Assessment

• Set of actions by which the nurse measures

the status of the family as a client, its ability to
maintain itself as a system and functioning
unit, and its ability to maintain wellness,
prevent, control or resolve problems in order
to achieve health and well-being among its
members.
Assessment
• Data collection: First level or Second level
assessment
• Data analysis or interpretation: sort data,
cluster/group related data, distinguish
relevant from irrelevant data, identify
patterns, compare patterns with norms or
standards, interpret results, make
inferences/draw conclusions
• Problem definition or nursing diagnosis
 Two major types of nursing
assessment
• First-level Assessment - Process whereby
existing and potential health conditions or
problems of the family are determined.
• Second-level Assessment – Defines the nature
or type of nursing problems that the family
encounters in performing the health tasks
with respect to a given health condition or
problem, and the etiology or barriers to the
family’s assumption of these tasks.
 Five types of data for First Level
Assessment

• Family structure, characteristics and dynamics

• Socio-economic and cultural characteristics
• Home and environment
• Health status of each member
• Values and practices on health
promotion/maintenance and disease
prevention
Constructing the Family Genogram
• A genogram is a pictorial display of a
patient's family relationships and medical
history.
• Uses symbols
• Date of birth (death) above the symbol and
name beneath
• Inside the symbol: age or disease condition
• Connecting lines denote relationships
 First Level Assessment

(1) Wellness state/s

(2) Health threats
(3) Health deficits
(4) Stress points or foreseeable crisis situations
 Presence of Wellness Condition
Wellness potential

• A wellness state or condition based on client’s

performance, current competencies or clinical
data, but NO explicit expression of client
desire.
 Wellness State
Potential for Enhanced Capability for:
• Healthy Lifestyle – nutrition/diet, exercise
• Health Maintenance/Health Management
• Parenting
• Breastfeeding
• Spiritual Well-being
• Others, specify
• Readiness for enhanced wellness state

