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CHN Idb 2D

This document contains a template for collecting data on family nursing practices. It includes sections to gather information on household members, family characteristics, socioeconomic factors, cultural influences, the family environment, neighborhood factors, and family health behaviors. The goal is to obtain a holistic understanding of the social, economic, and health conditions of the family.

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John Dave V. Villarmente
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103 views8 pages

CHN Idb 2D

This document contains a template for collecting data on family nursing practices. It includes sections to gather information on household members, family characteristics, socioeconomic factors, cultural influences, the family environment, neighborhood factors, and family health behaviors. The goal is to obtain a holistic understanding of the social, economic, and health conditions of the family.

Uploaded by

John Dave V. Villarmente
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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UNIVERSITY OF CEBU - BANILAD

COLLEGE OF NURSING
INITIAL DATA BASE FOR FAMILY NURSING PRACTICE

Family Surname: ____________________________________


Barangay: _______________________________________ Municipality/City:_______________________
Source (s) of Information: ___________________________ Contact No.:___________________________
Data Gathering: ________________________________ Date:_________________________________
Type of Family______________________________________

A. HOUSEHOLD MEMBERS (all who resides in the family)

NAME GENDER AGE RELATIONSHIP TO HEAD OF HIGHEST EDUCATIONAL OCCUPATION HEALTH PROBLEMS
HOUSEHOLD ATTAINMENT

Note: Insert genogram, family tree (indicating health problems of individual members)
GENOGRAM OF_______________ FAMILY
(NAME)

Grandparent Grandparent Grandparent Grandparent

Aunts and Uncles

Parent Parent

Child Child
FAMILY HEALTH TREE OF _____________ Family
(NAME)
1. Causes of death of decreases family members
_______________ _______________
_______________ _______________
_______________ _______________
_______________ _______________

2. Genetically linked diseases:


 Heart Disease
 Cancer
 Diabetes
 Hypertension
 Allergies
 Asthma
 Mental retardation

3. Environmental and occupational diseases

4. Psychological problem (mental illness/ obesity)

5. Infectious diseases

 TB
 Hepatitis
 Chicken Pox
 Measles
 Others :___________________

6. Family's methods of illness Prevention


 Exercise
 Periodic physical examination
 Pap smear
 Immunizations

7. How family cope with stress


B. FAMILY CHARACTERISTICS

1. Family members living outside the household

Name Age Relationship to Location Frequency and Means of


the Household Operating Communication
Contact

2. Family Mobile
2.1 Length of the current address ___________________________________
2.2 Address of Previous Residence ___________________________________
2.3 Frequency of geographic moves ___________________________________
3. Family dynamics
3.1 Emotional bonding of family members ___________________________________
3.2 Distribution of authority and power ___________________________________
3.3 How members communicate ___________________________________
3.4 How problems are solved ___________________________________
3.5 How conflict is handled ___________________________________
3.6 Division of labor ___________________________________

C. SOCIOECONOMIC AND CULTURAL CHARACTERISTICS

1. Family Social Integration


o 1.1 Language (s) or diabetes(S) spoker ___________________________________
o 1.2 Literacy (ability to read or write in language) _______________________________
o 1.3 Network with religious organization ___________________________________
o 1.4 Network with social organization ___________________________________
D. CULTURAL INFLUENCES: Values, Attitudes & Beliefs about:
1. Spirituality ___________________________________
2. Rituals (holidays & celebrations) ___________________________________
3. Dietary habits ___________________________________
4. Health ___________________________________
5. Traditional healers ___________________________________

E. FAMILY ENVIRONMENT
1. Home
1.1. Ownership ( ) owned ( ) rented ( ) rent-free
1.2. Construction materials used ( ) light ( ) mixed ( ) strong
1.3. Adequacy of Size _____________________
1.4. Lighting Facilities ( ) electricity ( ) kerosene
( ) others (specify) __________________
1.5. General Sanitary Condition _______________________________________________

2. Water Supply

2.1. Drinking water


2.1.1. Ownership ( ) individual (private) ( ) municipal (city)

2.1.2. Source ( ) Level 1 (point source)

( )Level II (communal faucet system or stand posts)


( ) Level Ill (waterworks system or individual house
connections)
( ) open dug wells
( ) unimproved springs
( ) wells not priming
( ) rainwater

2.1.3. Storage ( ) None (direct from faucet and pipe)


( ) jar or can with faucet
( ) jar or can without faucet
( ) others specify ____________
2.2. Water for household use

2.2.1. Ownership
( ) individual / private water system
( ) municipal/ city water system
2.2.2. Source ( ) ground water (specify) ____________
( ) surface water (specify) ____________
( ) rain water

2.2.3. Storage ( ) home (direct from faucet or pipe)


( ) jar or can
( ) others (specify) ________________________
3. Kitchen
3.1. Cooking Facility ( ) electric stove ( ) gas stove
( ) firewood/charcoal
3.2. Sanitary Condition _______________________________________________
3.3. Drainage Facility ( ) none ( ) open drainage
( ) blind drainage

4. Water Disposal
4.1. Refuse and Garbage
4.1.1. Container ( ) covered ( ) open
( ) none

4.1.2. Methods of Disposal ( ) hog feeding ( ) open dumping


( ) open burning ( ) burial in pit
( ) burial in pit ( ) composting
( ) incineration ( ) collection by government
( ) collection from private
( ) others (specify) ________________________

4.2. Toilet ( ) none ( ) pail system


( ) open pit privy ( ) closed pit privy
( ) bored hole latrine ( ) overhung latrine
( ) Antipolo system ( ) water sealed latrine
( ) flush type
( ) others (specify) ________________________

4.2.1. Distance from the house ________________________________________________


4.3. Sanitary Condition ________________________________________________
5. Domestic Animals

KIND NUMBER WHERE KEPT


________________________ ______________________ ________________________
________________________ ______________________ ________________________
________________________ ______________________ ________________________
________________________ ______________________ ________________________
________________________ ______________________ ________________________

F. FAMILY NEIGHBORHOOD
1. Location ________________________________________________
(Urban, rural, subdivision, slum area)

2. Type ________________________________________________
(Residential, semi commercial, commercial)

3. Safety
3.1. Traffic pattern ________________________________________________
3.2. Lighting ________________________________________________
3.3. Security ________________________________________________

4. Population density ________________________________________________


(crowding)

5. Sources of pollution
5.1. Air ________________________________________________
5.2. Water ________________________________________________
5.3. Soil ________________________________________________
5.4. Noise ________________________________________________

G. FAMILY HEALTH & HEALTH BEHAVIOR


1. Activities of daily living ________________________________________________
(How family spends a typical day)
2. Health Problems
2.1. Health Deficit / Need: (condition that can be alleviated with medical or social
technology)
___________________________________
___________________________________
___________________________________
2.2. Health Threats (conditions that will promote disease(s) or injury)
___________________________________
___________________________________
___________________________________
2.3. Foreseeable crisis (stressful conditions)
___________________________________
___________________________________
___________________________________

3. Home Remedies
___________________________________
___________________________________
___________________________________

4. Health Care Resources

___________________________________
___________________________________
___________________________________

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