First Level Assessment

I. Presence of Wellness Condition-stated as potential or Readiness-a clinical or nursing

judgment about a client in transition from a specific level of wellness or capability to a higher

level. Wellness potential is a nursing judgment on wellness state or condition based on client’s

performance, current competencies, or performance, clinical data or explicit expression of desire

to achieve a higher level of state or function in a specific area on health promotion and

maintenance. Examples of this are the following

A. Potential for Enhanced Capability for:

1. Healthy lifestyle-e.g. nutrition/diet, exercise/activity

2. Healthy maintenance/health management

3. Parenting

4. Breastfeeding

5. Spiritual well-being-process of client’s developing/unfolding of mystery through

harmonious interconnectedness that comes from inner strength/sacred source/God

(NANDA 2001)

6. Others. Specify.

B. Readiness for Enhanced Capability for:

1. Healthy lifestyle

2. Health maintenance/health management

3. Parenting

4. Breastfeeding

5. Spiritual well-being

6. Others. Specify.

II. Presence of Health Threats-conditions that are conducive to disease and accident, or may

result to failure to maintain wellness or realize health potential. Examples of this are the

following:

A. Presence of risk factors of specific diseases (e.g. lifestyle diseases, metabolic syndrome)

B. Threat of cross infection from communicable disease case

C. Family size beyond what family resources can adequately provide

D. Accident hazards specify.

1. Broken chairs

2. Pointed /sharp objects, poisons and medicines improperly kept

3. Fire hazards

4. Fall hazards

5. Others specify.

E. Faulty/unhealthful nutritional/eating habits or feeding techniques/practices. Specify.

1. Inadequate food intake both in quality and quantity

2. Excessive intake of certain nutrients

3. Faulty eating habits

4. Ineffective breastfeeding

5. Faulty feeding techniques

F. Stress Provoking Factors. Specify.

1. Strained marital relationship

2. Strained parent-sibling relationship

3. Interpersonal conflicts between family members

4. Care-giving burden

G. Poor Home/Environmental Condition/Sanitation. Specify.

1. Inadequate living space

2. Lack of food storage facilities

3. Polluted water supply

4. Presence of breeding or resting sights of vectors of diseases

5. Improper garbage/refuse disposal

6. Unsanitary waste disposal

7. Improper drainage system

8. Poor lightning and ventilation

9. Noise pollution

10. Air pollution

H. Unsanitary Food Handling and Preparation

I. Unhealthy Lifestyle and Personal Habits/Practices. Specify.

1. Alcohol drinking

2. Cigarette/tobacco smoking

3. Walking barefooted or inadequate footwear

4. Eating raw meat or fish

5. Poor personal hygiene

6. Self medication/substance abuse

7. Sexual promiscuity

8. Engaging in dangerous sports

9. Inadequate rest or sleep

10. Lack of /inadequate exercise/physical activity

11. Lack of/relaxation activities

12. Non use of self-protection measures (e.g. non use of bed nets in malaria and filariasis

endemic areas).

J. Inherent Personal Characteristics-e.g. poor impulse control

K. Health History, which may Participate/Induce the Occurrence of Health Deficit, e.g. previous

history of difficult labor.

L. Inappropriate Role Assumption- e.g. child assuming mother’s role, father not assuming his

role.

M. Lack of Immunization/Inadequate Immunization Status Specially of Children

N. Family Disunity-e.g.

1. Self-oriented behavior of member(s)

2. Unresolved conflicts of member(s)

3. Intolerable disagreement

O. Others. Specify._________

III. Presence of health deficits-instances of failure in health maintenance.

Examples include:

A. Illness states, regardless of whether it is 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 (e.g. aphasia or

temporary paralysis after a CVA) or permanent (e.g. leg amputation secondary to diabetes,

blindness from measles, lameness from polio)

IV. Presence of stress points/foreseeable crisis situations-anticipated periods of unusual

demand on the individual or family in terms of adjustment/family resources. Examples of this

include:

A. Marriage

B. Pregnancy, labor, puerperium

C. Parenthood

D. Additional member-e.g. newborn, lodger

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

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 fear of consequences of diagnosis of

problem, specifically:

1. Social-stigma, loss of respect of peer/significant others

2. Economic/cost implications

3. Physical consequences

4. Emotional/psychological issues/concerns

C. Attitude/Philosophy in life, which hinders recognition/acceptance of a problem

D. Others. Specify _________

II. Inability to make decisions with respect to taking appropriate health action due to:

A. Failure to comprehend the nature/magnitude of the problem/condition

B. Low salience of the problem/condition

C. Feeling of confusion, helplessness and/or resignation brought about by perceive

magnitude/severity of the situation or problem, i.e. failure to breakdown problems into

manageable units of attack.

