CHAPTER 2:

ASSESSMENT IN FAMILY HEALTH NURSING PRACTICE

Araceli S. Maglaya

FAMILY PERSPECTIVE IN COMMUNITY HEALTH NURSING

PRACTICE
Community health nurses in many parts of the world have been using the
family perspective to address individual clients' health needs or problems and enhance
family functioning for growth and development, coping with illness or loss,
mobilizing resources and maintaining an environment that support wellness and
health. Even in the western world, like the USA, where managed care system is the
structure for patient care delivery (such as health maintenance organizations and
independent practice associations) renewed focus on the family is emerging as
institution-based health care is significantly decreasing and home care is rapidly
growing.

There are several reasons for focusing on the family in community health nursing
practice, based on its characteristic as an open and developing system of interacting
personalities, with a structure and process enacted in relationships among individual
members, regulated by resources and stressors, and existing within the larger
community (Maurer and Smith 2005, p. 275). The family prevents, generates tolerates
and corrects health problems among its members (Freeman and Heinrich 1981, p.88).
It is a powerful influence on values, beliefs and practices on health and illness. For
example, based on studies on diabetes (Campbell 1987), poor diabetic control is
associated with chronic family conflict and poor organization, but the studies disagree
as to whether these families have low or high cohesion. Duhamel (1987) examined
family interaction and hypertension and generated a significant hypothesis that
hypertensive patients suppress anger and hostility. The suppression of these feelings
leads to unresolved marital conflicts that reciprocally reinforce the suppression of
anger and hostility. Because the family operates as a system, dysfunction in a member
may be related to disturbance in the whole family. Family information and partnership
are used in tracking down the occurrence and incidence of diseases. critical in
preventing the spread of communicable cases (Maurer & Smith, p.274). The family is
a critical resource in maintaining health and delivery of health care because it is the
locus of decision-making on use of manpower and economic support, especially
during illness or crisis. The family can be the most effective and efficient link with the
entire community if organized action and partnership are to be established to create
and sustain an environment that promote healthy lifestyle or early case finding,
prompt and appropriate treatment of diseases. Chapter 18 describes a thirty-month
experience with families in a rural village in Danglas Municipality, Abra Province,
where families created mechanisms for malaria prevention and control using the
participatory action methodology.

Family health nursing perspective includes two views: the family as unit of care and
the family as context or setting of individual client care. This chapter and the next two
chapters will cover concepts that elucidate on family health nursing practice focusing
on the family as a functioning unit and client-partner. These concepts are also
applicable to individual client care within the family as context or setting.
FAMILY NURSING PRACTICE: THEORETICAL PERSPECTIVES
Family nursing practice emphasizes the need to understand the behavior of the
family as a dynamic, functioning unit which affects its capability to help itself and
maintain system integrity, or its readiness to work with the nurse in enhancing
wellness or addressing problems on health and illness. Theoretical frameworks
provide directions by which the nurse can organize observations, focus inquiries,
design the application of the nursing process in family nursing practice and
communicate realities and outcomes of care (Meleis 1985).

The Family Systems Theory views the family as a living social system within a
context in which multiple environmental actions or factors occur over the life course.
It is composed of interrelated and interdependent individuals who are organized into a
single unit so as to attain specific family functions or goals. Within the family system,
the family members interact as a functional whole. The behaviors of different
members are complementary or reciprocal, involving give and take, action or reaction.
The interrelationships in a family system are intricately tied together such that a
change in any one part inevitably results in changes in the entire system. The
interrelatedness of components in the family system gives rise to new qualities and
characteristics that are a function of that interrelatedness (Friedman 1992, p.118). The
family as a system has boundaries or filtering mechanisms (i.e. norms, values,
attitudes and rules) which regulate the amount and flow of energy, information,
resources and stimuli to and from the external environment, or between family
members as subsystems with separate boundaries affecting each other and the family
system as a whole (Clemen Stone & others 2002, p.181). In healthy family
functioning, inputs (i.e. energy, stimuli, resources and information that the family
system receives and processes) are screened so that the family takes in what is needed
from the environment and assimilates or modifies it to promote its own survival and
growth (Friedman 1992, p.119). The family as a system has the propensity to evolve
and grow so that as growth takes place, the system becomes more complex, articulate
and discriminate (Minuchen 1974). Transactional processes or interactions among
family members, who occupy position/s or role/s, promote or inhibit family
functioning (Clemen-Stone & others 2002, p.178).

The Interactional Approach or Symbolic Interactional Framework views the

family as a unity of interacting personalities whose actions are based on meanings
they derive from interactions and taken in an ever changing process of new
interactions, new interpretations, and new meanings. Symbolic communication
evolving from the self and the environment helps individuals interpret and select the
environment to which they respond. This framework identifies how relationships with
others affect an individual's functioning. The Interactional Approach emphasizes
the antecedents and consequences of such processes as communication, decision-
making and problem solving; conflict management/resolution; reactions to stress; and
other family situations influenced by family interactions and interactive processes
(Aldous 1978; Hill and Hansen 1960). To understand the family's behavior and
realities, the nurse must see the experience from the family's point of view, striving
for shared meanings through consensus and feedback.

The Developmental Approach views family development throughout its

generational life cycle, highlighting critical periods of family growth and
development across the life course (Hill & Hansen 1960; Duvall & Miller 1985). It
helps predict what a given family is experiencing at any particular time. While there
are socio-economic, cultural and ethnic variations in the family life cycle, the
developmental approach can guide analysis of assessment data related with
anticipated periods of unusual demands on the family in terms of resources or
adjustment as the family goes through an emotional process of transition and change
in the family status required to proceed in the life cycle (Clemen Stone & others 2002,
p.179). To illustrate, in the life cycle stage of families with young children, the key
principle of emotional process of transition is accepting new members into the family
system as the couple adjusts to make space for child(ren) and joining in childbearing,
financial and household tasks (Carter and McGoldrick 1988, p.15).

