LEVEL OF HEALTH ASSESSMENT

A. ASSESSMENT
Data collection
Data analysis
Nursing Diagnosis
Assessment/Collection
I. FIRST LEVEL ASSESSMENT/Data Collection
I.a. Initial Data Base
o Sorting of problems according to
✔ Wellness states

✔ Health Threats

✔ Health Deficit

✔ Stress points or foreseeable crisis

I.b. Data collection
o Methods
✔ Observation: Use of sensory capacities

✔ Physical Examination: Data on health status

obtained during direct examination
✔ Interview: Completion of health history; Asking
questions regarding health on the members
✔ Record Review: Reviewing records like charts,
lab/ diagnostic results
✔ Laboratory / Diagnostic Tests: Actual
performance of examination to support the
✔ Diagnosis

FIRST LEVEL ASSESSMENT PROCESS

● Process whereby existing and potential health conditions or problems of the family were
determined.

I. FIRST LEVEL ASSESSMENT: COLLECTION OF DATA FOR INITIAL

DATABASE

A. FAMILY STRUCTURE, CHARACTERISTICS AND DYNAMICS

● Tabular form
○ Name

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 ○ Age
○ Sex
○ Civil status
○ Position in the family
○ Relationship to the head of the family
● Textual form
○ Place of residence
○ Types of family structure
○ Dominant family members in decision making
○ General family relationship dynamics
✔ Presence of conflicts

✔ Characteristics of communications and interaction

patterns

B. SOCIO-ECONOMIC AND CULTURAL CHARACTERISTICS

● Textual form
o Income and Expenses
✔ Occupation, place of work and income of each working
member
✔ Adequacy to meet basic needs

✔ Decision making in terms of finances

o Educational attainment of each member
o Ethnic Background and religious affiliation
o Significant others – Role(s) they play on the family’s life
o Relationship of the family to the community

C. HOME AND ENVIRONMENT

● Textual form
o Housing
✔ Adequacy of living space

✔ Sleeping arrangement

✔ Presence of breeding or resting site of vector diseases

✔ Presence of accident hazards

✔ Food storage and cooking facilities

✔ Water supply – source, ownership, potability

✔ Toilet facility – type, ownership, sanitary condition

✔ Garbage /refuse disposal – type, sanitary condition

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 ✔ Drainage system – type, sanitary condition
o Kind of neighborhood – e.g. congested, slum, etc.
o Social and health facilities available
o Communication and transportation facilities available

D. HEALTH STATUS OF EACH MEMBER

● Textual Form
o Medical and nursing history
o Nutritional Assessment
Anthropometric data

✔ Weight

✔ Height

✔ Mid-upper arm circumference

✔ BMI

Dietary history

Eating/ feeding habits/ Practices

o Developmental assessments of infants, toddlers and
preschoolers
MMDST
o Risk factor assessment
o Physical Assessment
o Results of laboratory/ diagnostic exams
o Supportive of assessment findings
E. VALUES, HABITS, PRACTICES ON HEALTH PROMOTION, MAINTENANCE, AND
DISEASE PREVENTION
● Textual Form
o Immunization status of family members
o Healthy lifestyle practices
o Adequacy of:
✔ Rest and sleep

✔ Exercise and activities

✔ Use of protective measures

✔ Use of promotive – preventive health services

FIRST LEVEL ASSESSMENT: SORTING OF THE COLLECTED DATA

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● By using the Typology of nursing problems in family nursing practice
● Sort according
✔ Presence of wellness condition

✔ Presence of Health Threat

✔ Presence of Health Deficit

✔ Presence of Stress points / Foreseeable crisis Situations

● Tabular form
o Two columns
✔ Cues / Data

✔ First Level Assessment

● WELLNESS CONDITION
o A clinical nursing judgment about a client in transition from a specific level of
wellness or a capability to a higher level
✔ Wellness potential –based on client’s performance, current competencies
or clinical data but no explicit expression of client desire.
✔ Readiness for enhanced potential – based on a client’s current
competencies or performance, clinical data and explicit desire to achieve
higher level of state
● HEALTH THREAT
o Conditions that are conducive to disease and accident, or may result to failure to
maintain wellness or realize health potential
● HEALTH DEFICIT
o Instances of failure in health maintenance
o Actual illness state
● STRESS POINTS/ FORESEEABLE CRISIS
o Anticipated periods of unusual demand on the individual or family in terms of
adjustment/ family resources.

Illustration of First Level Assessment Sorting

Cues/Data First Level Assessment

Presence of Health Threats
●Nine members stay in a two-room house, each room Inadequate living space

with a dimension of 3 meters by 3 meters Inadequate family income

●Family income is 500 pesos per day

Garbage disposal is dumping in an open pit situated at Improper garbage disposal

the back of the house, two meters away; with plenty of

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 flies all over

Cues/Data First Level Assessment

Presence of Health Deficit
● Rina, three years old, weighs 10 kgs.; looks pale, Malnutrition

lethargic and apathetic; markedly underweight and

undernourished
●Rina is small in built since she was a baby. Not fond

of eating”
● Three preschool members usually left to the care of 8-

year old sister when parents are working and older

children at school
● Mother is very busy helping earn a living
● Family income is 500 pesos a day

SECOND LEVEL ASSESSMENT PROCESS

II. SECOND LEVEL OF ASSESSMENT: DIAGNOSING

● Data analysis and nursing diagnosing
● Identification of specific nursing problems
● During the interview
o Determine if the family recognize the existence of the condition or the problem
o If it is recognized, determine if something has been done
o Determine if the family encounters other problems in the implementation of the
interventions
o Determine how all the other members are affected by the problem

FIVE TYPES OF FAMILY NURSING PROBLEM

● Inability to recognize the presence of the condition/ problem due to...
● Inability to make decisions with respect to taking appropriate health action due to...
● Inability to provide nursing care to the sick, disabled, or dependent member of the
family due to...

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 ● Inability to provide a home environment which is conducive to health maintenance and
personal development due to...
● Failure to utilize community resources for health care due to…

SECOND LEVEL ASSESSMENT

Cues/Data Second Level Assessment

Health Deficits (from the first level assessment)
●37-year-old mother of seven at 21 A. Possible Complicated Pregnancy

weeks age of gestation 1. Inability to recognize presence of a possible

●BP 140/90 and slight bipedal edema complication of pregnancy due to lack of
knowledge
2. Inability to provide adequate nursing care to a
pregnant member due to:
a. Lack of knowledge on the nature and
management of the health condition
b. Lack of knowledge on the nature and extent
of nursing care needed