D. Lack of/inadequate knowledge/insight as to alternative courses of action open to them

E. Inability to decide which action to take from among a list of alternatives

F. Conflicting opinions among family members/significant others regarding action to take.

G. Lack of/inadequate knowledge of community resources for care

H. Fear of consequences of action, specifically:

1. Social consequences

2. Economic consequences

3. Physical consequences

4. Emotional/psychological consequences

I. Negative attitude towards the health condition or problem-by negative attitude is meant one

that interferes with rational decision-making.

J. In accessibility of appropriate resources for care, specifically:

1. Physical Inaccessibility

2. Costs constraints or economic/financial inaccessibility

K. Lack of trust/confidence in the health personnel/agency

L. Misconceptions or erroneous information about proposed course(s) of action

M. Others specify._________

III. Inability to provide adequate nursing care to the sick, disabled, dependent or

vulnerable/at risk member of the family due to:

A. Lack of/inadequate knowledge about the disease/health condition (nature, severity,

complications, prognosis and management)

B. Lack of/inadequate knowledge about child development and care

C. Lack of/inadequate knowledge of the nature or extent of nursing care needed

D. Lack of the necessary facilities, equipment and supplies of care

E. Lack of/inadequate knowledge or skill in carrying out the necessary intervention or

treatment/procedure of care (i.e. complex therapeutic regimen or healthy lifestyle program).

F. Inadequate family resources of care specifically:

1. Absence of responsible member

2. Financial constraints

3. Limitation of luck/lack of physical resources

G. Significant persons unexpressed feelings (e.g. hostility/anger, guilt, fear/anxiety, despair,

rejection) which his/her capacities to provide care.

H. Philosophy in life which negates/hinder caring for the sick, disabled, dependent, vulnerable/at

risk member

I. Member’s preoccupation with on concerns/interests

J. Prolonged disease or disabilities, which exhaust supportive capacity of family members.

K. Altered role performance, specify.

1. Role denials or ambivalence

2. Role strain

3. Role dissatisfaction

4. Role conflict

5. Role confusion

6. Role overload

L. Others. Specify._________

IV. Inability to provide a home environment conducive to health maintenance and personal

development due to:

A. Inadequate family resources specifically:

1. Financial constraints/limited financial resources

2. Limited physical resources-e.i. lack of space to construct facility

B. Failure to see benefits (specifically long term ones) of investments in home environment

improvement

C. Lack of/inadequate knowledge of importance of hygiene and sanitation

D. Lack of/inadequate knowledge of preventive measures

E. Lack of skill in carrying out measures to improve home environment

F. Ineffective communication pattern within the family

G. Lack of supportive relationship among family members

H. Negative attitudes/philosophy in life which is not conducive to health maintenance and

personal development

I. Lack of/inadequate competencies in relating to each other for mutual growth and maturation

(e.g. reduced ability to meet the physical and psychological needs of other members as a result of

family’s preoccupation with current problem or condition.

J. Others specify._________

V. Failure to utilize community resources for health care due to:

A. Lack of/inadequate knowledge of community resources for health care

B. Failure to perceive the benefits of health care/services

C. Lack of trust/confidence in the agency/personnel

D. Previous unpleasant experience with health worker

E. Fear of consequences of action (preventive, diagnostic, therapeutic, rehabilitative) specifically

:

1. Physical/psychological consequences

2. Financial consequences

3. Social consequences

F. Unavailability of required care/services

G. Inaccessibility of required services due to:

1. Cost constrains

2. Physical inaccessibility

H. Lack of or inadequate family resources, specifically

1. Manpower resources, e.g. baby sitter

2. Financial resources, cost of medicines prescribe

I. Feeling of alienation to/lack of support from the community, e.g. stigma due to mental illness,

AIDS, etc.

J. Negative attitude/ philosophy in life which hinders effective/maximum utilization of

community resources for health care

STATEMENT OF A FAMiLY HEALTH NURSiNG PROBLEM (NURSiNG DiAGNOSiS)

* A wellness condition is a nursing judgment related with the client’s capability for

wellness.

• A health condition or problem is a situation which interferes with the promotion

and/or maintenance of health and recovery from illness or injury.

• NURSING DIAGNOSIS in the FAMILYNURSING PRACTICE

-the family’s failure to perform adequately specific health tasks to enhance the wellness

state or manage the health problem.

• TYPOLOGY OF NURSING PROBLEMS IN FAMILY NURSING

PRACTICE –classification system of family nursing problems.

DEVELOPiNG THE FAMiLY NURSiNG CARE PLAN :

i. Priority setting : Criteria

ii. Defining/setting goals/objectives

iii. Plan of intervention

iv. Plan of evaluating care

PRiORiTY SETTiNG : CRiTERiA

(FOUR CRiTERiA)

The nature of the problem

a. Health Threat

b. Health Deficit

c. Foreseeable Crisis

Modifiability of the problem

= The probability of success in minimizing, alleviating, or totally eradicating the

problem through intervention.

Preventive Potential

= The nature and magnitude of future problems that can be minimized or totally

prevented if intervention is done on the problem under consideration.

Salience

= The family’s perception and evaluation of the problem in terms of seriousness and

urgency of attention needed.

DEFiNiNG/SETTiNG GOALS/OBJECTiVES

GOALS OBJECTiVES

General statement of the condition

or state to be brought about by

specific courses of action.

Client outcomes.

Goals tell where the family is

going.

More specific statements of desired

results or outcomes of care.

Specify the criteria by which the

degree of effectiveness of care are

to be measured.

Must be specific in order to

facilitate its attainment.

Milestones to reach the destination.

Goals ;

Must be set together with the family.

Family must be able to recognize and accept the presence of existing health needs and

problems.

Nurse must ascertain the family’s knowledge and acceptance of the problems and the

desire to make actions to resolve them.

BARRIERS TO GOAL-SETTING

1) Failure of the family to perceive the existence of the problem.

= family may feel satisfied with the existing situation

2) Family is too busy with other concerns or preoccupations at the moment.

3) Family does not see the existence of a problem as serious enough to necessitate

attention.

4) Family may perceive the problem and the need to take action, but they face to do

something about the situation.

5) Failure between the nurse and the family to establish a working relationship.

= TRUST AND CONFIDENCE

TIME SPAN OF OBJECTIVES

1) Short Term / Immediate Objectives

- immediate att’n; results: can be observed in a period of short time

2) Medium – Term / Intermediate Objectives

- required to attain long – term objectives

3) Long – Term or Ultimate Objectives

- several N-F contact + more resources

- takes time to see the result

PLAN OF iNTERVENTiON

Nurse must choose among set of alternatives.

Nurse must specify the most effective or efficient method of Nurse-Family contact;

1. Home visit

2. Clinic conference

3. Visit in work, place, school

4. Telephone call

5. Group approach

6. Mail

Nurse must specify the most effective or efficient resources;

a. Teaching kits – visual aids, handouts, charts

b. Human – other team members, community leaders

HOW TO CHOOSE THE APPROPRIATE

NURSING INTERVENTION?

A.Analyze w/ the Family the Current Situation and Determine Choices and Possibilities

based on a Lived Experience of Meanings and Concerns

B.Develop / Enhance Family’s Competencies as Thinker, Doer and Feeler

C.Focus on Interventions to Help Perform the Health Tasks

D.Catalyze Behavior Change through Motivation and Support

PLAN OF EVALUATiNG CARE

-Criteria/Outcomes Based on

Objectives of Care

-Methods/Tools

Reference :

http://www.rnpedia.com/home/notes/community-health-nursing-notes/a-typology-of-nursing-

problems-in-family-nursing-practice

GROUP 2

report

Submitted by :

Khrysty Rose B. Aquino

Steven B. Lim

Princess J. Mohammad Adhan

Abusayid A. Tapsirun

Zherfaina T. Udday

Rhea Mae Q. Piedad