UNIT IV

FAMILY NURSING PROCESS

Introduction

Family Health Nursing Process is a systematic approach to help family to

develop and strengthen its capability to meet its health needs and solve health
problem. Family health nursing process is closely related to community health
nursing process. The main objective or goals of family health nursing process are
health promotion,prevention from disease and control of health problem. Five
sequential steps are assessment, diagnosis, planning, implementation, and
evaluation.

Topics

A. Family Health Assessment

1. Tools for assessment
 Initial Data Base
 Typology of Nursing Problems in Family Nursing Practice
 Family Health Task
 Family Coping Index

2. Family Data Analysis

 Socioeconomic and Cultural Characteristics
 Home Environment
 Family Health Status
 Family Values and Health Practices
 Family Values and Health Practices

Family Health Assessment

Nursing assessment is the first major phase of the nursing process, In

family health nursing practice, this involves a set of actions by which the nurse
determines the status of the family as a client, ts ability to maintain itself as a system
and functioning unit , and its ability to maintain wellness, prevent, control or resolve
problems in order to achieve health and well-being among its members.

1.Tools for assessment

Initial Data Base

A. Family Structure Characteristics and Dynamics

1. Members of the household and relationship to the head of
the family.
 2. Demographic data-age, sex, civil status, position in the
family
3. Place of residence of each member-whether living with the
family or elsewhere
4. Type of family structure-e.g. patriarchal, matriarchal,
nuclear or extended
5. Dominant family members in terms of decision making
especially on matters of health care
6. General family relationship/dynamics-presence of any
obvious/readily observable conflict between members;
characteristics, communication/interaction patterns among
members.
B. Socioeconomic and Cultural Characteristics
1. Income and expenses
a. Occupation, place of work and income of each working
member
b. Adequacy to meet basic necessities (food, clothing,
shelter)
c. Who makes decision about money and how it is spent
2. Educational Attainment of each Member
3. Ethnic Background and Religious Affiliation
4. Significant others-role (s) they play in family’s life
5. Relationship of the family to larger community-nature and
extent of participation of the family in community activities
C. Home and Environment
1. Housing
a. Adequacy of living space
b. Sleeping in arrangement
c. Presence of breathing or resting sites of vector of diseases
(e.g. mosquitoes, roaches, flies, rodents, etc.)
d. Presence of accident hazard
e. Food storage and cooking facilities
f. Water supply-source, ownership, pot ability
g. Toilet facilities-type, ownership, sanitary condition
h. Garbage/refuse disposal-type, sanitary condition
i. Drainage System-type, sanitary condition
2. Kind of Neighborhood, e.g. congested, slum etc.
3. Social and Health facilities available
4. Communication and transportation facilities available
D. Health Status of Each Family Member
1. Medical Nursing history indicating current or past significant
illnesses or beliefs and practices conducive to health and illness
 2. Nutritional assessment (especially for vulnerable or at risk
members)
 Anthropometric data: measures of nutritional status of
children-weight, height, mid-upper arm circumference;
risk assessment measures for obesity : body mass
index(BMI=weight in kgs. divided by height in
meters2), waist circumference (WC: greater than 90 cm.
in men and greater than 80 cm. in women), waist hip
ration (WHR=waist circumference in cm. divided by
hip circumference in cm. Central obesity: WHR is
equal to or greater than 1.0 cm in men and 0.85 in
women)
 dietary history specifying quality and quantity of food
or nutrient per day
 Eating/ feeding habits/ practices
3. Developmental assessment of infant, toddlers and preschoolers-
e.g. Metro Manila Developmental Screening Test (MMDST).
4. Risk factor assessment indicating presence of major and
contributing modifiable risk factors for specific lifestyle
diseases-e.g. hypertension, physical inactivity, sedentary
lifestyle, cigarette/ tobacco smoking, elevated blood lipids/
cholesterol, obesity, diabetes mellitus, inadequate fiber intake,
stress, alcohol drinking, and other substance abuse.
5. Physical Assessment indicating presence of illness state/s
(diagnosed or undiagnosed by medical practitioners )
6. Results of laboratory/diagnostic and other screening procedures
supportive of assessment findings.
A. Values, Habits, Practices on Health Promotion, Maintenance and Disease
Prevention. Examples include:
1. Immunization status of family members
2. Healthy lifestyle practices. Specify.
3. Adequacy of:
1. Rest and sleep
2. Exercise/activities
3. Use of protective measure-e.g. adequate footwear
in parasite-infested areas; use of bed nets and
protective clothing in malaria and filariasis
endemic areas.
 Relaxation and other stress management activities
4. Use of promotive -preventive health services
Typology of Nursing Problems in Family Nursing Practice
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.
 Chronic Illness K.
Loss of job L.
Hospitalization of a family member M.
Death of a member N.
Resettlement in a new community O.
Illegitimacy P.
Others, specify.___________

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
5.
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 K.
Others, specify __________

Family Health Task

a. Health task differ in degrees from family to family

b. TASK- is a function, but with work or labor overtures
assigned or demanded of the person

c.Duvall & Niller identified 8 task essential for a family to

function as a unit:

