BROKENSHIRE COLLEGE

Madapo, Davao City

FAMILY NURSING ASSESSMENT TOOL

FAMILY ASSESSMENT GUIDE

Name of the Family: Largosa Address: _Upper Madapo Hills Davao City_
Date of Assessment: 2/2/2021
I. DEMOGRAPHIC DATA
Household No. _261 Barangay House No.
FAMILY DATA
Length of residency in the area: _15 years_____ Place of origin: Davao City_
Family size: _5__ Religion: Protestant_
II. FAMILY MEMBERS CHART
Name of Member Age Sex Civil Position in Educational Occupation
Status the Family Attainment
1.Michael Largosa 46 M married Father high school farmer
2. Ana Marie Largosa 43 F married mother College Callcenter
agent
3.Elijah David Largosa 19 M single son Student 2nd yr none
college
4. Arriadne Chelsea Largosa 16 F single daughter Student grade none
12 SH
5. Creazun Mavic Nierra 20 F single daughter Student 3rd yr none
College

Are all the members living with the family? ✓ Please specify names of members not living
with the family and the reason:
______________________________________________________________________________
______________________________________________________________________________
III. FAMILY CHARACTERISTICS
A. Type of Family Structure (please check):
Extended ____ Matriarchal _____ Nuclear ✓ Patriarchal _____

B. General Family Dynamics

Criteria Present Remarks
(Pls. (Note personal observations and
check) description from informant)
1. Presence of any observable conflicts
between family members.
2. Communication patterns among ✓ Every time they have
members. misunderstanding, they talk about
it as a family
3. Patterns of decision-making (Who makes ✓ The father decides what they eat
the decisions on matters of health?) every day since his the one making
money for the family

C. Family Dietary Habits

What did you eat yesterday? (24-hours dietary recall)
Breakfast:
_coffee, bread
Lunch:
_ vegetable ,rice, water
Dinner:
__ Adobo rice water

D. Monthly Family Income and Source (Please check)

Source: Husband ✓ Wife ___✓__ Others (Pls. specify): ____________________
Income Bracket:
Below P5,000.00
5,000.00 – 10,000 ______
More than 10,000 – 15,000 ___✓___
E. Family Health Status/Health History
(Note: Please specify any previous hospitalization, operation, or any history of a medical
problem or complaint)
Name of the Member Health History
1.Michael Largosa Skin allergy
2. Ana Marie largosa none
3.David largosa none
4. Chelsea Largosa none
5. Creazun Nierra none
F. Felt Family Needs
(Note: Allow the family to enumerate any felt family needs and have them rank there needs
according to priority)
1. Money
2. Food
3. Shelter
4. Electricity
5. Water
HOME ENVIRONMENT
A. Do you own this lot? Yes (✓) No ( )
B. Do you own this house? Yes (✓) No ( )
C. Type of housing materials: Wood ( ) Mixed ( ✓ ) Concrete ( )
Others, please specify
D. Is the living space adequate for the family? Yes (✓) No ( )
E. Type of garbage disposal:
Collected ( ✓ ) Burned ( ) Segregated ( ) Buried ( )
Fed to animals ( ) Thrown in the river ( ) Open dumpling ( )
Others, please specify: _________________
F. Type of waste disposal:
Flush type ( ) Pit privy ( ) Wrap and throw ( ✓ )
Water-sealed type ( ) Others, please specify: _______________
G. Type of drainage system:
Open ( ✓ ) Closed ( )
H. Type of water supply:
Owned (✓ ) Shared ( )
Bought ( ) Others, please specify: _____________
I. Drinking water storage:
Refrigerated (✓ ) Covered ( ) Uncovered ( )
J. Containers used:
Plastic pitchers (✓ ) Jars, clay pots ( ) Bottles ( )
Others, please specify: __________
K. Food Storage:
Covered ( ) Uncovered ( ) Refrigerator (✓ ) Cabinet ( )
Stoved ( ) Others, please specify: __________
L. Owned household pets and animals: __1__
M. Are there breeding sites of insects, rodents, etc. present? Yes ( ✓ ) No ( )
N. Are the pets and animals kept in a specific place? Yes (✓ ) No ( )
O. Are there accident hazards present? Yes (✓ ) No ( )