Structural perspective specifies family characteristics such as member roles, family

forms (e.g. nuclear, single parent, blended, extended), power structures (e.g.
matriarchal, patriarchal), communication processes and value systems which provide
order to family interactions and interdependent relationships and serve to organize
performance of roles and functions (Friedman 1998). Using the Structural
Functional perspective, Friedman (1998) specifies four structural dimensions: role
structure, value system, communication processes, and power structure. She identifies
five functional areas: affective function, socialization and family placement function,
reproductive function, economic function and health care function. Denham (2003)
generated more precise concepts and variables on the structural and functional
framework through her professional nursing practice and research findings from three
qualitative studies about family health among Appalachian families in two
southeastern Ohio counties. She developed the Family Health Model as framework to
describe, explain and predict health outcomes and means to circumscribe the
boundaries of household production of health, defined as the dynamic process through
which households combine their (internal) knowledge, resources, and behavioral
norms and patterns with available (external) technologies, services, information and
skills to restore, maintain, and promote the health of their members (Berman, Kendall
and Bhattacharyya 1994, p.2). According to Denham, seven functional processes
(p.125) are used by families to incorporate information, values and beliefs into
behavior, activities and routines relevant to family health. They involve ways family
members interact to potentiate, negate, threaten, mediate and enhance individual and
family health. Denham specifies these functional processes as: (1) caregiving; (2)
cathexis (emotional bond between individuals and family); (3) celebration (tangible
forms of shared meanings); (4) change (dynamic nonlinear process implying altering
or modifying the form, direction and outcome thru alternatives); (5) communication
(primary ways to socialize children about health beliefs, values, attitudes and
behaviors and use information, knowledge and actions applicable to health); (6)
connectedness (ways the family as a system are linked together); (7) coordination
(cooperative sharing of resources, skills, abilities, and information within the family
and with the larger contextual environment to optimize individual's health potentials,
potentiate the household production of health and achieve family goals). The family
health model specifies family routines as basic structure which provide order to
family member's lives and serve to organize health within the household where
individuals assume interdependent relationships, roles, functions and purposes.
Denham's family routines (p.184) include: (1) self-care routines (patterned behaviors
related to usual activities of daily living experienced across the life course, such as
dietary, hygiene, sleep-rest, physical activity and exercise, gender and sexuality); (2)
safety and prevention (pertain to health protection, disease prevention, avoidance and
participation in high-risk behavior and efforts to prevent unintended injury across the
life course, such as immunization status, abuse and violence, smoking, alcohol and
substance abuse); (3) mental health behaviors (ways by which individuals and
families attend to self-efficacy, cope with daily stresses and individuate, such as self-
esteem, personal integrity, work and play, stress levels); (4) family care (daily
activities, traditional behaviors and special celebrations that give meaning to daily life
and provide shared enjoyment, pleasure and happiness for multiple members, such as
relaxation activities, vacations, celebrations, traditions, spiritual and religious
practices); (5) illness care (ways by which members make decisions related to health-
care needs; choose when, where, and how to seek supportive health services; and
determine ways to respond to medical directives and health information); (6) member
caregiving (ways by which family members act as interactive caregivers across the
life course as they socialize children and adolescents about health-related ideals,
participate in health and illness care needs and support members individual routine
patterns, such as provision of care during illness, supportive member actions and
member roles and responsibilities). As basic structures, Denham explains that family
routines are habitual family patterns on health and health care which provide for the
family an efficient way to organize interactive processes to carry out family functions.

An adaptation of the Family Health Tasks Perspective (initially conceptualized by

Freeman and Heinrich 1981, pp. 94-95) has been utilized as operational framework in
family health nursing practice (Bailon and Maglaya 1978; Maglaya 1997, 2004) as a
precise methodology to integrate the application of theoretical perspectives which
converge particularly at the critical role of family performance of functions to attain,
sustain, maintain and regain individual and family health. This operational framework
is based on the principle that in order to achieve wellness among family members and
reduce or eliminate family health problems, the family as a functioning unit performs
the following health tasks: (1) recognize the presence of a 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; and (5) utilize community resources
for health care. This operational framework was used in the early part of 1970s as
basis for generating, categorizing and finalizing A Typology of Nursing Problems in
Family Health Nursing Practice (Table 2.2). The first field - tested typology was
published in 1978 by Bailon and Maglaya. Through the years the typology has been
updated, specifically in 1994, 1997, 2003 and 2009. This chapter presents the
typology as part of the discussion on formulating the nursing diagnosis in family
nursing practice.

