1st and 2nd Level of Assessment
I. Wellness Condition
CUES LEVEL 1 ASSESSMENT LEVEL 2 ASSESSMENT
The family usually have 6-9 hours of Readiness for Enhanced Capability
sleep every day. They also allot time for: Healthy life style as Presence of
in exercising such as doing household wellness condition
chores and walking. Mang Danny
also assists aling Dionisia in
performing simple exercises of her
extremities.
The family prepares a balanced meal Potential for Enhanced Capability for:
despite of limited budget. Their meal Healthy life-style in nutrition as
comprises rice, vegetables, meat and Presence of wellness condition
fruits. Their breakfast includes either
bread or rice and meat/poultry
products/dried fish. Lunch and dinner
would usually include rice and either
meat or fish and vegetable.
Sometimes they include budget some
snacks in between meals like corn,
suman, or bread. They drink around 6
to 8 glasses of water per day
II. Health Deficit
CUES LEVEL 1 ASSESSMENT LEVEL 2 ASSESSMENT
Lola Dionisia cannot move the left Illness states: Stroke with bedsore as Inability to provide adequate nursing
side of her body. Upon observation Presence of health deficit care to the sick, disabled, dependent
she has a muscle strength on both member of the family related to:
right upper and lower extremities a. Inadequate family resources for care
scored 4/5, presence of pressure ulcer such as financial constraints
on her sacral area, as big as a one- b. Lack of inadequate knowledge and
peso coin, reddish in color with skill in carrying out necessary
yellowish border, with yellowish treatment/interventions.
discharge and foul-smelling. Mang
Manny stated,“Dati gumaling na iyan,
pero ngayon meron na naman. Medyo
mahal iyong nireseta ng Doctor na
ipapahid kaya nilalagyan ko na lang
ng dahoon ng saging kasi malamig
iyon para hindi masakit kapag
nauupuan nya…Meron naman sya
Amlodipine para sa highblood nya.
Minsan may binibigay din iyong taga
health center na Vitamins daw nya.
Iyon lang kasi mahal iyong ointment
kaya hindi ako makabili.” Also, mang
Manny took the responsibility of
taking care of her.
Vico has cough and cold for the past Illness states: Asthmas as Presence of Inability to provide a home
3 days. “Nanibago ata kasi kagagaling health deficit environment conducive to health
lang nya sa Manila eh sobrang init maintenance and personal development
doon at madumi ang hangin doon, related to: Lack of/inadequate
tapos pagdating pa dito eh medyo knowledge of preventive measures
malamig ang hangin kaya inubo at
sinipon.” He also added that Vico is
prone to cough and colds because
they have history of Asthma in the
family. Since cough and cold is self-
limiting, Mang Manny said that he
just advised his son to drink plenty of
water and rest. He also said, “Lagi ko
rin syang pinapaalalahanan na wag
hayaan matuyuan ng pawis and likod
nya.”
They believe that illnesses are Illness states: Kulam as Presence of Inability to make decisions with respect
sometimes caused by kulam. They health deficit to taking appropriate health actions
also believe in faith healers and related to:
manggagamot. Their choice on whom a. Failure to comprehend the
to consult during illness depends on nature/magnitude of the problem
what they think has caused the illness. b. Lack of/inadequate
knowledge/insight as to alternative
courses of action open to them
Mang Manny’s Blood pressure got Illness state: Hypertension as Inability to recognize the presence of
160/100. Mang Many stated, “Ay presence of health deficit the condition or problem related to:
ganon ba? Baka napagod lang ako a. Lack of or inadequate knowledge
kasi nagsibak ako ng kahoy kanina, b. Attitude
kasi wala naman
akong nararamdaman ngayon na
kakaiba.”
