St.

Paul University Philippines

Tuguegarao City, Cagayan 3500

SCHOOL OF NURSING AND ALLIED HEALTH SCIENCES

College of Nursing
First Semester, AY 2024 – 2025

NCM 104: Community Health Nursing 1 – Individual and Family as a Client

Overview
St. Paul University Philippines (SPUP) and its College of Nursing (CON) have a long-
standing legacy of community organizing that spans decades. This enduring commitment has been
a cornerstone of the college’s approach to service - learning, deeply rooted in fostering strong
relationships with its partner communities. Through continuous engagement and collaboration, the
college has cultivated programs that not only address immediate health concerns but also empower
communities to take active roles in their own development.
Moreover, the college has long been recognized for its methodical and participatory
approach to community organizing, particularly through the Community Organizing Participatory
Action Research (COPAR) framework.
The college has partnered with the Local Government Unit (LGU) of Sta. Maria, Isabela
with a memorandum of agreement which serves the latter as the area of placement of student nurses
enrolled to nursing care management courses that has community as part of the related learning
experience.
Along with this partnership is the three-year development plan of the college in the said
municipality using the six (6) phases of COPAR as process-oriented approach to empower the
communities to take active roles in addressing their own issues. Hence, achieving the ultimate goal
of community health nursing which is self – reliance.
This plan follows this operational framework:

The process of COPAR in Sta. Maria started on September 2023 with the activities on pre
– entry and entry phases. On its first year, the theme revolves around Mobilizing Individuals, with
activities focuses on establishing baseline data and core group formation.
This year, the theme anchors on Empowering Families, with the activities on Organization
– Building Phase and Community Action Phase being shared by student nurses in Levels and III.
 A community health nurse deals with individual sick or well daily. Since the health
problems of individuals are intertwined with those of the other members of the family, and the
community, they are also considered as an “entry point” in working with these clients.
From a systems perspective, a family is defined as a collection of people who are
integrated, interactive and interdependent. The family members, interact with each other and the
health problem of one member affects the whole family. The family is responsible for the health
of all members. It performs the different health tasks fir the family to function well. In the family
level, the family is the client which means that the nurse provides care to two or more individuals
in a single household. Because most people belong to a family and their heath is strongly
influenced by the home situation, the family is considered the basic unit of care in community
health nursing.
For the Level II students, the activities were designed to implement interventions to
individuals as the entry point and the family as the unit of service in community health nursing.
The family is an effective and available channel for much of the community health nursing
efforts. Improved community health is realized only through improved health of families.
With these ongoing health efforts of the college in scaling up interventions to improve
health literacy and mainstream health promotion and disease prevention among individuals and
families. Hence, this implementation guidelines in the delivery of the family nursing care plan
were crafted.
This will serve as the basis in utilizing the family nursing and the nursing process to
individual and family as client while applying the competencies gained from Nursing Care
Management (NCM) courses in nursing curriculum.
Implementation Guidelines
1. Each group will be designated to one or two puroks as their assigned area or catchment
zone.
2. The community instructor will divide the students into pairs within each group. If the group
has an odd number of members, one subgroup will consist of three students.
3. During the case finding, the students will select individual and their family as clients of
their nursing care. Their clients should be well and not sick. Although during assessing
individual and family, the nurse may identify a potential health problem that necessitates
the risks for the entire family.
4. The students should maintain a professional, purposeful interaction in the family’s
residence aimed to promote and maintain family or its members while utilizing the steps
of home visits and bag technique.
5. The students should follow the nursing process in the implementation of their care plan.
6. During assessment the student nurses should obtain the following through interviews,
observations, physical examinations and other health assessments and review of secondary
data. The student nurses may construct their interview questionnaires and utilize the
baseline data survey form in gathering relevant data.
I. Family Assessment
1. Initial Data Base
a. Family Structure, Characteristics, Dynamics
➢ composition and demographic data on household membership including
their relationship to the head and place of residence and family members
living outside the household
➢ type of family
➢ family mobility
➢ family dynamics which include the following:
• emotional bonding
 • authority and power structure
• autonomy of members
• division of labor
• patterns of communication
• decision making
• problem and conflict resolution
Data on family structure should be visualized clearly through graphic tools
such as genogram, ecomap and family health tree.
▪ Genogram – this outlines the family’s structure to diagram
the family. Generally, three generations of family members
are included with symbols denoting genealogy.
▪ Family Health Tree – based on the genogram, this provides
a mechanism for recording the family’s medical and health
histories.
▪ Ecomap – this is used to depict a family’s linkages to its
suprasystems.
b. Socio – economic and Cultural Characteristics
➢ financial resources
➢ work history
➢ educational experiences and literacy
➢ social integration as follows:
• ethnic origin, languages and / or dialects spoken
• social networks
• leisure time interests
➢ cultural influences including spirituality or religious affiliations
c. Home Environment
➢ physical environment inside the family’s home / residence and its
neighborhood
➢ information on housing and sanitation facilities which includes:
• housing agency, sleeping arrangements, food storage, cooking
facilities, electrical and water supply and source, ownership,
potability, presence of accident hazards, toilet, garbage disposal
➢ availability of social, health, communication and transportation
facilities in the community
d. Family Health and Health Behavior
➢ current health status
➢ health history
➢ family’s activities of daily living
➢ self – care
➢ risk behaviors
➢ health care resources
2. Family Health Tasks – Review
a. Recognizes interruptions of health or development
b. Seeking health care
c. Managing health and non – health crises
d. Providing nursing care to sick, disabled, or dependent members of the
family
e. Maintaining a home environment conducive to good health and personal
development.
f. Maintaining a reciprocal relationship with the community and its health
institutions.