In conclusion, the Systems Framework, the Interactional and Developmental

Approaches, and the Structural-Functional model are examples of major
theoretical perspectives which describe, explain and predict family behavior critical to
understanding the family as a functioning unit and as a client partner. Particularly in
assessment, theoretical perspectives provide a systematic guide for the nurse to
identify what assessment data are needed and how to generate, sort out, organize and
analyze large amount of disparate data about the family (Friedman 1992, p.59). The
unique behavior of the family as a functioning unit explains the realities and degree of
openness to change as client and partner of the nurse in family nursing practice.
Theoretical frameworks which explain and predict this unique behavior of the family
provide directions on how the nurse can work with the family (as functioning unit and
client partner) by enhancing its system effectiveness in sustaining resource/energy -
availability and use for system change and facilitating boundary efficiency in
allowing access to external support or use of information to promote wellness,
enhance growth and development, create an environment for a healthy lifestyle, or
manage health or related problems. Respect for family values and readiness to
understand and maximize use of family rules, norms, and family attitudes (as
components of family boundaries and filtering mechanisms) are essential in creating
efficient, semi-permeable family system boundaries through a working relationship
based on trust and guided by clear and mutually established goals and expectations.
Within an atmosphere of respect, trust and belief in an egalitarian relationship to
enhance the family's empowering potential, the family-nurse partnership can
maximize experiential learning processes such as creating options, deconstructing
mindsets or current worldviews by analyzing meanings to gain new insights, and/or
reordering patterns and relationships in original ways that result in fresh meanings,
expanded ways of thinking, and different values to discover new interpretations and
explanations for what was previously thought of as fixed and absolute (Denham 2003
pp.154, 276 and 280). Chapters 3 and 4 focus on how to facilitate these processes of
creating, deconstructing, and reconstructing experiences, meanings, different values
and expanded ways of thinking to help the family systematically handle the
challenges of going through behavior change.

NURSING ASSESSMENT: OPERATIONAL FRAMEWORK

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, its 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. Data about
the present condition or status of the family are gathered and analyzed based on how
family dynamics, realities, possibilities and vulnerabilities generate the antecedents or
factors associated with health and illness experiences. Utilizing theoretical models to
understand the characteristics and behavior of the family as a functioning unit and
client, the operational framework for assessment, as described in this chapter, focuses
on types of assessment data to generate, method and tools to collect these data, and
finally, application of the Family Health Tasks Perspective in determining family
health nursing problems associated with specific health conditions or problems.

Nursing assessment includes data collection, data analysis or interpretation and

problem definition or nursing diagnosis. Nursing diagnosis is the end result of two
major types of nursing assessment in family nursing practice based on the framework
used in this book. These are: (1) first-level assessment; (2) second-level assessment.
First-level assessment is a process whereby data about the current health status of
individual members, the family as a system and its environment are compared against
norms or standards of personal, social and environmental health and interactions/
interpersonal relationships within the family system. As end result of data analysis
during the first-level assessment, specific health conditions or problems are identified
and categorized as: (1) wellness state/s; (2) health threats; (3) health deficits; and (4)
stress points or foreseeable crisis situations (see Table 2.2). Second-level assessment,
on the other hand, specifies the nursing problems that the family encounters in
performing the health tasks with respect to a given health condition or problem, and
the causes, barriers or etiology of the family's inability to perform the health task.

These two levels of assessment specify a hierarchy of two sets of data and their
analyses. They reflect depth of data gathering and analysis on what health conditions
or problems exist (first-level assessment), and why each health condition or problem
related with maintaining health or wellness exists. The latter is stated as explanation
about the family's problem related to maintaining health/wellness, managing health
problems/ illness experience, or providing a home environment conducive to health
maintenance and personal development (second-level assessment).

STEPS IN FAMILY NURSING ASSESSMENT

There are three major steps in nursing assessment as applied to family nursing
practice: data collection; data analysis; and formulation of diagnosis. Figure 2.1
illustrates these steps. Data collection for first-level assessment involves gathering of
five types of data which generates the categories of health conditions or problems of
the family. These data include:
1. Family structure, characteristics and dynamics;
2. Socio-economic and cultural characteristics;
3. Home and environment;
4. Health status of each member; and
5. Values and practices on health promotion/maintenance and disease
prevention.

Second-level assessment data include those that specify or describe the family's
realities, perceptions about and attitudes related to the assumption or performance of
family health tasks on each health condition or problem identified during the first-
level assessment.

Data analysis involves several sub-steps: (1) Sorting of data for broad categories such
as those related with the health status or practices of family members or data about
home and environment; (2) Clustering of related cues to determine relationships
between and among data; (3) Distinguishing relevant from irrelevant data to decide
what information is pertinent to understanding the situation at hand based on specific
categories or dimensions; (4) Identifying patterns such as physiologic function,
developmental, nutritional/dietary, coping/adaptation or communication or interaction
patterns and lifestyle; (5) Relating family data to relevant clinical/research findings
and comparing patterns with norms or standards of health (e.g. nutritional intake,
immunization status, growth and development, social and economic productivity,
environmental health requisites) family functioning and assumption of health tasks;
(6) Interpreting results based on how family characteristics, values, attitudes,
perceptions, lifestyle, communication, interaction, decision making, or role/task
performance are associated with specific health conditions or problems identified; and
(7) Making inferences or drawing conclusions about the reasons for the existence of
the health condition or problem and risk factor/s related to non-maintenance of
wellness state/s which can be attributed to non-performance of family health tasks.

