ENDTERM CHN RLE NOTES – Lara Marie D.

Junsay

NURSE – FAMILY CONTACT

A nursing home visit is a family-nurse contact 5.To make use of the inter-referral system
that allows the health worker to assess the and to
home and family situations promote the utilization of community
The nurse starts with establishing a working services.
relationship based on:
 RESPECT
 TRUST
 SHARED GOALS PHASES OF HOME VISIT
 CLARITY OF EXPECTATIONS  PHASE 1: INITIATION PHASE
- Clarify the Purpose of Home Visit
TYPES OF FAMILYNURSE CONTACT:
 Clinic visit  PHASE 2: PRE-VISIT PHASE
 Home visit - Initiate contact with family
 Telehealth -Determine family willingness -schedule home
visiting
I. CLINIC VISIT -Review records
 Patient visits the Health center to avail of the  PHASE 3 - ON HOME PHASE
services offered by the facility primarily for the - Introduction him/her self -warm greeting
consultation on that ailed them physically. - Social interaction (to develop trusting
II. HOME VISIT relationship)
 Family nurse contact which allows the health - Implement nursing process
worker to assess the home and family situations - Assess Diagnose Plan Implement Evaluate
in order to provide the necessary nursing care  PHASE 4 -TERMINATION PHASE
and health related activities. - Review visit with family
Note: - Plan for future visit
 The families need the assistance of the health  PHASE 5 - POST - VISIT PHASE
center that’s why home visit was done to the - Record visit plan for next visit
family.
 The person who makes the home visit is STEPS IN CONDUCTING HOME VISIT:
rendering services on behalf of the health 1.Greet the client and introduce self.
center. 2.State the purpose of the visit.
PURPOSE OF HOME VISIT: 3.Assess health needs.
1.To give nursing care to the clients . 4.Perform the bag technique.
2.To assess living conditions of the patient 5.Perform nursing care and give health
and teachings.
his family and their health practices. 6.Record all data, observation and care
3.To give health teachings regarding rendered.
prevention 7.Make appointment for a return visit.
and control of diseases.
4.To establish close relationships between GUIDELINES REGARDING THE FREQUENCY OF HOME
the VISIT:
health agencies and the public. 1.Needs of the client.
2.Acceptance of the family.
 3.Policy of the specific agency. PUBLIC HEALTH BAG
4.Other health agencies and personnel  Is an essential and indispensable equipment of
involved a public health nurse which he/ she has to carry
in care of family. along during her home visits.
5.Past services given to the families.  It contains basic medications and articles, which
6.Ability of clients to recognize own are necessary for giving care.
needs.
SPECIAL CONSIDERATIONS
Points to consider:
1. The bag should contain all necessary articles,
supplies and
equipment’s that will be used to answer
3.TELEHEALTH emergency needs.
- Defined as the delivery and facilitation of health 2. The bag and its contents should be cleaned
and health-related services including medical care, very often, supplies replaced and ready for use
provider and patient education, health information anytime.
services, and self-care via telecommunications and 3. The bag and its contents should be well-
digital communication technologies. protected from contact with any article in the
patient’s home.
-Live video conferencing, mobile health apps, “store 4. The arrangement of the contents of the bag
and forward” electronic transmission, and remote should be the one most convenient for the user,
patient monitoring (RPM) are examples of to facilitate efficiency and avoid confusion.
technologies used in telehealth.
Note: BP Apparatus is kept separately from
PHN bag