IV. HEALTH AND HEALTH PRACTICES

A. Were there any common illnesses the family encountered the past six (6) months?
_n/a___ . If yes, what were these illnesses and the treatment applied?
________________________
B. Whom do you consult for health-related problems?
Manghihilot ( ✓) Albularyo ( )
Midwife ( ) Nurse ( ✓ )
Doctor ( ) Health center staff ( ✓ ) Others,
please specify: _________________
C. For problems other than health, whom do you consult?
Family members (✓ ) Relatives (✓ )
Friends ( ) Barangay officials ( )
Priest ( ) Others, please specify: _________________
D. Immunization status of the family: (OPV, DPT, Measles, BCG, HepaB, TT
Name of the Child Complete Lacking
_All family member___ ___ ✓_____ ________
E. For the past week, have you experienced the following?
Adequate rest and sleep Yes ( ) No ( ✓ )
Exercise Yes (✓) No ( )
Relaxation activities Yes (✓) No ( )
Stress management activities Yes ( ✓ ) No ( )

V. ENVIRONMENT
A. Kind of neighborhood:
__peaceful, relaxing_______________________________________________
Social and health facilities available:
__Barangay health center, hospital_______________
B. Communication and transportation facilities:
Tricycle , taxi_
Name five (5) formal and informal leaders of the community whom you consult in times
of problems.
1. Barangay captain
2. Sk chairman
3. Pastors
LISTING AND CATEGORIZING HEALTH PROBLEMS
I. FIRST-LEVEL ASSESSMENT

A. List of Health Problems

Cues/Data Health Problem

Health Problem: Presence of Vectors Inability to provide home environment
conducive to health maintenance and
Subjective “we have rats’ holes in the personal development due to: Lack of
kitchen, and there are cockroaches under knowledge on how to throw the garbage
the kitchen cabinets” properly

Objective: in the backyard near the

kitchen there’s a garbage bin and the
kitchen cabinets it is there they put our
garbage
Health Problem Illness Inadequate to provide nursing care to the
dependent member of the family due to:
Subjective: “my daughter is malnourished Lack of knowledge of the nature and
she always eat unhealthy foods and extent of nursing care needed.
because of poverty and lack of financial
we can’t afford to buy real food for them”

(Note: Use separate sheet/s if necessary.)

B. Scale for Ranking Health Conditions and Problems

Health Condition/Problem: Poor Sanitation due to the presence of vectors

Criteria Computation Actual Justification/Remarks
Score

1. Nature of the Problem 2/3 0.66 The worry or issue is a Health

threat that needs immediate
action
2. Modifiability of the Problem 2/2 1 The issue is easily modifiable
The family has the man power to
address the problem
3. Preventive Potential ½ 0.5 Preventive potential is high the
family genuinely expresses
willingness to clean the house
and surrounding.
4. Salience of the Problem 3/3 1 Family does not perceive the
problem as needing immediate
attention because of the shallow
knowledge
Total Score 3.16

Health Condition/Problem: Presence of Illness

Criteria Computation Actual Justification/Remarks
Score

1. Nature of the Problem 3/3 1 Problem is a health deficit that

needs proper attention.

2. Modifiability of the Problem ½ 1 Problem is partially modifiable.

3. Preventive Potential 2/3 2 Malnutrition is a chronic

condition that can be prevented
and cured when proper medical
4. Salience of the Problem 1/2 0.5 management is present.

The preventive potential is not

that low since the patient is old
enough and can take care of
himself. The mother does
provide the patient the needed
care
The family is aware of the
existence of the problem
Total Score 4.5

C. List of Health Conditions/Problems Ranked According to Priority

Problem No. Health Conditions/Problem Actual Score

1) Poor Sanitation due to the 3.16
presence of vectors
2) Presence of Illness 4.5

(Note: Use separate sheet/s if necessary.)

II. SECOND-LEVEL ASSESSMENT

Cues/Data Family Nursing Problem

1. Inability to Recognize the Lack of Adequate knowledge
Presence of the Problem due to:
2. Inability to make Decisions with Lack of inadequate knowledge insight as
Respect to Taking Appropriate to alternative courses of action open to
Health Action due to them.

(Note: Use separate sheet/s if necessary.)

Submitted by: _Creazun Mavic Nierra __ Section: _BSN3-A____________

Date of Submission: _10/6/2021________________________
Clinical Instructor: Rambe Jr Ramel RN__