7. The nursing diagnoses will be formulated using the Typology of Nursing Problems in
Family Nursing Practice.

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. 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. Loss of job
 K. Hospitalization of a family member
L. Death of a member
M. Resettlement in a new community
N. Illegitimacy
O. 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
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 __________

8. On formulation of the plan of care, student nurses should plan for the family’s benefit and
must never lose sight of the fact that the family has the right to self – determinations. In
the end, family decisions regarding health care must be respected. As suggested by,
Stanhope and Lancaster (2010), the nurse’s role at this stage consists of offering guidance,
providing information and assisting the family in the planning setting. The plan should be
based on the principle of mutuality, this means that the family is given the opportunity to
decide for itself how they can best deal with a health situation, just as the student nurse
takes into consideration his or her own resources – competence, material resources, time.
The students together with their clients should identify atleast five (5) health needs /
problems. From the five, the students will prioritize three (3) health needs / problems as
basis in the implementation of the family nursing care plan.

▪ Prioritizing Setting – this determines the sequence in dealing with identified

family needs and problems; the following factors need to be considered:
a. Family safety
b. Family perception
c. Practicality
d. Projected effects
▪ Prioritizing Health Problems
A. Nature of the Problem Score
Health deficit 3
Health threat 2
Foreseeable crisis 1
B. Modifiability of the Problem Score
Easily modifiable 2
Partially modifiable 1
Not modifiable 0
C. Preventive Potential Score
High 3
Moderate 2
Low 1
D. Salience Score
A serious problem, immediate attention needed 2
A problem, not needing immediate attention needed 1
Not seen as a problem 0
▪ Establishing Goals and Objectives
• Goal – desired observable family response to planned
interventions in response to a mutually identified family need.
The goal is the end that the nurse and the family aim to achieve.
e.g. After 8 weeks, the family will be able to maintain
ability to recognized signs of health and
development.
 • Objectives – define the desired step – by – step family responses
as they work toward a goal.
e.g. At the end of 8 weeks, the family will be able to:
✓ identify signs of health and
development
✓ perform usual activities for health and
development
Workable, well – stated objectives should be:
a. Specific – clearly articulates who is expected to do
what
b. Measurable – observable, measurable, and whenever
possible, quantifiable indications of the family’s
achievement because of their efforts toward a goal
provide a concrete basis for monitoring and
evaluation
c. Attainable – the objective must be realistic and in
conformity with available resources, existing
constraints and family traits
d. Relevant – the objective is appropriate for the family
need or problem that is intended to be minimized,
alleviated or resolved
e. Time – bound – having a specified target time or date
helps the family and the nurse in focusing their
attention and efforts toward the attainment of the
objective.

