Status of Children

Anthropometric data (Children)

Name of the family member Weight Height Mid arm circumference

N/A

Anthropometric data (Adults)

Name of family member Weight Height Body mass index Waist circumference Waist hip ratio
Kristoff Lim 60kg 5’4 22 34in 39in
Elsa Lim 50kg 5’4 18.9 35in 35in
Rey Lim 55kg 5’3 21.5 31in 37in
JB Lim 58kg 5’3 22.6 34in 36in
Mae Lim 45kg 5’2 18.1 25in 32in

b. Dietary History specifying quality and quantity of food intake per day

Breakfast: Minimum of 1 bowl of porridge, 1 boiled egg and a cup of coffee or tea for each of the family. Lunch: Minimum of 1 bowl of rice, meat (dish varies), and
vegetables as side dish for each family member. Dinner: Minimum of 1 bowl of rice, meat (dish varies), and vegetables as side dish for each family member. And for snacks, fruits
and vegetables.

c. Eating and feeding habits

Water intake. Breakfast, lunch, dinner and snacks.

d. Risk factor assessment indicating presence of major and contributing risk factors for specific lifestyle diseases

Exposure to poor environment sanitation

e. Result of laboratory 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

Name of child Immunization status Remarks

N/A N/A

2. Health lifestyle practices

____________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________

3. Adequacy of
a. Rest and sleep Yes No
b. Exercise Yes Specify Morning jog/walk, basketball
c. Use of protective measures Yes Specify Eyeglasses with UV, face mask No Why ______________________________

d. Relaxation and other stress management activities Yes No

e. Opportunities which enhance feelings of self-worth, self-efficacy and sense of connectedness to self, others and a higher power essence of meaningfulness

Yes Specify Discernment No

4. Use of promotive-preventive health services yes Specify Exercise every morning, monthly check-ups, meds and vitamins No Why
_________________________
5. Use of Family Planning Method
a. Type
Natural

Abstinence Lactational Amenorrhea Method Basal Body Temperature Cervical Mucus Method
Symptothermal Method Standard Days Method Others: specify ____________________________________
Artificial
Hormonal
Oral Contraceptive Specify: Progesterone-Only Oral Contraceptive Low-Dose Combined Oral Contraceptive
Injectable [depot medroxyprogesterone acetate / Depo-Provera (DMPA)]
Norplant Implants
Barrier
Intrauterine Devices Condom Diaphragm Cervical Cap Other: specify___________________
Permanent
Tubal Ligation Vasectomy
None Are you willing to practice Family Planning Method? Yes No

What hinders you from practicing Family Planning Method? Biological Psychological Social Cultural
Religion Others, specify: ________________________

b. Who taught you about Family Planning Method?

PHN/PHM BHW Friend Neighbor Print/Visual Ads Student Nurse Others; specify:_____________

c. Is your husband aware of your usage of Family Planning Method? Yes No

d. Do you know side effects of family planning method as a result of its use? Yes No
Changes in menstrual bleeding headache nausea weight gain moodiness
Delayed return of fertility dizziness acne in women nervousness change in appetite
Enlargement of ovaries/ovaran cyst hair loss breast tenderness others; specify: _____________________________

e. Do you have misconceptions about Family Planning Methods? Yes No

Some FP methods causes abortion Using contraceptives will render couples sterile Using contraceptive methods will result to loss of sexual desire
Others; specify: ____________________________________________________________