The last step in family nursing assessment involves making a diagnosis. This includes
two types: (1) definition of wellness state/potential or health condition or problems as
an end product of first-level assessment; and (2) definition of family nursing problems
as an end result of second-level assessment. The family nursing problem is stated as
an inability to perform a specific health task and the reasons (etiology) why the family
cannot perform perform such task.
 Recognize Need to Use Data based on Evidence
 Ensure Accuracy and Reliability of Data
 Check for Inconsistencies
 Complete Missing Information

DATA COLLECTION DATA ANALYSIS HEALTH CONDITIONS/

Framework: Use an Organized and PROBLEMS AND
Comprehensive Approach to  Sort Data FAMILY NURSING
Assessment DIAGNOSES
 Cluster/Group Related
First-level-Data on Status/ Condition Data First-level Assessment:
of Define the Health
 Family/Household Members  Distinguish Relevant
 Home and Environment from Irrelevant Data Conditions/Problems
(categorized as: wellness
Second-level-Data on Family's,  Identify Patterns (e.g., states, health deficits, health
Assumption of Health Tasks on each function, behavior, threats, foreseeable crises or
Health Condition/ Problem identified lifestyle) stress points)
in first-level assessment
 Relate family data to Second-level Assessment:
Methods/Sources: First-level relevant clinical data Define the Family Nursing
Assessment: and research findings Problems/Diagnoses (Table
 Health Status of Family/ 2.2) as Statements of:
Household Member:  Compare Patterns with
 Health Assessment Norms or Standards Family's Inability to Perform
 Laboratory/ Diagnostic Health Tasks on each Health
Test Results  Interpret Results Condition/ Problem
Records/Reports specifying the i Barriers to
 Make Inferences/ Draw Performance or Reasons for
 Home and Environment Conclusions Non performance of Family:
 Health Tasks
 Observation/Ocular Survey

 Interview

 Laboratory/Diagnostic Test
Results

 Records/Reports

Second-level Assessment:
 In-depth interview on
Realities/Perceptions about and
Attitudes towards Assumption/
Performance. of Health Tasks

Observation: Relate Verbal with Non-

verbal Cues
Continuous Data Validation/Update for Adequacy of Evidence to Support Diagnosis

Fig 2.1 The Assessment Phase In Family Health Nursing Practice The Critical
Thinking Approach
DATA COLLECTION

The nurse is concerned about two important things to ensure effective and efficient
data collection in family nursing practice. Firstly, she has to identify the types or
kinds of data needed. Secondly, she needs to specify the methods of data-gathering
and the necessary tools to collect such data. Types of Data in Family

Types of Data in Family Nursing Assessment

What data are needed to arrive at a measure of the family's ability to achieve
health and well-being among its members, while it maintains itself as a system and as
a functioning unit? Based on theoretical frameworks which describe family
characteristics, explain and predict family behavior, two types of data are needed at
two levels of assessment in family nursing practice. As shown on Table 2.1
(Assessment Data Base) the following constitute the first type of data taken during the
first-level assessment:

1. Family structure, characteristics and dynamics-include family composition

and demographic data, type of family form and structure, decision-making
patterns, interpersonal relationships, interactional patterns/interpersonal
relationships (such as presence of dyadic and triadic boundaries which have
the potential to alter members' diverging health beliefs, knowledge and
behavior) and communication patterns or processes affecting family
relatedness (e.g. expression of feelings or emotions particularly related with
addressing converging and diverging motivations or perceptions, such as
during conflict) consistency and congruence between intended and received
messages; and, explicitness of message for appropriateness, effectivity and
efficiency of the communication process related with role performance,
individual members' health and family system integrity.

2. Socio-economic and cultural characteristics-include occupation, place of

work, and income of each working member; educational attainment of each
family member; ethnic background and religious affiliation; family traditions,
events or practices affecting members' health or family functioning; significant
others and the role(s) they play in the family's life; and the relationship of the
family to the larger community.

3. Home and environment-include information on housing and sanitation

facilities; kind of neighborhood and availability of social, health,
communication and transportation facilities in the community.

4. Health status of each member-includes current and past significant health

condition/s or illness/es; beliefs and practices conducive to health and illness;
nutritional and developmental status; physical assessment findings and
significant results of laboratory/diagnostic tests/screening procedures.

5. Values and practices on health promotion/maintenance and disease

prevention include use of promotive-preventive services as evidenced by
immunization status of at-risk members and use of other healthy lifestyle
related services; adequacy of rest/sleep, exercise, relaxation activities, stress
 management or other healthy lifestyle practices; opportunities which enhance
feelings of self-worth, self-efficacy and connectedness to self, others and a
higher power; essence of meaningfulness.

A tool for gathering this assessment data base (ADB) is presented in Table 2.1.
Through this ADB, the nurse can identify existing and potential wellness state/s,
health threats, health deficits and stress points/foreseeable crises in a given family.
Each family has its own way of behaving towards or responding to situations in the
face of these problems. The other type of data taken during the second-level
assessment reflects the extent to which the family can perform the health tasks on
each health condition or problem identified. These data include:

1. The family's perception of the condition or problem;

2. Decisions made and appropriateness; if none, reasons, and
3. Actions taken and results; if none, reasons; and
4. Effects of decisions and actions on other family members.

Data-gathering Methods and Tools

There are several methods of data-gathering that the nurse can 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/inaccurate and inadequate data can lead to
inaccurately defined health and nursing problems which, in turn, lead to poorly
designed family nursing care plan.

To ensure quality assessment data, a combination of methods and sources can provide
cross-checks and data validation. To illustrate, a combination of interview,
observation, ocular survey, direct examination (physical assessment), use of
laboratory or diagnostic tests and record review can be utilized to generate first-level
assessment data using the tool, Assessment Data Base for Family Nursing Practice
(Table 2.1). The following are brief descriptions of common methods of gathering
data 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-sight, 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 status can be inferred from the signs and
symptoms of problem areas reflected in the following:
a. Communication, interaction patterns and interpersonal relationships
expected, used and tolerated by family members;
b. Role perceptions/task assumptions by each member, including
decision-making patterns; and
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, auscultation, 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 be aware of the health status of its members. Data generated
from physical assessment form a substantive part of first-level assessment
which may indicate presence of health deficits (illness states). The techniques
employed during the physical examination process are discussed extensively
by Bickley (2007) and Barkauskas, Stoltenberg-Allen, Baumann, and Darling-
Fisher (2002).