5. Hand washing is done as frequently as the

PHN BAG situation calls
BAG TECHNIQUE for, helps in minimizing or avoiding
 A tool by which the nurse performs nursing contamination of the
procedures with ease and deftness, saving time bag and its contents.
and effort, with the end view of rendering 6. The bag when used for a communicable case
effective nursing care to client during her/ his should be
visit. thoroughly cleaned and disinfected before
keeping and
OBJECTIVES: re-using.
 To render effective nursing care to the Note: BP Apparatus and stethoscope are
members of the family during home visit. carried
Separately
PRINCIPLES:
1. Minimize, if not prevent the spread CONTENTS OF PHN BAG
of infection. TOP Wastepaper bag or Extra
2. Save time and effort on the part of paper for making waste
the nurse. bag, Plastic/Linen lining,
Paper lining, 1 pair of
3. Should show effectiveness of total
sterile gloves
care given to an individual or family
FRONT Thermometer
4. Can be performed in a variety of
(oral/rectal), 2 test tubes,
Way test tube holders, 2 pairs
of forceps, scissor
 CENTER Apron, 2 Hand towels,
Soap in a soap dish,
Baby’s scale, Tape
measure, Sterile
dressings – cotton balls &
OS or gauze, Micropore
or adhesive plaster,
disposable syringe with
needles G23&25,
Hypodermic needles
G19,22,23,25, Alcohol
Lamp
REAR 70% Alcohol, Betadine,
Hydrogen peroxide,
Zephiran
(Benzalkonium) or Cidex,
opthalmic ointment,
spirit of
amonia, Benedict’s
solution (glucose), Acetic
Acid PROCEDURE
(protein)
PROCEDURE
STEPS RATIONALE
CONTENTS OF PUBLIC HEALTH BAG
1. Prepare the needed To save time and energy.
equipment.
2. Upon arriving at the To protect the bag from
client’s home, place the contamination
bag on the table or any
flat surface lined with
paper lining, clean side
out (folded part touching
the table). Put bag
handle or strap beneath
the bag
3. Ask for a basin of To be used for
water and a glass of handwashing.
water if faucet is not To protect the work field
available. Place these from being wet.
outside the working
area.
4. Open the bag, take To make a non-
the plastic lining and contaminated
spread over work field. work field or area
The paper lining clean
side out (folded part out)
5. Take out hand towel, To prepare for hand
soap dish & apron and washing.
place them at one
TEST FOR SUGAR AND PROTEIN IN URINE corner of the work area.
6. Do handwashing . To prevent possible
Wipe dries with towel. infection from care
Leave the plastic provider to client.
wrappers of the towel anecdotal notes
and soap dish in the bag. preparatory to final
7. Put on apron right To protect the nurse’s reporting.
side out & wrong side uniform. 18. Make appointment
out with crease touching for the next visit (either
the body, sliding the home or clinic) taking
head into the neck strap. note of the date, time &
Neatly tie the straps at purpose.
the back.

8. Put out things most To have them readily AFTER CARE:

needed accessible. 19. After keeping all
for a specific case, articles in
(thermometer, the bag, clean and
kidney basin, cotton ball, alcoholized them.
waste 20. Get the bag from the
receptacle) and place at table, fold the paper
one lining (and insert) and
corner of the work area. placed in between the
9. Place wastepaper bag To prevent flaps and cover the bag.