III. Health Threat
CUES LEVEL 1 ASSESSMENT LEVEL 2 ASSESSMENT
Lola Dionisia’s husband died five Presence of risk factors of specific Inability to provide adequate care to
years ago because of heart attack disease: heart attack as presence of the sick, disabled, dependent or
health threat vulnerable risk member of the family:
Lack of/inadequate knowledge about
the disease/health condition (severity
and nature)
To manage stress, Mang Manny said Unhealthful lifestyle and personal Inability to make decisions with
that he manages stress by drinking habits: Alcohol drinking and cigarette respect to taking appropriate health
alcoholic beverages or smoking as presence of health threat action related to: Lack of/inadequate
sometimes by smoking. knowledge/insight as to alternative
courses of action open to them
Their utensils are stored on an open Poor home/environmental sanitation: Inability to provide a home
dish drainer. Lack of food storage facilities as environment conducive to health
presence of health threat maintenance and personal
development related to: Lack of skill
in carrying out measures to improve
home environment
Their house is about 40 sqm, made-up Poor home/ environmental condition: Inability to provide a home
of light materials and usually gets Inadequate living space and improper environment conducive to health
flood after the rain. drainage system as health threats maintenance and personal
development related to:
a. Lack of/inadequate knowledge of
preventive measures
b. Lack of skill in carrying out
measures to improve home
environment
Ivanah stand 4’11” and weighs 130 Faulty eating habits: Faulty eating Inability to make decisions with
lbs. The computed BMI of Ivannah is habits as health threat respect to taking appropriate health
26.61 kg/m2 and categorized as action related to: Lack of/inadequate
overweight. Mang Manny attributes knowledge/insight as to alternative
this to Ivanah having big bone courses of action open to them
structures since she was “big” even
when she was a baby. Also, Ivanah
manages stress by eating or
sometimes by going out with her
friends.
IV. Foreseeable Crisis
CUES LEVEL 1 ASSESSMENT LEVEL 2 ASSESSMENT
Aling Jengky and his earning are Inadequate earnings as presence of Inability to provide a home
sometimes not enough for their foreseeable crisis environment conducive to health
family’s needs. Also, Mang Manny maintenance and personal
cannot get a regular job. Oftentimes, development related to:
he can only work during weekends, a. Inadequate family resources
holidays and Limited financial resources
vacation, only when Ivanah is there to
take care of her Grandmother.
Prioritization of Problem
I. Health Deficit
Stroke with bedsore as Presence of health deficit
CRITERIA SCORING JUSTIFICATION
Nature of the Problem (3/3)*1=3 This is considered as health deficit
that requires immediate attention
and adequate management in order
to minimize other cause of
diseases. Also, the presence of
bedsore needs an intervention.
Modifiability (2/2)*2= 2 This is highly modifiable because it
can be managed by turning the
position, giving the right medication
and exercising.
Preventive Potential (3/3)*1=1 It is highly preventable if Aling
Dionisia is willing to do the given
interventions. She must not depend
totally to other people. Doing the
interventions (exercising) given to
her even without companion can
help her to have a progress.
Salience (2/2)*1=1 It is high salience since stroke is a
serious disease that can lead to other
complications if not given an
immediate attention.
TOTAL 6
Asthmas as Presence of health deficit
CRITERIA SCORING JUSTIFICATION
Nature of the Problem (3/3)*1=1 It is a health deficit since asthma was
triggered due to the change of
weather and environment.
Modifiability (2/2)*2=1 This is highly modifiable because
asthma can be triggered in many ways
and in order to prevent that is to avoid
the causes of it. Proper sanitation and
proper nutrition can also be helpful.
Preventive Potential (3/3)*1=1 It is highly preventable because
environment can be manipulated by
cleaning the surroundings. Asthma
can be prevented by avoiding its
triggering factors.
Salience (1/2)*1=0.5 Asthma is self-limiting and can be
easily prevented so it does not require
an immediate action. Proper
management of surroundings and
sanitation must be done.
TOTAL 3.5
Kulam as a disease as Presence of health deficit
CRITERIA SCORING JUSTIFICATION
Nature of the Problem (3/3)*1=1 It is considered as health deficit since
their belief about a certain disease and
refer it as “kulam” needs an
immediate health teaching.
Modifiability (½)*2=1 Partially modifiable because it
depends on the family if they will
acknowledge the health teaching.
Preventive Potential (2/3)*1=0.67 It can only be prevented with the help
of the family in considering the given
health teaching.
Salience (2/2)*1=1 High salience since it needs an
immediate action.
TOTAL 3.67
Hypertension as presence of health deficit
CRITERIA SCORING JUSTIFICATION
Nature of the Problem (3/3)*1=3 Hypertension is a Health deficit in
which will cause complications that
requires immediate attention and
adequate management of one’s blood
pressure
Modifiability (1/2)*2=1 Current knowledge, interventions and
resources are available to solve the
problem of high blood pressure or
hypertension. It depends on the
person if he/she will acknowledge the
health teaching.
Preventive Potential (3/3)*1=1 Increase blood pressure can be
prevented through proper health
teaching and proper health
management of hypertension
Salience (2/2)*1=1 The family perceives Hypertension as
a serious problem needing attention
TOTAL 6
II. Health Threat
heart attack as presence of health threat
CRITERIA SCORING JUSTIFICATION
Nature of the Problem (2/3)*1=0.67 It is health threat because Lola
Dionisia’s husband died they might
have it in their gene.
