BULACAN STATE UNIVERSITY
COLLEGE OF NURSING
City of Malolos
ASSESSMENT DATA BASE
Family Name: PAED FAMILY
Purok(s) 4 , Brg SAN PABLO , MALOLOS , Bulacan
Informant: Time Started:__________ Time Finished:____________
A. Family Structure, Characteristics, and Dynamics
Name of Family Age Sex Civil Position In Place of
Member Status the Family Residence
Type of family structure
( ) Nuclear ( ) Extended ( ) Dyad
( ) Single- parent ( ) Homosexual/Same Sex
( ) Cohabiting/Communal
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Dominant family members in terms of decision making
( ) Patrifocal/Patriarchal ( ) Matrifocal/Matriarchal
( ) Egalitarian ( ) Matricentric
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General family relationship/dynamics
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B. Socio-Economic and Cultural Characteristics
Family Member Occupation Income Educational Religion
Attainment
Relationship of the family to larger community
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C. Home and Environment
Housing
a. Adequacy of living space
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b. Sleeping arrangement
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c. Presence of breathing or resting sites of vector of diseases
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d. Presence of accident hazard
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e. Food storage and cooking facilities
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f. Water supply
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g. Toilet facilities
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h. Garbage/refuse disposal
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i. Drainage System
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j. Lighting Facilities
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Kind of Neighborhood
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Social and Health facilities available
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Communication and transportation facilities available
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D. Health Status of Family Member
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Medical History of Diseases
Name Age Gender Disease
Nutritional Assessment
Anthropometric Measurements
Age Wt. in Ht. in BMI Waist Hips Waist
Mid Arm
Name in kg. m (Wt. in Remarks Circumference Circumference Hips Remarks Circumference Remarks
kg / Ht. in (WC) in cm. (HC) in cm.
Ratio
mos m2) (WC/HC)
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24-hour Dietary Recall
Date Time of the day Food taken
BREAKFAST
SNACK
LUNCH
SNACK
DINNER
MIDNIGHTSNACK
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Developmental assessment of infant, toddlers and preschoolers
(See MMDST Tool)
Risk factor assessment
Cigarette Smoking
Is there a member of the family who is a cigarette smoker?
( ) Yes ( ) No ( ) frequency/sticks or packs/day ________
Name Age Age started smoking Reason
Use of prohibited / dangerous drugs
Is there a member of the family who uses prohibited/dangerous drugs?
( ) Yes ( ) No ( ) Types of Drugs : ______/Solvent_________
Name Age Age started using Reason
drugs
Drinks alcoholic beverages
Is there a member of the family who drinks alcoholic beverages? ( ) Yes ( ) No
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Name Age Age started drinking Frequency Type Reason
alcohol
Physical Assessment
(See Physical Assessment Tool)
E. Values, Habits, Practices on Health Promotion, Maintenance and Disease
Prevention
Immunization status of family members
Incom Fully
Age Complete
DPT DPT DPT Hepa B Hepa B Hepa B OPV OPV OPV Meas plete Immun
Name in Gender BCG according
1 2 3 1 2 3 1 2 3 les accdg ized
mos to Age
to Age Child
Healthy lifestyle practices
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Adequacy of:
Rest and sleep
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Exercise/activities
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Use of protective measure
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Relaxation and other stress management activities
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Use of Promotive-Preventive Health Services
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GENOGRAM
(Draw your genogram here)
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ECOMAP
(Draw your Ecomap Here)
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First Level Assessment
Cues/Data Health Condition
A. Health Threat
B. Health Deficit
C. Stress Points/Foreseeable Crisis
Second Level Assessment
Health Condition Family Nursing Problem
A. Health Threat
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B. Health Deficit
C. Stress Points/Foreseeable Crisis
Scoring & Prioritization
A. ___________________________________________
Criteria Computation Actual Justification
Score
1. Nature of the
problem
2. Modifiability of
the Problem
3. Preventive
Potential
4. Salience of the
Problem
Total Score
B. _____________________________________________
Criteria Computation Actual Justification
Score
1. Nature of the
problem
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2. Modifiability of
the Problem
3. Preventive
Potential
4. Salience of the
Problem
Total Score
C. _____________________________________________
Criteria Computation Actual Justification
Score
1. Nature of the
problem
2. Modifiability of
the Problem
3. Preventive
Potential
4. Salience of the
Problem
Total Score
Prioritization of Problems
Rank Score Problem
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Documentation
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