at the work area. contamination of the 21. Wash hands To prevent infection
work area.
10. Close the bag. To prevent BAG TECHNIQUE
contamination of the
bag and contents. CLEANING:
11. Proceed to the The inner part of the bag should be clean & sterile
specific nursing care. Should be done every after-home visit
12. After completing To protect care giver and
Never endorse the bag
nursing care or prevent spread of
treatment, clean and infection to others.
GUIDING PRINCIPLES:
alcoholized the things
used. The less one opens the bag, the lesser chance of
13. Do hand washing contamination
again. In general, the bag is open 3x:
14. Open the bag and 1. Putting out materials for hand
put back all articles in washing
their proper 2. Putting out materials used for nursing
places. care
15. Remove apron 3. Returning all what have been used.
folding away from the Care of Communicable Case(s)
body, with soiled side  Should be disinfected with the use of 70% isopropyl
folded inward, and the alcohol or Lysol which should be done at the health
clean side out. Place it in
center and not at home.
the bag.
16. Fold linen/ plastic
lining clean; placed it in
the bag and close the
bag. NUTRITIONAL ASSESSMENT
17. Make post visit To be used as reference WORLD HEALTH ORGANIZATION
conference on for future visit.
matters relevant to
health care, taking
  Health is a state of complete physical, mental,
and social well-being and not merely the
absence of disease or infirmity.
WELLNESS
 Is an active process of becoming aware of
HEART
 and making choices toward a healthy and PURPOSE OF NUTRITIONAL ASSESSMENT
MIND RISK OF MALNUTRITION
 fulfilling life. It is more than being free from  To identify individuals or
BODY population groups at risk of
 illness: it is a dynamic process of change and becoming malnourished
growth. MALNOURISHED
 To identify individuals or
population groups who are
NUTRITIONAL ASSESSMENT malnourished
 Refers to the nutritional status of an HEALTH CARE PROGRAMS
individual between the nutrient  To develop health care to To
intake and the nutrient expenditure develop programs that meet
or need community needs which are
NUTRITIONAL STATUS defined by the assessment
 is the current body status of a person or a EVALUATE PROGRAMS
population group related to their state of  To measure the
nourishment effectiveness of the
INTERNAL OR CONSTITUTIONAL nutritional programs and
 Age, sex, nutrition, behavior, physical interventions once initiated
activity and diseases
ENVIRONMENTAL METHODS OF NUTRITIONAL
 Food safety, cultural, social, and economic ASSESSMENT
circumstances 1. DIRECT METHODS
AN ADDITIONAL STATUS • Refers to the general appearance of
 occurs when the supply of nutrients conforms the client from head to toe
to the nutritional requirements or needs assessment
APPLE – Nutrient intake • Deals with the individual and
EGG – Requirements measure’s objective criteria
2. INDIRECT METHODS
DIETS ARE RATED IN QUALITY • Uses community indices that reflect
 according to the balance of nutrients they the community nutritional status
provide and not solely on the type of food and needs
eaten DIRECT METHODS OF NUTRITIONAL ASSESSMENT
or the amount of caloric intake 1. Anthropometric Methods
2. Biochemical or Biophysical Methods
3. Clinical Methods
4. Dietary Evaluation Methods

DIRECT METHOD - ANTHROPOMETRIC

 Measures the person’s height, weight, and
proportions. they are used to evaluate over and
under nutrition
Weight for Height for Wight for Mid upper arm
age age height circumference

Weight Compare Compare Indicates

child with a actual weight with mortality rik
growth height with ideal height associated with
chart ideal height malnutrition
for age

Growth STUNDED – WASTED –

chart is height falls weight falls
used for below ideal below ideal
SOME USEFUL CONVERSIONS FOR HEIGHT
weight for height for weight
age age HEIGHT
 Height in Philippines,
- Usually in feet and inches
like 5’4’’

 Multiply the feet by 12 and add the inches

- Multiply the product by 2.54 to get answer
in cm

 Divide the cm by 100

- The final answer is in m
 MID UPPER ARM CIRCUMFERENCE (MUAC)

Landmark: midpoint between the tip of the

shoulder and the tip of the elbow
❖ MUAC tape or Shakir Strip with 4 color
bands

RED (DANGER) ¿ 11CM SEVERE ACUTE

MALNUTRITION
ORANGE 11CM – 12.5CM MODERATE
ACUTE
MALNUTRITION
YELLOW 12.5 – 13CM RISK FOR
(WARNING) ACUTE
MALNUTRITION
GREEN ¿ 13.5 CM WELL
(NORMAL) NOURISHED
BMI calculations

Body Mass Index

 A simple index of weight-for-age used to
classify underweight, overweight, and
obesity in adults. This is an international
standard for assessing body size.

ANOTHER HELPFUL CONVERSION

 PEAR SHAPED (HIPS & BUTTOCKS)

APPLE SHAPED (ABDOMEN)

WAIST CIRCUMFERENCE
 Measure at the level of the umbilicus to the
nearest 0.5 cm
1. Stand and place a tape measure around your
middle, just above your hipbones
2. Make sure that the tape is horizontal around
the waist
3. Keep the tape snug around the waist, but not
compressing the skin.
4. Measure your waist just after you breathe

BMI WEIGHT STATUS CATEGORIES

BMI WEIGHT STATUS

Below 18.5 Underweight

18.5 – 24.9 Normal
25 – 29.9 Overweight
30 & above Obese

WAIST TO HIP RATIO

WAIST TO HIP RATIO INTERPRETATION
MALE FEMALE HEALTH RISK

0.95 or below 0.8 or below Low risk

0.95 to 1.0 0.81 – 0.85 Moderate risk
1.0 + 0.85 + High risk
DIRECT METHOD - BIOCHEMICAL
 Utilizes blood samples, urine and stool COMMON NUTRITIONAL PROBLEM
specimen 1. Protein – energy malnutrition

Marasmus

Testing Options: Mouth swab, Urine, Kwashiorkor

Blood sample

DIRECT METHOD-CLINICAL
1. Simplest and practical method to assess
nutritional status
2. It utilizes a number of physical signs (specific or
nonspecific) that are known to be associated
with malnutrition and deficiency of vitamins 2. XEROPHTHALMIA
and micronutrients. - Severe Vitamin A Deficiency
3. Involves the general examination and physical - impairment of night vision or of the
appearance of an individual. eyes.
3. BERI-BERI

4. SCURVY DIRECT METHOD – DIETARY EVALUATION

 Utilizes blood samples, urine and stool
specimen
A. Food consumption studies (24-h recall, food
frequency, food history)
B. Studies on Health Conditions
C. Studies on Food Supply
D. Studies on Socio-economic conditions

7. ANEMIA
- caused primarily by Iron Deficiency.

NUTRITIONAL STATUS CLASSIFICATION FOR

CHILDREN 2 months to 5 years:
5. RICKETS
1. Severe Malnutrition or Severe Anemia
S/S: Visible severe body wasting
Edema on both feet
Severe palmar pallor
2. Anemia or Very Low Weight
S/S: Some palmar pallor
Very low weight for age
3. No Anemia or Normal Weight

GENERAL EXAMINATION
 Hair
 Mouth
 Skin
 Transverse
6. GOITER (IODINE DEFICIENCY DISORDER)
INDIRECT METHODS OF NUTRITIONAL ASSESSMENTS
1. Ecological variables including agricultural crops
production
 2. Economic factors like household income, resources, provides and monitors all levels of
community income, population density, food technical care or skills
availability and prices (BP taking and wound care etc)
3. Vital statistics: morbidity, mortality and other
health indicators; utilization of maternal and EVALUATION
child health care services, fertility indices and ✓Determining step whether the
sanitary conditions goals and objectives have been met or
4. Cultural and social habits not.
✓ Documentation of care given and the
client’s
progress toward goal achievement.

TYPOLOGY OF NURSING PROBLEMS

✓ A tool to facilitate the process of
defining family health nursing
problems, a classification system of
family health nursing problems.
FAMILY NURSING PROCESS ✓ it utilizes Family Nursing Assessment
 Is a systematic approach to assess the health
needs? analyze, identify health problems and FAMILY NURSING ASSESSMENT
their solutions by using the Family Nursing Care ✓It involves a set of actions by which the nurse
Plan as applied to the family in the community determines the status of the family as a client, the
STEPS OF FAMILY NURSING CARE PLAN (FNCP) ability to maintain wellness, prevent, control or
 Assessment resolve problems in order to achieve health and
wellbeing among its members.
 Diagnosis
 Planning ✓ Includes data collection, data analysis,
 Implementations/ Interventions formulation of family nursing diagnosis
 Evaluation
❖2 TYPES OF FAMILY NURSING ASSESSMENT
ASSESSMENT I. First Level Assessment
 Happens on the first and succeeding home ✓ The process of determining existing and
visits. Making objective observation can be potential health conditions or
coupled with subjective statements by each problems of the family
family member II. Second level assessment
✓ Identifies the nature or type of nursing
NURSING DIAGNOSING problems the family experiences in the
✓Identify both actual and potential client health performance of their health tasks with respect
problem/s to a certain health condition or health
✓ Prioritization must be applied ✓ It specified the measures that the family did
✓ Formulation of goals and objectives. NOT DO due to INABILITY.
✓ Encourage and permit client’s to
FIRST LEVEL ASSESSMENT
make their own health management
CATEGORIES OF HEALTH CONDITIONS/
decisions.
NATURE OF THE PROBLEMS:
I. Presence of Wellness Condition
INTERVENTION
✓ Stated as “Potential” or “Readiness”; a clinical
 ✓ Objective/s must bethe guidelines in making
or nursing judgment about a client in transition
nursing interventions including health
teachings, coordinates and uses referrals and
 from a specific level of wellness or capability to 2. Inability to make decisions with respect to
a higher level taking the appropriate health action
Example of Wellness Condition: 3. Inability to provide nursing care to the sick,
A. Wellness Potential – is a nursing judgment disabled, dependent or vulnerable/ at-risk
on wellness state but NO EXPLICIT member of the family
EXPRESSION of client desire. 4. Inability to provide a home environment
B. Readiness for enhanced wellness state – is conducive to health maintenance and
a judgment on wellness state based on personal development.
current 5. Inability to utilize community resources for
competencies and performance, clinical data health care.
and explicit expression of desire to achieve
higher level of functioning or state. 1. Inability to recognize the presence of the condition
or problem related to:
HEALTH THREATS A. Lack of or inadequate knowledge
II. Presence of Health Threats B. Denial about its existence or severity as a
➢are conditions that are conducive to result of fear of consequences of diagnosis of
disease, problem, specifically:
accident or failure.
➢Examples: Family size beyond family Social-stigma, loss of respect of peer/significant others
resources can adequately provide, Economic/cost implications
Faulty/Unhealthy Nutritional Habit, Physical consequences
Accident/Fire Hazards, Poor Emotional/psychological issues/concerns
Home/environmental Condition/Sanitation, C. Attitude/Philosophy in life, which hinders
Unsanitary Food Handling and Preparation, recognition/acceptance of a problem
Unhealthy Lifestyle and Personal Habits D. Others. Specify _________