Modifiability (1/2)*2=1 It is partially modifiable because
the family is able to provide
precaution to heart attack but it is
in their gene so it is not enough
and that there are still risks that are
unrecognized.
Preventive Potential (1/3)*1=0.33 It is low because there are factors
that the family cannot do about it
because their family has a history
of heart disease. The family should
see a cardiologist so they can plan
for treatment that will help them
bring that risk down.
Salience (1/2)*1=0.5 The family perceived as a serious
problem as they may acquire heart
diseases.
TOTAL 2.5
Alcohol drinking and cigarette smoking as presence of health threat
CRITERIA SCORING JUSTIFICATION
Nature of the Problem (2/3)*1=0.67 It is a health threat because alcohol
drinking and smoking may cause
another disease. The smoker and as
well as his children of the client are
expose to the smoke which may cause
respiratory diseases such as Chronic
obstructive pulmonary disease,
emphysema and chronic bronchitis.
Modifiability (1/2)*2=1 Partially modifiable since it depends
on the person if he is willing to stop
smoking and drinking alcohol.
Preventive Potential (3/3)*1=1 Highly preventive because the person
can get rid of these vices by giving
him health education regarding
smoking and drinking alcohol.
Salience (2/2)*1=1 High salience because it might affect
other people and can lead to other
diseases, the family perceived this not
a serious problem.
TOTAL 3.67
Inadequate living space and improper drainage system as health threats
CRITERIA SCORING JUSTIFICATION
Nature of the Problem (2/3)*1=0.67 It is a health threat because it can
affect the health of the family.
Modifiability (2/2)*2=2 Highly modifiable since it is the
decision of the family if they will
acknowledge the given health
teaching. Also, the nurse must
coordinate to the community in order
to have a proper drainage.
Preventive Potential (2/3)*1=0.67 Moderately preventive since it
depends on the community if they
will collaborate with the health
teaching.
Salience (2/2)=1 It requires an immediate action in
order to prevent other diseases.
TOTAL 4.34
Faulty eating habits as health threat
CRITERIA SCORING JUSTIFICATION
Nature of the Problem (2/3)*1= 0.67 It is a health threat because faulty
eating can cause other complications
such as obesity.
Modifiability (2/2)*2= 2 It is highly modifiable because
through health teaching about proper
management of stress and eating
habits it can be modified.
Preventive Potential (3/3)*1= 1 Highly preventive through giving
alternative option such eating
nutritious food.
Salience (2/2)=1 It needs an immediate intervention to
prevent other complications.
TOTAL 4.67
Lack of food storage facilities as presence of health threat
CRITERIA SCORING JUSTIFICATION
Nature of the Problem (2/3)*1= 0.67 It is a health threat because poor
sanitation can lead to link of
transmission of diseases such as
cholera, diarrhea, dysentery, hepatitis
A, typhoid and polio and exacerbates
stunting.
Modifiability (1/2)*2= 1 It is modifiable because it can be done
through teaching and demonstration
Preventive Potential (3/3)*1= 1 It is highly preventable since poor
sanitation can be managed through
cleaning and providing a closed
container for storing utensils.
Salience (2/2)=1 Cleaning and storing properly may
prevent to cause further complication
or disease.
TOTAL 3.67
III. Foreseeable crisis
Inadequate earnings as presence of foreseeable crisis
CRITERIA SCORING JUSTIFICATION
Nature of the Problem (1/3)*1=0.33 It is considered as foreseeable crisis
because they can’t sustain and don’t
have enough to provide their needs.
Modifiability (1/2)*2=1 It is partially modifiable because even
if they don’t have enough financial
resources they can go to barangay
health centers to get medications and
have check ups
Preventive Potential (3/3)*1=1 Highly preventive if they are willing
to comply with the interventions.
Salience (2/2)*1=1 Needs an immediate action in order to
provide their needs and sustain their
living.
TOTAL 3.33
Family Care Plan
Family Diagnosis:
Inability to provide adequate nursing care to the sick, disabled, dependent member of the family related to:
a. Inadequate family resources for care such as financial constraints
b. Lack of inadequate knowledge and skill in carrying out necessary treatment/interventions
GOALS AND FAMILY RATIONALE RESOURCES NEEDED
OBJECTIVES INTERVENTIONS