• Wellness state or condition based on client’s

current competencies or performance, clinical
data and explicit expression of desire to
achieve a higher level of state or function in a
specific area on health promotion and
maintenance.
 Wellness State
Readiness for Enhanced Capability for:
• Healthy Lifestyle
• Health Maintenance/Health Management
• Parenting
• Breastfeeding
• Spiritual Well-being
 Presence of Health Threats
• Conditions conducive to disease, and accident
or may result to failure to maintain wellness
or realize health potential.
A.Presence of risk factors of specific diseases
(lifestyle diseases, metabolic syndrome)
B.Threat of cross infection from a
communicable disease case
C.Family size beyond what family resources can
adequately provide
 Presence of Health Threats
D. Accident hazards
E. Faulty/unhealthful nutritional/eating habits or
feeding techniques practices
F. Stress-provoking factors
G. Poor home/environmental condition/sanitation
H. Unsanitary food handling and preparation
I. Unhealthful lifestyle and personal
habits/practices
J. Inherent personal characteristics
 Presence of Health Threats
K. Health history which may precipitate/induce
the occurrence of a health deficit.
L. Inappropriate role assumption
M. Lack of immunization/inadequate
immunization status specially of children
N. Family disunity
O. Others
 Presence of Health Deficits
• Instances of failure in health maintenance
A.Illness states, diagnosed or undiagnosed by
medical practitioner
B.Failure to thrive/develop according to normal
rate
C.Disability –whether congenital or arising from
illness; transient/temporary or permanent
Presence of Stress Points/Foreseeable
Crisis Situations
• Anticipated periods of unusual demand on the
individual or family in terms of
adjustment/family resources.
A.Marriage
B.Pregnancy, labor, puerperium
C.Parenthood
D.Additional member
E. Abortion
F. Entrance at school
G. Adolescence
H. Divorce or Separation
I. Menopause
J. Loss of Job
K. Hospitalization of a Family Member
L. Death of a Member
M. Resettlement in a new community
N. Illegitimacy
O. Others
 Second Level Assessment
• Should reflect the extent to which the family
can perform the health tasks on each health
condition or problem identified during the first
level assessment.
• Describes the family’s realities, perceptions
and attitudes to the assumption or
performance of health tasks.
Data for Second Level Assessment
• Family’s perception of the problem
• Decisions made and appropriateness; if none,
reasons
• Actions taken and results; if none, reasons
• Effects of decisions and actions on other
family members
 Standard Health Tasks
• Recognize the presence of a wellness state or
health condition or problem;
• Make decisions about taking appropriate health
action to maintain wellness or manage the health
problem;
• Provide nursing care to the sick, disabled,
dependent or at-risk members;
• Maintain a home environment conducive to
health maintenance and personal development
• Utilize community resources for health care.
 Second-level Assessment
I. Inability to recognize the presence of the
condition or problem due to:
A. Lack of or inadequate knowledge
B. Denial about its existence or severity as a
result of consequences of diagnosis of
problem
C. Attitude/philosophy in life which hinders
recognition/acceptance of a problem
D. Others
II. Inability to make decisions with respect to
taking appropriate health actions due to:
III. Inability to provide adequate nursing care to
the sick, disabled, dependent or
vulnerable/at-risk member of the family due
to:
IV. Inability to provide a home environment
conducive to health maintenance and
personal development due to:
V. Failure to utilize community resources for
health care due to:
 Nursing Diagnosis
• Cough and colds seen as a health deficit
1.Inability to make decisions with respect to
taking appropriate health actions due to:
a. Failure to comprehend the nature/magnitude of
the problem or condition
2. Inability to provide adequate nursing care to
the sick member of the family due to:
a. Inadequate knowledge about the health condition
 Family Care Plan
• Blueprint of the care that the nurse designs to
systematically minimize or eliminate the
identified health and family nursing problems
through explicitly formulated outcomes of
care and deliberately chosen set of
interventions, resources and evaluation
criteria, standards, methods and tools.
Steps
1. Prioritization of identified health problems
2. Statement of goals or objectives of care
3. Selection of appropriate nursing
interventions
4. Means of evaluation
 Prioritization
Criteria:
1.Nature of the condition or problem presented
2.Modifiability of the condition or problem –
refers to probability of success in enhancing
the wellness state, improving the condition,
minimizing, alleviating or totally eradicating
the problem through interventions
 Prioritization
3. Preventive Potential – refers to the nature
and magnitude of future problems that can be
minimized or totally prevented if intervention
is done on the condition or problem under
consideration
4. Salience – refers to the family’s perception
and evaluation of the condition or problem in
terms of seriousness and urgency of attention
needed or family readiness.
Scale
Criteria Weight
1. Nature of the Condition or 1
Problem Presented
Wellness State 3
Health Deficit 3
Health Threat 2
Foreseeable Crisis 1
 Criteria Weight
2. Modifiability of the 2
Condition or Problem
Easily Modifiable 2
Partially Modifiable 1
Not Modifiable 0
 Criteria Weight

3. Preventive Potential 1

High 3

Moderate 2

Low 1
 Criteria Weight
4. Salience 1
A condition or problem 2
needing immediate attention
A condition or problem not 1
needing immediate attention
Not perceived as a problem 0
or condition needing change
Scoring
1. Decide on a score for each of the criteria.
2. Divide the score by the highest possible score
and multiply by the weight (Score/Highest
Score) x weight
3. Sum up the scores for all the criteria. Highest
score is 5, equivalent to the total weight.
 Formulation of Goals of Care
• General statement of the condition or state to
be brought about by specific courses of action.

• After nursing intervention, the family will

manage PTB as a disease and threat.
 Developing Intervention Plan
1. Analyze with family choices/possibilities
based on lived experience of
meanings/concerns.
2. Develop/enhance cognition (thinker), volition
(doer) and emotion (feeler)
3. Focus on interventions to help the family
perform the health tasks
3.1. Help the family recognize the problem.
3.2. Guide the family on how to decide on
appropriate health actions to take.
3.3. Develop the family’s ability and commitment to
provide nursing care to its members.
3.4. Enhance the capability of the family to provide
a home environment conducive to health
maintenance and personal development.
3.5. Facilitate the family’s capability to utilize
community resources for health care.
4. Catalyze behavior change through motivation
and support.
 Developing an Evaluation Plan
• Specifies how the nurse will determine
changes in health status, condition, or
situation and achievement of the outcomes of
care.
• Shall include criteria or indicators.
 FAMILY NURSING CARE PLAN
Health Problem:
Goal:
Outcome Indicators:

Family Health Interventions Evaluation

Task
 Implementation Phase
• Home Visits
• Health Teachings
• Referrals
• Community Meetings
• Skills Trainings and other training programs
• Monthly Community Classes
• Linkages
• Provision of health services
 Evaluation
• Comparing “what actually is” with “what
should be”
• Based on the objectives and criteria set.