HEALTH DEFICITS 2. Inability to make decisions with respect to taking

III. Presence of Health Deficits the appropriate health action related to:
➢are instances of failure in health A. Failure to comprehend the nature/magnitude
maintenance of the problem/condition
➢Examples: Illness states, regardless of B. Low salience of the problem/condition
whether is diagnosed or undiagnosed, C. Feeling of confusion, helplessness and/or
Failure to Thrive/ Develop according to resignation brought about by perceive
normal rate, Disability magnitude/severity of the situation or problem,
i.e. failure to break down problems into
FORSEEABLE CRISIS manageable units of attack.
IV. Presence of Stress Points/ Foreseeable Crisis D. Lack of/inadequate knowledge/insight as to
Situations alternative courses of action open to them
E. Inability to decide which action to take from
➢are anticipated periods of unusual demand
among a list of alternatives
on the individual or family in terms of
F. Conflicting opinions among family
adjustment/ family resources.
members/significant others regarding action to
➢ Examples: Marriage, Pregnancy, Parenthood,
take.
Loss of Job, Entrance at school, Chronic Illness,
G. Lack of/inadequate knowledge of community
Hospitalization, Death of a family member,
resources for care
Resettlement in a new community
H. Fear of consequences of action, specifically:
SECOND LEVEL ASSESSMENT
Social consequences
1. Inability to recognize the presence of the
Economic consequences
condition or problem
 Physical consequences I. Member’s preoccupation with on
Emotional/psychological consequences concerns/interests
I. Negative attitude towards the health condition or J. Prolonged disease or disabilities, which
problem-by negative attitude is meant one that exhaust supportive apacity of family members.
interferes with rational decision-making. K. Altered role performance, specify.
J. In accessibility of appropriate resources for care, Role denials or ambivalence, Role
specifically: strain, Role dissatisfaction, Role
Physical Inaccessibility conflict, Role confusion, Role overload
Cost’s constraints or economic/financial L. Others. Specify. _________
inaccessibility
K. Lack of trust/confidence in the health 4. Inability to provide a home environment conducive
personnel/agency to health maintenance and personal development
L. Misconceptions or erroneous information about related to:
proposed A. Inadequate family resources specifically:
course(s) of action Financial constraints/limited financial
M. Others specify. _________ resources 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
3. Inability to provide nursing care to the sick, improvement
disabled, dependent or vulnerable/ at-risk member of C. Lack of/inadequate knowledge of
the family related to: importance of hygiene and sanitation
A. Lack of/inadequate knowledge about the D. Lack of/inadequate knowledge of
disease/health condition (nature, severity, preventive measures
complications, prognosis and management) E. Lack of skill in carrying out measures to
B. Lack of/inadequate knowledge about child improve home environment
development and care F. Ineffective communication pattern within
C. Lack of/inadequate knowledge of the nature the family
or extent of nursing care needed G. Lack of supportive relationship among
D. Lack of the necessary facilities, equipment family members
and supplies of care H. Negative attitudes/philosophy in life which
E. Lack of/inadequate knowledge or skill in is not conducive to health maintenance and
carrying out the necessary intervention or personal development
treatment/procedure of care (i.e. complex I. Lack of adequate competencies in relating to
therapeutic regimen or healthy lifestyle each other for mutual growth and maturation
program). Example: reduced ability to meet the physical
F. Inadequate family resources of care and psychological needs of other members as a
specifically: result of family’s preoccupation with current
Absence of responsible member problem or condition.
Financial constraints J. Others specify. _________
Limitation of luck/lack of physical
resources 5. Inability to utilize community resources for health
G. Significant persons unexpressed feelings care related to:
(e.g. hostility/anger, guilt, fear/anxiety, A. Lack of/inadequate knowledge of
despair, rejection) which his/her capacities to community resources for health care
provide care. B. Failure to perceive the benefits of health
H. Philosophy in life which negates/hinder care/services
caring for the sick, disabled, dependent, C. Lack of trust/confidence in the
vulnerable/at risk member agency/personnel
 D. Previous unpleasant experience with health health family as a health
worker deficits: verbalized, “Lima na deficit:
E. Fear of consequences of action (preventive, Scabies kabulan na 1. Inability to
diagnostic, therapeutic, rehabilitative) ga antos kami sg ka decide about
specifically : katol bag-o na check making
Physical/psychological consequences sg doctor” appropriate health
action due to
Financial consequences
Presence of scabies failure to
Social consequences
among all family comprehend the
F. Unavailability of required
members magnitude of
care/services the problem.
G. Inaccessibility of required services
due to: 2. Inability to
Cost constraints provide adequate
Physical inaccessibility nursing care to the
H. Lack of or inadequate family resources, sick
specifically members of the
Manpower resources, e.g. baby sitter family due to
Financial resources, cost of medicines lack of knowledge
prescribe about the
disease 'nature,
I. Feeling of alienation to/lack of support from
severity,
the community
complication,
e.g. stigma due to mental illness, AIDS, prognosis and
etc. management
J. Negative attitude/ philosophy in life which
hinders effective/maximum utilization of III. PROBLEM LIST
community resources for health care Health Supporting Family Nursing
K. Others, specify __________ condition/ Data/ Problem
problem Cues
I. PROBLEM LIST 3. Presence of - Father is a Presence of health
Health Supporting Family nursing Health Threats: Pedicab driver threat:
condition/problem data/cues problems Family size - earns family size beyond
1. Presence of Spread of Presence of poor beyond what P200/day what family
Health Threats: scabies lifestyle and family - With 6 school- resources can
Unhealthy lifestyle among personal habits as resources can aged adequately
practices and family a health threat: adequately children provide R/T inability
personal habits members that 1. Inability to provide to provide a home
specifically started provide a home environment
poor personal with one environment conducive to health
hygiene. family conducive maintenance and
member only to health personal
maintenance and development due to
contracting the a limited financial
disease and resources.
treatment.

II. PROBLEM LIST

Health Supporting Data/ Family Nursing
condition/ Cues Problem
problem
2. Presence of The head of the Presence of scabies
  FAMILY NURSING CARE PLAN (FNCP)
FAMILY GOALS/ NURSING EVALUATION
NURSING OBJECTIVES OF NURSING INTERVENTION
DIAGNOSIS CARE