Eight Family Tasks (Duvall & Niller)

1. Physical maintenance- provides food shelter, clothing, and health

care to its members being certain that a family has ample
resources to provide
2. Socialization of Family– involves preparation of children to live in
the community and interact with people outside the family.
3. Allocation of Resources- determines which family needs will be
met and their order of priority.
4. Maintenance of Order– task includes opening an effective means of
communication between family members, integrating family
values and enforcing common regulations for all family
members.
5. Division of Labor – who will fulfill certain roles e.g., family
provider, home manager, children’s caregiver
6. Reproduction, Recruitment, and Release of family member
7. Placement of members into larger society –consists of selecting
community activities such as church, school, politics that
correlate with the family beliefs and values
8. Maintenance of motivation and morale– created when members
serve as support people to each other

Family Coping Index

Purpose:
To provide a basis for estimating the nursing needs of a particular family.
Health Care Need
A family health care need is present when:

1. The family has a health problem with which they are unable to cope.
2. There is a reasonable likelihood that nursing will make a difference in
the in the family’s ability to cope.

Relation to Coping Nursing Need:

 Coping may be defined as dealing with problems associated with health
care with reasonable success.
 When the family is unable to cope with one or another aspect of health
care, it may be said to have a “coping deficit”

Scaling Cues
The following descriptive statements are “cues” to help you as you rate family
coping. They are limited to three points –
1 no competence,
3 moderate competence
5 complete competence.

Areas to Be Assessed
1. Physical independence: This category is concerned with the ability to
move about to get out of bed, to take care of daily grooming, walking
and other things which involves the daily activities.
2. Therapeutic Competence: This category includes all the procedures or
treatment prescribed for the care of ill, such as giving medication,
dressings, exercise and relaxation, special diets.
3. Knowledge of Health Condition: This system is concerned with the
particular health condition that is the occasion of care
4. Application of the Principles of General Hygiene: This is concerned
with the family action in relation to maintaining family nutrition,
securing adequate rest and relaxation for family members, carrying out
accepted preventive measures, such as immunization.
5. Health Attitudes: This category is concerned with the way the family
feels about health care in general, including preventive services, care of
illness and public health measures.
6. Emotional Competence: This category has to do with the maturity and
integrity with which the members of the family are able to meet the usual
stresses and problems of life, and to plan for happy and fruitful living.
 7. Family Living: This category is concerned largely with the interpersonal
with the interpersonal or group aspects of family life – how well the
members of the family get along with one another, the ways in which
they take decisions affecting the family as a whole.
8. Physical Environment: This is concerned with the home, the
community and the work environment as it affects family health.
9. Use of Community Facilities: generally keeps appointments. Follows
through referrals. Tells others about Health Departments service

Data gathering Methods and tools

There are several methods of data-gathering that the nurse cn select from,
depending on availability of resources such as material, manpower, time and facilities.
The critical point in the choice is concern for accuracy, validity, reliability, and
adequacy of assessment data. Poor quality/inaccurately defined health nad nursing
problems which, in turn, lead to poorly designed family nursing care plan.

The following are brief description of common methods of gathering dta about a
family, its health status and state of functioning.

1. Observation. This method of data collection is done through

the use of the sensory capacities-insight, hearing, smell, and
touch. Through direct observation, the nurse gathers
information about the family”s state of being and behavioral
responses. The family”s health statuscan be inferred from
the signs and sypmtoms of problem areas reflected in the
following:
A. Communication, interaction patterns and interpersonal
relationships expected’ used and tolerated by family
memebers;
B. Role perceptions/task assumptions by each member,
including decision-making patterns
C. Conditions in the home and environment.

Data gathered through this method have the advantage of being subjected to
validation and reliability testing by other observers.

2. Physical Examination. Significant data about the health status of

individual family members can be obtained through direct
examination. This is done through inspection, palpation,
percussion, auscultations, measurement of specific body parts
and reviewing the body systems. It is essential for the nurse
to have the skill in performing physical assessment/ appraisal
 in order to help the family to be aware of the health status of
its members.
3. Interview. 2 types of interview
1. First type of interview is completing a health history for each
family member. The health history determines the current
health status based on significant past health history ( ex.
Developmental accomplishment, known illnesses,
allergies,restorative treatment, residence in endemic areas
for certain diseases or exposure to communicable diseases)
and social history , such as intrapersonal and interpersonal
factors affecting the family member’s social adjustment or
vulnerability to stress and crisis.
2. Second type is collecting data by personally asking significant
family members or relatives questions regarding health,
family life experiences and home environment to generate
data on what wellness condition/s and health problems exist
in the family and the corresponding family nursing
problems for each health condition or problem. Ensuring
confidentiality and respect for the family’s right to
self-determination are key principles to consider during all
phases of the nursing process.
4.Record review . The nurse may gather information through
reviewing existing records and reports pertinent to the client.
These include the individual clinical records of the family
member, laboratory and diagnostic reports, immunization
records, reports about the home and environmental conditions,
or similar sources.