3. Interview. Another major method of data-gathering is the interview. One

type of interview is completing a health history for each family member. The
health history determines current health status based on significant past health
history (e.g. developmental accomplishments, known illnesses, allergies,
restorative treatment, residence in endemic areas for certain diseases or
exposures to communicable diseases); family history (e.g. genetic history in
relation to health and illness) and social history, such as intrapersonal and
interpersonal factors affecting the family member's social adjustment or
vulnerability to stress and crisis (Clemen-Stone and others 1991, p.271).

A second type of interview 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 (First level Assessment,
see Table 2.2) and the corresponding family nursing problems for each health
condition or problem (Second-level Assessment, Table 2.2). Ensuring
confidentiality and respect for the family's right to self-determination are key
principles to consider during all phases of the nursing process.

The nurse can also collect information from colleagues who work with the
family according to their particular service specialties as well as school
personnel, employers, significant others and community workers who can give
reliable and relevant information on the family's life and experiences.

Productivity of the interview process depends upon the use of effective

communication techniques to elicit the needed responses. One major problem
encountered by practitioners in gathering data (especially for the second-level
assessment) is how to determine where the client is in terms of perception of
the health condition or problem and the patterns of coping utilized to resolve
or address it. There is a tendency among community health nurses to readily
give out advice, health teachings or solutions once they have identified the
health conditions or problems. There are very few instances when they
determine first the client's perception of the health condition or problem and
resources in dealing with it before they take action or do nursing interventions.

Interview questions and communication techniques must be guided by

theoretical perspectives in family health care. Respect, trust and
confidentiality are critical values to maintain when conducting the interview.
Confidence on the use of communication techniques can come after being
familiar with and being competent on the use of types of questions that aim to
explore, validate, clarify, offer feedback, encourage verbalizations of thoughts
and feelings, and offer needed support or reassurance.

Second-level assessment can be adequately done for each wellness state,

health threat, health deficit or crisis situation by going through the following
steps with family members who may need to help each other validate
interview data on realities or experiences regarding performance of the family
health tasks:

a. Determine if the family recognizes the existence of the condition or

problem. If the family does not recognize the presence of the condition
or problem, explore the reasons why.
Sample interview questions:
i. What does the family think about the situation/condition
of...? (Ano ang palagay/tingin ninyo sa kalagayan o kondisyon
ng. ?)

ii. What do you think is the reason why he/she appears (e.g.
thin, lethargic)? Or, why do you think he/she is behaving this
way...? (Ano sa palagay ninyo ang dahilan kung bakit siya
nagkakaganyan?) ?

iii. What do you think is happening to your…?(Ano sa palagay

ninyo and nangyayari sa inyong...?)

iv. Why do you think he/she is...? (Ano sa palagay/tingin ninyo

ang dahilan niya...?)

b. If the family recognizes the presence of the condition or problem,

determine if something has been done to maintain the wellness state or
resolve the problem. If the family has not done anything about it,
determine the reasons why. If the family has done something about the
problem or condition, determine if the solution is effective.
Sample interview questions:
i. What has been done to improve the condition or situation?
(Ano na ang nagawa para magbago ang kalagayan...o mapaigi
and pakiramdam...?)
ii. What is the family's plan regarding this? (Ano ang binabalak
ng pamilya tungkol dito?)
iii. What improvements in the condition of ... have been
observed? (Anong mga pagbabago ang inyong napansin sa
kalagayan ni...?)
iv. What do you think the family should do about...? (Ano sa
palagay ninyo ang dapat gawin ng pamilya tungkol sa...?)

c. Determine if the family encounters other problems in implementing

the interventions for the wellness state/potential, health threat, health
deficit or crisis: What are these problems?
Sample interview questions:
 i.What were the problems or barriers encountered in...? (Anu-
ano ang inyong naging problema sa pagpapatupad ng mga
solusyon sa. ..? or Anu-ano ang mga naging sagabal o balakid
nang inyong ginawa ang...?)
ii. What do you think are the reasons why there is no
improvement in the condition of ? (Anu-ano sa palagay ninyo
ang dahilan kung bakit walang pagbabago ang kalagayan ni...?)
iii. Why did you stop doing what you used to do regarding…?
(Bakit ninyo itinigil o hindi ipinagpatuloy ang dati ninyong
ginagawa sa …?)
iv. Why did you not continue doing what we have discussed
regarding...? (Bakit hindi ninyo ipinagpatuloy and ating pinag-
usapan tungkol sa...?)
v. How did you do it? (Papaano ninyo ginawa ito?) Or how
often did you do it? (Gaano ninyo kadalas ginawa ito?)

d. Determine how the other family members are behaving towards

each other or how they are affected by the health condition or problem.
Sample interview questions:
i. How are the other members affected by...? (Ano ang naging
epekto ng... sa ibang miyembro ng pamilya?)
ii. How are the other members reacting to .? (Ano and reaksyon
ng ibang miyembro ng pamilya sa...?)

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 members, laboratory and diagnostic
reports, immunization records, reports about the home and environmental
conditions, or similar sources.

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

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

The Assessment Data Base (ADB) is supported and complemented by other family
assessment tools to elicit generational information about family structure and
processes (genogram), factual data about family relationship with the external
environment and its resources (ecomap), and interactive processes and family
relationship problems/ difficulties and strengths (family-life chronology).