9. The student nurses then determine appropriate interventions based on the identified family
needs and the goals and objectives. The interventions may range from the simple or
immediate, such as offering information about external health resources to the family to
the complicated or prolonged. The interventions may be categorized into three types:
a. Supplemental interventions – actions that nurse
performs on behalf of the family when it is unable to
do things for itself such as providing direct nursing
care to a sick or disabled family member.
b. Facilitative interventions – actions that remove
barriers to appropriate health action, such as assisting
the family to avail of maternal and early childcare
services
c. Developmental interventions – improve the capacity
of the family to provide for its own health needs,
such as guiding the family to make responsible health
decisions, this is directed toward family
empowerment.
Interventions may be a mix of two or all three of these categories, with the nurse making
sure that they are appropriate to the family situation. In addition, the principle of
personalization requires that the nursing care plan fits the unique situation of a family: its
needs, style, strengths, and patterns of functioning.

10. Nursing interventions should be implemented where the family and the student nurse
execute the plan of action. The pattern of implementation is determined by the mutually
agreed upon goals and objectives and the selected course of action. Interventions must be
appropriate to the family members. The student nurses must be conscious of possible
barriers to implementing planned strategies. Such barriers include imposing ideas, negative
labeling, overlooking family strengths, and neglecting cultural and gender implications of
family interventions. Interventions must focus on health promotion and disease prevention
activities. In addition, coordination with the other members of the health team and other
 agencies involved in the care of the family maximizes resources by preventing duplication
of services. If the clients have serious conditions, referral maybe initiated.

11. Evaluation determines the value of nursing care that has given to a family by the student
nurses. A well – formulated goals and objective in the nursing care plan serve as the
framework for evaluation. The product of this step is used for further decision making: to
terminate, continue, or modify intervention (s). The student nurses may conduct an
evaluation as formative or summative.
a. Formative evaluation – judgement made
about effectiveness of nursing interventions
as they are implemented.
b. Summative evaluation – determining the end
results of family nursing care and usually
involves measuring outcomes or the degree
of which goals have been achieved.
Aspects of evaluation that are useful in family healthcare include effectiveness,
appropriateness, adequacy and efficiency.

12. Along with the evaluation of the nursing care, student nurses should secure an Action –
Reflection Faith in Action from their respective clients.

13. The Level II student nurses may collaborate with the programs implemented of Level III
students as long as the programs were appropriate to the needs of their clients.

14. The format of the case study is attached to this guideline.

15. Student nurses are required to submit one case study with three (3) family nursing care
plans. However, as stipulated on the RLE Guidelines and Policies particularly on sanctions,
student nurses who incur one incomplete is required to accomplish one additional (1) FNCP
and a student who incur one late is required to accomplish one (1) full case study.

16. The student nurses should follow the timeline of activities in the implementation of their
care plan.

17. Case studies must be written on an A5 notebook.

18. The oral presentation of the case study will be done as scheduled. A separated evaluation
tool will be used during the presentation. Refer to the attachments.

19. The selected family of the student nurses will convene on a Family Health Fair which will
be conducted on their respective catchment areas. A separate guideline will be utilized on
the conduct of the culminating activity.

