OLIVAREZ COLLEGE TAGAYTAY

E. Aguinaldo Highway, San Jose, Tagaytay

College of Nursing and Health Related Sciences 

Family Name: Pagal Family

Address: Purok 1, Barangay Iba Ibaba Silang, Cavite
 
I. Demographic data:        
Household number:   040                                     Brgy. House number: 
 
II. Family Data:
Length of residency: 34 years
Place of origin: Masbate
Family size: 6(six)
Religion: Roman Catholic
               Husband: Roman Catholic
               Wife: Roman Catholic
Family Member’s Chart:

Family Age Sex Civil Position in  Relationship Educational  

Member’s (yrs./mo.) (M/F) Status Family to family head Attainment Occupation
Name

Elna Pagal 34years old F Married Mother Wife 2nd year high school N/A

Mark Lenard 31 years old M Married Father Head of the family Elementary graduate Fish vendor
Pagal

Mark Joseph 11 M Single 1st born Son Grade 2 N/A

Pagal

Angela Pagal 7 F Single 2nd born Daughter Grade 1  N/A

Angelo Pagal 7 M Single 2nd born Son Grade 1 N/A

Baby Shell Pagal 4 F Single 3rd born Daughter N/A N/A

 Monthly Family Income Source:
A. Husband: Estimated 12,000Php
B. Wife: N/A
C. Others:N/A
Monthly Family Income Sources Total: (check bracket)
    〇  Below Php 5,000.00
    〇  Above Php 5000.00 – 9,999.99
    〇  Above Php 10,000.00 – 14,999.99
    〇  Above Php 15,000.00 – 19,999.99
    〇  Above Php 20000.00 – 29.999,99
    〇  Above Php 30000.00 – 39999.99
    〇  Above Php 4000.00 – 49,999.99
    〇  More than 50,000.00
 
III. Family Characteristics:
Type of family structures:
      〇  Nuclear 
      〇  Extended
      〇  Patriarchal
      〇  Matriarchal
      〇  Patrilocal
      〇  Matrilocal
      〇  Bilocal
      〇  Others, specify:    
Dominant family member: Husband
General family relationship/dynamics:
A. Observations conflicts between family members: Third party/ Adultery
B. Characteristics of communication: Direct communication
C. Interaction pattern among members: They talk to each other with respect.
Family traditions, events, or practices that may affect members’ health or family
functioning: whom do you consult for health-related problems?
    〇  Doctor 
    〇  Nurse
    〇  Midwife
    〇  Barangay health workers
    〇  Health center
    〇  Albularyo
    〇  Manghihilot
    〇  Others, specify:
 
For problems other than health, whom do you consult?
     〇  Family members
     〇  Relatives
     〇  Friends
     〇  Priest
     〇  Brgy. Officials
     〇  Others, specify:
Others:

Ecogram (relationship of the family to larger community)

Health Iba,
Center Elementary
jjj (RHU) School
 Pagal

Silang
Market

IV. Home and environment

A. Is your lot owned?
      .       yes                                                        .  ✓       no
B. Is your house owned?
      . ✓      yes                                                        .         no
C. Type of housing materials
      .  ✓     Wood                                                   .        Makeshift
      .       Concrete                                               .        others, specify:
D. Is the living space adequate?
      .   ✓    yes                                                       .         no
E. Number of rooms used for sleeping       1      .
F.  Type of lighting facilities:
      .  ✓     electricity (Jumper)                                             .        candle
      .       kerosene                                             .         others, specify:
G. What are the appliances owned by the family?
1. Refrigerator
2. Television
3. DVD
4. Speaker
H. Type of water supply:
      .       owned                                                   .    ✓    bought (Nawasa)
I. Drinking water storage:
      .  ✓     covered                                                 .        refrigerated
      .       uncovered                                             .        others, specify:
J. Containers used
      .       pitchers                                                 .         jars or clay pots
      .       bottles                                                   .     ✓   others, specify: Water
gallon
K. Food storage/cooking facilities:
      .   ✓    covered                                                 .     ✓    stove (electric/gas)
      .       uncovered                                              .        firewoods/charcoal
      .   ✓    refrigerator                                         .         others, specify:
L. Type of garbage disposal
      .       collected                                                .         burial in pit
      .       segregation                                            .         hog feeding
      .    ✓   open dumping                                        .        composting
      .    ✓   open burning                                          .        others, specify:
M. Type of waste disposal
      .       flush type                                               .         balot system (wrap and
throw)
      .       water-sealed latrine                               .         pail system
      .       pit privy                                                  .    ✓    others, specify: Chamber
pots
N.  Type of drainage system?
      .   ✓    open                                                       .        closed
O. Pets/animals kept in the yard/home
1. Dog ( not vaccinated)
2. Cat
P. Common household pests found at home:
1. Cockroaches
2. Snake
3.Mosquito
 4. Rat
Q. Are there breeding sites of insects, rodents, etc present?
      .    ✓   yes                                                        .         no
R. Are there any accident hazards present?
      .     ✓  yes                                                        .         no
S. Kind of Neighborhood: Joyful, “Marites”
 
T. Social and health facilities available: Center (RHU)
 
U. Communication facilities: Cellphone
 
V. Transportation facilities: Tricycle
 
V. Awareness of community organization
A. