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COMMUNITY HEALTH NURSING RLE

PART A. INITIAL DATA BASE


I. CHARACTERS:
A. What is the type of family structure?
/ Nuclear Single - Parent
Extended Others (specify)
B. What is the type of family based on authority?
Patriarchal
/ Matriarchal
C. Who makes decisions regarding health care? Mother
D. What is the present family relationship?
with conflicts between members
/ without conflicts between family members
E. Activities of daily living:
1. Sleeping pattern:
Retiring/getting up hours 1hour
Nap during the day 2-3hous
Do members sleep together no
2. Eating pattern
How many meals each day? 3 times a day
Who appears overweight? Father
Who appears underweight? none
3. Leisure time activities
How does each member spend leisure hours? Watching movies
Is it appropriate for the sex and age group? Yes
What is the effect on the family? Creating a bond
Any joint activity for leisure? Watching together

II. FAMILY INFORMATION


Head of the family: Mrs. Lhen
Address:Corner Ilang-ilang and Gladiola violeta
village
Members of the household: 5
NAME RELATIONSHIP AGE EDUCATIONAL ATTAINMENT
rd
John Gil Son 21 3 year college
John Patrick Son 18 Grade 12
Dennis Father 48 College Graduate
Kiara Daughter 23 College Graduate
Lhen Mother 49 College Graduate

/avg 1
III. SOCIO-ECONOMIC AND CULTURAL FACTORS
A. Income

NAME OCCUPATION PLACE INCOME /


MONTH
Mr. dennis Gardener Violeta Village 40,000

1. Does the working family member meet the basic necessities?


/ Yes No
2. Who makes decisions regarding money matters? mother
3. Religious affiliation: christian
4. What roles does the family play in the community? Parental Responsibility

IV. ENVIRONMENTAL FACTORS


A. Housing
1. Ownership
/ Owned Rented Rent-Free Others (specify)
2. Construction materials used
Light Mixed / Strong
3. Living space
/ Adequate Inadequate
4. Sleeping arrangement:
5. Adequacy in furniture
/ Adequate Inadequate
6. Water source
/ Private Public
7. Food storage
/ Refrigerator Jars/container Others (specify)
8. Cooking facility
/ Electric stove Firewood Others (specify)
/ Gas Stove Kerosene
9. Drainage facility
/ Open drainage Blind drainage None
10. Toilet facilities/type
/ Flushed Overhung latrine
Water-sealed latrine Bored-hole latrine
Pail system Others (specify)
11. Sanitary condition
/ Fair Good Poor
Provide brief description: All goods

12. Neighborhood
/ Congested Slum Other
13. Availability of Health Care Facility
/avg 2
Describe briefly: near to us
14. Garbage disposal
Dumped at street corner / Picked up by garbage collector
Buried Burned then buried Others(specify)

V. HEALTH MEDICAL HISTORY


NAME PAST ILLNESS DIAGNOSED / ILLNESS STATE HEALTH ACTION
UNDIAGNOSED TAKEN
Mrs.lhen Heart disease Undiagnosed Controlled Food supplements

VI. VALUE PLACED ON PREVENTION OF DISEASE

Vaccinations

NAME AGE COMPLETE INCOMPLETE

John Patrick 18 Covid 19 vaccine

John Gil 21 Covid 19 vaccine

Dennis 48 Covid 19 vaccine

Kiara 23 Covid 19 vaccine

Lhen 49 Covid 19 vaccine

Other preventive practices employed by the family:


Sources of Health Care:
Health Center Government Hospital
/ Private Hospital Others (specify)

/avg 3
PART B.

DETERMINE AT LEAST 3 FAMILY HEALTH PROBLEMS. IF NONE, DETERMINE THE FAMILY’S PROMOTIVE OR PREVENTIVE
PRACTICES.
FAMILY HEALTH PROBLEMS. / TYPOLOGY OF HEALTH PROBLEM
(WELLNESS STATE , HEALTH DEFICIT,HEALTH THREAT,
(IF NONE, FAMILY’S PROMOTIVE OR FORESEEABLE CRISIS)
PREVENTIVEPRACTICES.)

1. Heart disease Health deficit

2.

PART C.

DO THE SCALING OF THE 3 IDENTIFIED HEALTH PROBLEMS OR PROMOTIVE PRACTICES OF THE FAMILY.

HEALTH PROBLEM 1:

CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION

NATURE OF THE PROBLEM

MODIFIABILITY OF THE
PROBLEM

PREVENTIVE POTENTIAL

SALIENCE

TOTAL

/avg 4
HEALTH PROBLEM 2:

CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION

NATURE OF THE PROBLEM

MODIFIABILITY OF THE
PROBLEM

PREVENTIVE POTENTIAL

SALIENCE

TOTAL

HEALTH PROBLEM 3:

CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION

NATURE OF THE PROBLEM

MODIFIABILITY OF THE
PROBLEM

PREVENTIVE POTENTIAL

SALIENCE

TOTAL
Surveyed by _________________________
Date ______________________________

/avg 5

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