20. At the end of their RLE, the student nurses should submit a consolidated report with the
following contents:

1. Cover Page
2. Cover Page with name of the students
3. List of Content
4. Work Plan
5. Tasking
6. Action Plans
7. Accomplishment Reports
8. Minutes of the Meeting
9. DBHS List
11. ARFA
 10. Case Studies (with attachments)
11. Team Building (Narrative Report, Session Module, Evaluation Results, Photo
Documentation)
12. Family Health Fair ((Narrative Report, Session Module, Evaluation Results,
Photo Documentation)
13. Appendices
➢ Communication Letter
➢ Updated Community Spot Map
➢ Photo Documentation

Prepared by:

SHERWIN T. PAZZIBUGAN, RN
Coordinator for Community Health Nursing

Noted by:

GENALIN L. TAGUIAM, MSN

Program Coordinator for Nursing

MELANIE T. REBOLDERA, PhDNS

Program Coordinator for Nursing

Approved by:

ANUNCIACION T. TALOSIG, DNS

Dean, SNAHS
 St. Paul University Philippines
Tuguegarao City, Cagayan 3500

SCHOOL OF NURSING AND ALLIED HEALTH SCIENCES

College of Nursing
First Semester, AY 2024 – 2025

NCM 104: Community Health Nursing 1 – Individual and Family as a Client

FORMAT
I. Family Assessment
1. Initial Data Base
a. Family Structure, Characteristics, Dynamics
b. Socio – economic and Cultural Characteristics
c. Home Environment
d. Family Health and Health Behavior

2.Family Health Tasks – Review

a. Recognizes interruptions of health or development
b. Seeking health care
c. Managing health and non – health crises
d. Providing nursing care to sick, disabled, or dependent members of the family
e. Maintaining a home environment conducive to good health and personal development.
f. Maintaining a reciprocal relationship with the community and its health institutions.

II.Prioritization of Health Need / Problem

Health Need / Problem

Criteria Computation Actual Score Justification
A.Nature of the
problem
B. Modifiabily of the
problem
C.Preventive
Potential
D. Salience of the
Problem
Total Score:
III.Family Nursing Care Plan

Health Need / Problem:

First Level Assessment:
Second Level Assessment:
ANALYSIS
GOALS AND REQUIRES
CUES OF THE INTERVENTIONS RATIONALE METHODOLOGY EVALUATION
OBJECTIVES RESOURCES
PROBLEM

IV. Annexes
▪ Information, Education and Campaign (IEC) Materials
▪ Session Modules during health teaching sessions
▪ ARFA of Clients
▪ Photo Documentation
V. References
 St. Paul University Philippines
Tuguegarao City, Cagayan 3500

SCHOOL OF NURSING AND ALLIED HEALTH SCIENCES

College of Nursing

Case Study Presentation Scoring Worksheet

Name of Group Members:

1. __________________________________
2. __________________________________
3. __________________________________

Date Presented: _________________

Total Score: ____________________

The scoring has been adapted from the elements of the core competencies by the
Commission on Higher Education (CHED), the Nursing as Caring Framework, and the
guidelines standards for case presentation.

Write the scores on the boxes provided.