Genograms graphically display information about family members and their

relationships over at least three generations. The Family Systems Theory of Murray
Bowen (1978) is used as the conceptual framework for constructing and analyzing
genogram patterns (i.e. structural, relational and functional information about a
family) viewed horizontally across the family context and vertically through
generations. The breadth of the current family context captures the connectedness of
nuclear and extended family members as well as significant non-family members who
have ever lived with or played a major role in the family's life, including family
strengths and vulnerabilities in relation to the overall situation. Depending on the
level of assessment competencies of the nurse, nodal and critical events in the family's
history are assessed within and through life cycle transitions, placing present issues in
the context of the family's evolutionary patterns. Current behavior or problem/s of
family members can be analyzed from multiple perspectives. Data about the index
person (IP), the person with the problem or symptom, can be viewed in the context of
various subsystems (such as siblings, complementary and symmetrical, reciprocal
relationships) or in relation to the broader socio-cultural context (e.g. the community
and social institutions). Family members are interviewed about the present situation in
relation to the themes, myths, rules and emotionally charged issues of previous
generations, suggesting possible connections between family events. Patterns of
previous illness and earlier shifts in family relationships brought about through
changes in family structure and other critical life changes can easily be noted on the
genogram, providing a rich source of information about what leads to change in a
particular family (McGoldrick and Gerson 1985, pp. 2-3).

An ecomap visually diagrams the family's interactions or relationships with the

external environment and its resources. It summarizes on one page the family
strengths, conflicts and stresses in relation to its interactions with individuals and
agencies outside the family system. As one of the forerunners to use the ecomap,
Hartman (1978) used the tool to examine boundary maintenance aspects of family
functioning. The ecomap dramatically illustrates the amount of energy used by a
family to maintain its system, as well as the presence or absence of situational
supports and other family resources. It helps identify how family energies are being
used and when relationships with the external environment are positively or
negatively influencing family functioning. To illustrate, if a family's flow of energy as
depicted on the ecomap reflects only an outward directional process (- ), the family
may have difficulty providing a nurturing environment for family members and
achieve its goals (Clemen-Stone and others 2002, p.194-195). The ecomap is
particularly useful when the family is involved with several community systems or
when the family perceives a lack of support from significant others.

Family-life chronology helps capture family interactive processes that have evolved
(Satir 1967). It can help the family identify the strengths in family member
relationships over time and the need to alter family functioning to reduce stress. By
identifying relationship difficulties within the family, the nurse can facilitate the
development of effective family processes by encouraging members to find ways to
discuss and address their differences in support of individual and family wellness
(Clemen-Stone and others 2002 pp. 195-196).

Appendices B1 to B3 describe how the genogram, ecomap and family-life chronology

are constructed.

DATA ANALYSIS
Utilizing the data generated from the tool on Assessment Data Base in Family
Nursing Practice (See Table 2.1), the nurse goes through data analysis. She sorts out
and classifies or groups data by type or nature (e.g. which are wellness states, 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 recurring 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;

2. Home and environmental conditions conducive to health development, and;
3. Family characteristics, dynamics or level of functioning conducive to family
growth and development.

The first type normal health of members involves the physical, social and emotional
well-being of each family member. Home and environmental conditions include both
the physical as well as the psychological and socio-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 socio-cultural norms, values, expectations or modes
of life which enhance health development and prevent or control risk factors and
hazards. The third type- family characteristics or functioning - 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 relationships with the broader
neighborhood and community (Clemen-Stone and others 1991, pp. 269-270).

In order to achieve 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 a 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; and,
5. Utilize community resources for health care.

After relating family data to relevant clinical or research findings and comparison of
patterns with norms or standards, assessment data, as categorized or reorganized, are
interpreted and inferences are drawn. The end result of this analysis during the first-
level assessment is a conclusion or a statement of a health condition or 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
member;
3. Condition of home and environment conducive to disease/illness or
accidents; and,
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 process of data gathering
for this analysis has been described earlier (see Interview, Data-gathering Methods
and Tools). 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. The causes of or the reasons for the existence of
the condition or health condition or problem reflect barriers to the family's capabilities
to promote and maintain health among its members as it maintains family system
integrity. Figure 2.1 summarizes the critical thinking process during the assessment
phase in family health nursing practice.

NURSING DIAGNOSES: FAMILY NURSING PROBLEMS

The end result of the second-level assessment is a set of family nursing
problems for each health condition or problem.

A wellness condition is a nursing judgment related with the client's capability for
wellness. A health condition or problem is a situation which interferes with the
promotion and/or maintenance of health and recovery from illness or injury. A
wellness state or health condition/problem becomes a family nursing problem when is
stated as the family's failure to perform adequately specific health tasks to enhan or
sustain the wellness state or manage the health problem. This is called the nursing
diagnosis in family nursing practice, specifically defined as a clinical judgment about
the family's response to actual or potential health problems or life processes (North
American Nursing Diagnosis Association [NANDA] 2001).

One of the major barriers to the effective operationalization and application of the
nursing process in family health care is the absence of a classification system for
nursing problems that reflect the family status and capabilities as a functioning unit.
To facilitate the process of defining family nursing problems, a classification system
of family nursing problems was developed and field tested in 1978. This tool, called
A Typology of Nursing Problems in Family Nursing Practice (see Table 2.2), has
been used by nursing students, community health nurse practitioners and educators
Through the years revisions have been done to ensure all-inclusiveness and mutual
exclusiveness of the list. In 2003, presence of wellness condition has been added in
the first-level assessment part of the typology.

THE TYPOLOGY OF NURSING PROBLEMS IN FAMILY

HEALTH CARE
The organizing framework of the typology is based on the family health tasks
(Freeman and Heinrich 1981, pp. 94 - 95). The rationale for adopting these health
tasks as the framework of the typology is the fact that in community health nursing
practice, the nurse deals mostly with problems within the domain of human behavior
or human response to health and illness. It is not very often that the community health
nurse deals with the physical, psychological or clinical condition of the patient
requiring her sustained direct services such as nursing care during the acute phase of
an illness in the hospital setting. Much of the nurse's efforts are directed at effecting
change in the behavior of clients to achieve optimum health. The community health
nurse works with and through the family to improve its capability to achieve health
and wellness among its members.

The typology contains six main categories of problems in family nursing care (see
Table 2.2). The first category refers to the presence of wellness states, health threats,
health deficits and foreseeable crisis situations or stress points. The result of the
analysis of data taken during the first level assessment (utilizing the tool Assessment
Data Base for Family Nursing) is reflected as statement of the health condition or
problem, a wellness state, health threat, health deficit or foreseeable crisis/stress point.
After identifying these health conditions or problems, the nurse determines the
family's ability to perform the five health tasks on each one. The remaining five main
categories of problems contain statements of the family's inability to perform the
health tasks. The results of the analysis of data taken during the second - level
assessment are reflected as statements of the family nursing problems. There are five
main types, namely;
1. Inability to recognize the presence of the condition/problem due to...
2. Inability to make decisions with respect to taking appropriate health action
due to...
3. Inability to provide nursing care to the sick, disabled, dependent or at-ris
member of the family due to...
4. Inability to provide a home environment which is conducive to health
maintenance and personal development due to…
5. Failure to utilize community resources for health care due to...

The categorization of problems in the typology constitutes several levels according to

the degree of generality or specificity. After each main category of family nursing
problem, several more specific problems are identified reflecting contributory
problems to or explanations for the existence of the main problem. This is parallel to
the concepts of immediate cause, intermediate cause and ultimate cause when
identifying the cause(s) of morbidity or mortality, or Mundinger and Jauron's concept
of a nursing diagnosis (Mundinger and Jauron 1975. pp. 96-97). According to the
latter, a nursing diagnosis consists of two parts:
1. The statement of the unhealthful response; and,
2. The statement of factors which are maintaining the undesirable response
and preventing the desired change.

The more specific the problem definition (which depends on the depth and breadth of
the assessment), the more useful is the nursing diagnosis in determining nursing
intervention. Therefore, as many as three or four levels of problem definition can be
stated. To illustrate, in a family with a prenatal patient who is at the same time the
breadwinner of the family and who is not receiving any care/supervision, the nursing
problem may be stated as:

(General) Inability to utilize community resources for health care due to

inadequate family resources, specifically:
(Specific) a. financial resources
b. manpower resources
c. Time
With the inclusion of wellness states as part of the first-level assessment, the family
nursing problems specifically related with sustaining wellness states within the family
system is added in the updated typology.
TABLE 2.1 ASSESSMENT DATA BASE IN FAMILY NURSING PRACTICE*

A. Family Structure, Characteristics and Dynamics/Relational Patterns

1. Members of the household: birthdate, sex, civil status, position in the family
and relationship to the head of the family)

2. Sociodemographic data of members not currently living in the household

but with major role in resource generation and use.

3. Type of family structure and form-e.g. matriarchal or patriarchal, nuclear,

extended or blended

4. Dominant family members in terms of decision making (especially on

matters of health care) and care tending

5. Family dynamics, communication pattern/s, interactional processes and

interpersonal relationships (e.g. dyadic and triadic interactions) which possess
innate or great potential to mediate or potentiate factors relevant to health,
illness, growth, development and the family's ability to handle conflict,
change, anticipated and unexpected events.

*Developed and published by Salvacion G. Bailon-Reyes and Araceli S. Maglaya,

1978 (see Bailon SG and Maglaya AS: Family Health Nursing - The Process, Printing
4. Manila. Brainchild Managers and Consultants, 1990); reviewed & updated in 1994,
1997, 2003 and 2009 by A.S. Maglaya.

B. Socio-economic and Cultural Characteristics

1. Income and Expenses
a. Occupation, place of work and income of each working
b. Adequacy to meet basic necessities (food, clothing, shelter)
c. Who makes decisions about money and how it is spent

2. Educational attainment of each member

3. Ethnic background and religious affiliation
4. Family Traditions, events or practices affecting members' health or family
functioning
5. Significant Others-role(s) they play in family's life
6. 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 arrangement
c. Presence of breeding or resting sites of vectors of diseases (e.g.
mosquitoes, roaches, flies, rodents, etc.)
d. Presence of accident and fire hazards
e. Food storage and cooking facilities
f. Water supply-source, ownership, potability
g. Toilet facility-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 and nursing history indicating current or past significant illnesses
beliefs and practices conducive to health and illness
2. Nutritional assessment (specially for vulnerable or at-risk members)
a. 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 meters), waist circumference (WC: greater than 90 cm. in
men and greater than 80 cm. in women), waist hip ratio (WHR= waist
circumference in cm. divided by hip circumference in cm. Central
Obesity: WHR equal to or greater than 1.0 cm. in men and 0.85 in
women).
b. Dietary history specifying quality and quantity of food/nutrient
intake per day
c. Eating/feeding habits/practices

3. Developmental assessment of infants, 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 of

undiagnosed by medical practitioners)

6. Results of laboratory/diagnostic and other screening procedures supportive

of assessment findings

E. 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:
a. rest and sleep
b. exercise/activities
c. use of protective measures-e.g. adequate footwear in parasite-
infested areas; use of bednets and protective clothing in malaria and
filariasis endemic areas
d. relaxation and other stress management activities.
 e. oportunities which enhance feelings of self worth, self efficacy and
sense of connectedness to self, others and a higher power, essence of
meaningfulness.