5.Laboratory/Diagnostic test. Another method of data collection is

through performing laboratory test, diagnostic procedure, or
other test integrity and functions carried out by the nurse herself and/or
other health workers.

2.Family Data Analysis

Utilizing the data generated from the tool on Assessment Data Base in
Family Nursing Practice , the nurse goes through data analysis. She sorts out and
classifies or groups data by type or nature ( ex. Which are wellness state, threats,
deficits or stress points.foreseeable crises ) She relates them with each other and
determines patterns or reoccurring themes among the data. She then compares
these data and the patterns or reoccurring themes with norms or standards.

The standards or norms utilized in determining the status of the family as a

client or patient can be classified into three types:
 1. Normal health of individual members . Involves the physical, social and
emotional well-being of each family member.

2. Home and environmental conditions conducive to health development.

Includes both physical as well as the psychological and social-cultural
milieu. Such a milieu considers the type and quality of housing,
adequacy of living space , adequacy of sanitation facilities and resources
both in the home and the community, the kind of neighborhood,
psychological or social-cultural norms, values,expectations or modes of
life which enhance health development and prevent or control risk
factors and hazards.

3. Family characteristics, dynamics or level of functioning conducive to

family growth and development. Constitutes the client’s ability as a
system to maintain its boundary integrity and achieve its purposes
through a dynamic interchange among its members while responding to
the external multi-environments along a time continuum.
Characteristics of healthy family functioning are described as flexible
role patterns, responsiveness to needs of individual members, dynamic
problem-solving mechanisms, ability to accept help. Open
communication patterns, experience of trust and respect in a warm and
caring atmosphere and capacity to maintain and create constructive
relationship with the broader neighborhood and community.

In order to achieve a wellness among its members and reduce or eliminate

health problems, the standard or norm of the family as a functioning unit involves
the ability to perform the following health tasks:

1. Recognize the presence of wellness state or health condition or

problem

2. Make decisions about taking appropriate health action to maintain

wellness or manage the health problem

3. Provide nursing care to the sick, disabled , dependent or at risk

members

4. Maintain a home environment conducive to health maintenance and

personal development

5. Utilize community resources for health care.

The end result of this analysis is a conclusion or a statement of a health condition/

problem, classified as a wellness potential, health threat, health deficit or stress
point/foreseeable crisis. This definition constitutes any of the following:
 1. Transition state from a specific level of wellness to a higher
level

2. Medical or nursing diagnosis indicating current health status of

each family members

3. Condition of home and environment conducive to

disease/illness or accidents

4. Maturation/developmental or situational crisis situation.

The second level of Analysis ends with a definition of family nursing problems. To
define family nursing problems, each wellness state or health condition or
problem must be analyzed in terms of how the family handles it. The
patterns and implications of these data reflect explanations and
inferences about the family as a functioning unit in terms of its problems
related to performance of family health tasks.

B. Family Nursing Diagnosis

Nursing diagnosis may be formulated at several levels: as individual family
members, as a family unit, or as the family in relation to its
environment/community. Specific diagnosis as proposed by NANDA-
International (NANDA-1,2011) serve as a common framework of expressing
human responses to actual and potential health problems.

An alternative tool for nursing diagnosis is the Family Coping Index. This
tool is based on the premise that nursing action may help a family in providing
for a health need or resolving a health problem by promoting the family’s coping
capacity. The family coping index provides a system of identifying area that may
require nursing intervention and areas of family strengths that may be used to
help the family deal with health needs and problems. If a family member is
unable to cope in a particular category, but other family members are able to
compensate, the family is still rated as adequately coping.

Example:

Assessment Nursing Diagnosis

Presence of accident hazards related to to fall High risk for injury

hazards: the house is almost surrounded by
bamboo trees and three coconut trees and presently
bare fruits.
 Summary

Family health assessment is a process of getting information from the family about
health promotion and disease-prevention activities. Family assessment includes
nurse's perceptions about family constitution, norms, standards, theoretical
knowledge, and communication abilities.

Initial data base refers to members of the household and relationship to the head of
the family. Demographic data-age, sex, civil status, position in the family. Place of
residence of each member-whether living with the family or elsewhere. Type
of family structure-e.g. patriarchal, matriarchal, nuclear or extended.

A nursing diagnosis is defined by NANDA International (2013) as a clinical judgment

concerning a human response to health conditions/life processes, or vulnerability for
that response, by an individual, family, group, or community.

Student Task

1. Case: This is a case of S. Family. S. Family is composed of 5 children and

both parents were alive. Upon observation the family practices inappropriate
hygiene in eating and waste disposal. The 5 children have 2 to 3 years of age
gaps, having the youngest child to be 1 year old and the oldest to be 9 years
old.

Assessment Nursing Diagnosis

1.

1. Make an assessment of your environment and family. Identify at least

three health problem may it be individual, member, a family as a unit or
environment

Assessment Nursing Diagnosis

1.

2.

3.

References:
Cuevas , Frances Prescilla L. (2007) Public Health Nursing in the Philippines.
10th Edition
Maglaya, Araceli S. (2007) Nursing Practice in the Community. 5th Edition

Famorca,Zenaida U. (2013) Nursing care of the Community