I. FORMAT AND PRESENTATION

A. DELIVERY
1. Manages presentation time
2. Facilitates group discussion and audience interaction effectively
3. Presents material in a clear, concise and organized manner
4. Clear enunciation strong projection; proper volume; eye contact with entire
audience; and with effective presentation posture
5. Projects a professional image by dressing up properly
5 4 3 2 1
Demonstrates Demonstrates Demonstrates Demonstrates Demonstrates
all the any 4 of the any 3 of the any 2 of the only 1
parameters parameters parameters parameters parameter
B. USE OF VISUAL AIDS
1. Utilizes informatics, creative work and other devices that contribute to learning
2. Media and visual aids are prepared in professional manner
3. Main points of the case stand out in the use of media and visual aids
4. Media and visual aids are large enough and with appropriate colors to be seen
4 3 2 1
Demonstrates all the Demonstrates any 3 Demonstrates any 2 Demonstrates only 1
parameters of the parameters of the parameters parameter
C. OPEN FORUM
1. Demonstrates ability to answer with current and accurate knowledge of case study
2. Responds confidently to all questions with explanation and elaboration
3. Holds attention of entire audience with the use of direct eye contact and with a good
command of the English language when explaining
4. Easily able to convey the point one is trying to make
4 3 2 1
Demonstrates all the Demonstrates any 3 Demonstrates any 2 Demonstrates only 1
parameters of the parameters of the parameters parameter
 FAMILY NURSING CARE
A. ASSESSMENT
1. Provides detail / depth needed to clearly describe the client’s and family’s health status
2. Describes relevant subjective and objective data as it relates to family’s initial data
3. Provides data relevant to family’s tasks
4. Identifies preferences and usual patterns of daily living necessary to family nursing care plan
5. Provides clear display of the family structure
5 4 3 2 1
Demonstrates all of Demonstrates any 4 Demonstrates any 3 Demonstrates any 2 Demonstrates only 1
the parameters of the parameters of the parameters of the parameters parameter
B. FAMILY NURSING PROBLEM
1. States family nursing problem according to typology of nursing problems in family nursing problem
2. Lists family needs or problems in order of priority
3. Includes appropriate family nursing problems or needs based on data collected
4. States problems or needs that are appropriate for the nurse’s scope of practice
5. Demonstrates correlation between data clusters and defining characteristics for each problem or need
5 4 3 2 1
Demonstrates all of Demonstrates any 4 Demonstrates any 3 Demonstrates any 2 Demonstrates only 1
the parameters of the parameters of the parameters of the parameters parameter
C. GOAL SETTING AND FORMULATION OF OBJECTIVES
1. States goal as a change in the health status or expected health outcomes
2. Specifies realistic time expected for the change or outcomes to occur or be demonstrated
3. Objectives reflect the family health tasks to be performed by the family to achieve the goal
4. States objectives as desired behaviors performed by the family in terms of knowledge, skills and attitude /
habits or practices
5. Specifies the desired behavior which can be measured an / or observed, attainable considering available
resources and can be attained or observed over specified period of time and condition
5 4 3 2 1
Demonstrates all of Demonstrates any 4 Demonstrates any 3 Demonstrates any 2 Demonstrates only 1
the parameters of the parameters of the parameters of the parameters parameter
D. NURSING INTERVENTIONS
1. Identifies nursing interventions that are realistic for client and family and correlate with stated outcomes
2. Decided on nursing interventions that are adequate and comprehensive to address the problem
3. Selects appropriate interventions according to categories
4. Identifies the role/s that the nurse will assume in the provision of care to the family
5. Modifies standard measures to tailor fit on the needs and available resources of the family
6. States rationale for actions that demonstrate theoretical/scientific principles and integrates research
5 4 2 1
6 3
Demonstrates Demonstrates Demonstrates Demonstrates
Demonstrates all Demonstrates any 3
any 5 of the any 4 of the any 2 of the only 1
the parameters of the parameters
parameters parameters parameters parameter
E. EVALUATION OF PLAN
1. Identifies if outcomes are met, not met or partially met with rationale to support
2. Describes the expected health outcomes or behavior changes to be observed over a certain period of time
3. Decides on the standards or the expected level / degree of performance based on objective realities of the
family
4. Summarizes pertinent observations to support conclusions
5. States modifications of the plan based on client/family response
5 4 3 2 1
Demonstrates all of Demonstrates any 4 Demonstrates any 3 Demonstrates any 2 Demonstrates only 1
the parameters of the parameters of the parameters of the parameters parameter
 F. CARING AND CULTURAL COMPETENCIES
1. Shows respect for the worth and dignity of the client/family whatever their gender, religion, age,
socioeconomic class
2. Accepts the rights of individuals/families to participate in care
3. Acknowledges cultural issues and interacts with client/family in culturally sensitive ways
4. Incorporates client/family’s preferences, health beliefs and behaviors, and traditional practices into the
nursing care plan
5. Supports clients and families to meet their spiritual needs in the perspective of health and illness experiences
6. Respects wishes of patients and families regarding expression of beliefs
6 5 4 3 2 1
Demonstrates all Demonstrates Demonstrates Demonstrates any 3 Demonstrates Demonstrates
the parameters any 5 of the any 4 of the of the parameters any 2 of the only 1
parameters parameters parameters parameter

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