Presence of a After nursing 1. Assess the family’s level of Goal partially met.
health threat: poor home and intervention understanding regarding the After _ weeks of nursing
environmental sanitation R/T the family will problem Identified. intervention the family
inability to recognize the be able to: 2.Establish rapport from the demonstrated proper
presence of the condition or identify the family. method of waste disposal.
problem due to lack of different ways 3.Demonstrate proper ways on
knowledge of proper how to segregate waste
disposal of 4. Encourage family to clean
Objective Cues: garbage their surroundings
▪ Garbage scattered everywh
minimizing, alleviating or
EXAMPLE OF HEALTH PROBLEMS: totally eradicating the
• Improper Waste Disposal problem through
• Poor Personal Hygiene intervention.
• Presence of Fire Hazards
• Alcoholic drinking
• Cigarette Smoking
• Nutritional Imbalance
• Improper Food Handling
• Poor Water Supply or No Potable Water Supply
• Poor Toilet Facility 3. Preventive Potential ✓ Refers to the nature
• Inadequacy of living space and magnitude of
• Presence of breeding or resting sites of vectors of future problems that can
diseases be minimized
or totally prevented if
• Family size beyond what family resources
intervention is
done on the problem
SCALE FOR RANKING FAMILY HEALTH
under
CONDITONS/ PROBLEMS ACCORDING TO consideration.
PRIORITIES: 4. Salience ✓ Refers to the family’s
perception and
PRIORITIZING THE HEALTH PROBLEMS evaluation of problems
1. Nature of the Problem ✓ Categorized into HD, in terms of
HT, FC seriousness and urgency
2. Modifiability of the ✓ Refers to the of attention
problem probability of success in needed.
 personal hygiene
CRITERIA SCORE WEIGHT will
I. Nature of the condition 3 1 be practiced
❑ Health Deficit (HD) 2 Salience 0/2X1 0 The family does not
❑ Health Threat (HT) 1 recognize it as a
❑ Foreseeable Crisis (FC) problem.
II. Modifiability of the condition 2 2 TOTAL SCORE: 3.6
❑Easily Modifiable 1
❑Partially modifiable 0
❑ Not modifiable
III. Preventive Potential 3 1
❑High 2
❑Moderate 1
❑Low
IV. Salience of the Problem 2 1
❑Problem needing immediate 1
attention 0
❑Problem not needing
immediate attention
❑Not perceived as problem
needing change

SCORING:
1. Decide on a score for each of the criteria
2. Divide the score of the highest possible
score and multiply by the weight
Formula: SCORE/HIGHEST SCORE X WEIGHT
3. Sum up the score for all the criteria the
highest score is equivalent to the total weight.

Scale for Ranking Health Conditions According to

Priorities:
1. Unhealthy lifestyle practices and personal habits
specifically poor personal hygiene
CRITERIA COMPUT ACTUAL JUSTIFICATION
ATION SCORE

Nature of the 2/3X1 0.6 It is a health threat

Problem does not demand
immediate action
Modifiability of 2/2X2 2 The resources and
the interventions
Problem needed
to solve the
problem
are available to the
family.
Preventive 3/3X1 1 Occurrence of
Potential diseases can be
prevented if proper
CRITERIA Incomplete Poor Fair Good
4pts. 6pts. 8pts. 10 pts.

Assessment Assessment portion Does not include all Includes all Includes all
is incomplete. pertinent data pertinent data pertinent data
related to nursing related to nursing related to nursing
diagnosis. May also diagnosis, but also diagnosis and does
include data that includes data not not include data that
does not relate to related to nursing is not related to
nursing diagnosis. diagnosis. nursing diagnosis.
Diagnosis Diagnosis portion is Diagnosis is not Diagnosis is Diagnosis is
incomplete. appropriate for appropriate for appropriate for
client and ordinal client and ordinal client and ordinal
level (first diagnosis, level level. and diagnosis
second diagnosis also includes all
etc). parts and
information is listed
in correct part of
diagnosis
Planning Goal portion is Goal statement is Goal statement Goal statement is
incomplete. not client or family isclient or family client or family
oriented oriented, and oriented, and
and may not have contains at least one contains two
measurable criteria measurable criteria measurable
or a target date or or a criteria and a target
time. target date/time. date or time.
Implementation Interventions Interventions Interventions Interventions
portion is portion does not portion portion
incomplete. include adequate contains adequate contains adequate
number of number of number of
interventions to help interventions interventions
client/family meet to help client/family to help client/family
goal. meet goal. meet
goal.
Evaluation Evaluation Evaluation portion Evaluation portion Evaluation portion
Evaluations portion does not contain does contain data does contain data
is incomplete. data that is listed as that is listed as that is listed
criteria in goal criteria in goal as criteria in goal
statement. May also statement, but does statement. Does
not describe goal as not describe goal as describe goal as met,
met, partially met, met, partially met, or not
or not met. May also partially met, or not met. If goal was
not include revision met. May also not partially met or not
or new evaluation include revision or met, includes
date/time. new evaluation revision and/or
date/time. new evaluation
date/time