4. Use of promotive-preventive health services (such as maternal and chilld

health supervision) and use of healthy life style-related services

*Source: Compendium of Philippine Medicine. Guidelines for a Healthy and Safe

Weight Management Program, PASOO Recommendation, 3rd Ed. (2000).

TABLE 2.2 A 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 (NANDA, 2001). Wellness potential is a nursing judgment
on wellness state or condition based on client's performance, current competencies or
clinical data but no explicit expression of client desire. Readiness for enhanced
wellness state is a nursing judgment on wellness state or condition based on client's
current competencies or performance, clinical data and explicit) expression of desire
to achieve a higher level of state or function in a specific area on health promotion
and maintenance. Examples of these are the following:

A. Potential for Enhanced Capability for:

1. Healthy Lifestyle - e.g. nutrition/diet, exercise/activity
2. Health Maintenance/Health Management
3. Parenting
4. Breastfeeding
5. Spiritual Well-being process of a 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
these are the following:

A. Presence of risk factors of specific diseases (e.g. lifestyle diseases,

metabolic syndrome)
B. Threat of cross infection from a communicable disease case
C. Family size beyond what family resources can adequately provide
D. Accident/ fire hazards. Example:
1. broken stairs
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 or

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 sites of vectors of diseases
mosquitoes, flies, roaches, rodents, etc.)
5. Improper garbage/refuse disposal
6. unsanitary waste disposal
7. improper drainage system
8. poor lighting and ventilation
9. noise pollution
10. air pollution

H. Unsanitary food handling and preparation

I. Unhealthful 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/inadequate relaxation activities
12. non-use of self-protection measures (e.g. non-use of bednets in
 malaria and filariasis endemic areas)

J. Inherent personal characteristics eig. poor Impulse control

K. Health history which may participate/induce the occurrence of a health
deficit, e.g. 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:

Ill. Presence of Health Deficits instances of failure in health maintenance.

Examples include:
A. lliness 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;
transitions (e. passage from one life phase, condition or status to another, causing a
forced or chosen change that results in the need to construct a new reality). Examples
of these include:
A. Marriage
B. Pregnancy, labor, puerperium
C. Parenthood
D. Additional member eg. 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
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
perceived magnitude/severity of the situation or problem, i.e., failure to break
down problems into manageable units of attack
D. Lack offinadequate 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

I. Negative attitude towards the health condition or problem is meant one that
interferes with rational decision making

J. Inaccessibility of appropriate resources for care, specifically:

1. physical inaccessibility
2. cast 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

Ill. 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 offinadequate knowledge about child development and care
C. Lack of/inadequate knowledge of the nature and extent of nursing care
needed
D. Lack of the necessary facilities, equipment and supplies for care
E. Lack of or inadequate knowledge and skill in carrying out the necessary
 interventions/treatment/procedure/care (e.g., complex therapeutic regimen or
healthy lifestyle program)
F. Inadequate family resources for care, specifically:
1. absence of responsible member
2. financial constraints
3. limitations/lack of physical resources - e.g., isolation room

G. Significant person's unexpressed feelings (e.g., hostility/anger, guilt, fear/

anxiety, despair, rejection) which affect his/her capacity 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 own concerns/interests
J. Prolonged disease or disability progression which exhausts supportive
capacity of family members
K. Altered role performance-specify:
1. role denial 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.g. lack of space to construct facility

B. Failure to see benefits (specifically long-term ones) of investment 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 patterns within the family
G. Lack of supportive relationship among family members
H. Negative attitude/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 -e.g., loss of esteem of peer/significant others

F. Unavailability of required care/service

G. Inaccessibility of required care/service due to:
1. cost constraints
2. physical inaccessibility, i.e. location of facility

H. Lack of or inadequate family resources, specifically:

1. manpower resources -e.g., baby sitter
2. financial resources -e.g., cost of medicine prescribed

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

* Developed and published by Salvacion G. Bailon-Reyes and Araceli S. Maglaya in

1978 (see Bailon SG and Maglaya AS: Family Health Nursing - The Process, Printing
4. Manila. Brainchild Managers and Consultants, 1990); reviewed and updated in
1994, 1997, 2003 and 2009 by A.S.Maglaya.

CONCLUSION:

Guided by four major theoretical models presented earlier in this chapter, family
nursing assessment is a deliberate and systematic process of gathering and analyzing
data to identify and continuously validate health and nursing problems of families.
The operational framework for family nursing assessment described in this chapter
guides the nurse on how to understand and work with the family as a system and
client as it goes through growth, development, health and illness experiences among
its members. By going through the process of data collection and analysis, the nurse
learns that families as clients have varied views of life, that they hold different
aspirations and that they respond to situations or problems in unique ways. Family
nursing assessment is an opportunity for learning about the families ways of knowing
The process challenges the nurse to evaluate her assumptions and premises in order to
arrive at valid conclusions. Accuracy in family nursing assessment is achieved as the
nurse gets as close to the family's lived experience as a functioning unit and client,
using the participatory approach. Through partnership, the nurse and the family can
enhance each other's capability to look at and analyze the family situation or reality
together in order to explore and plan for the most effective, efficient and sustainable.
options for action.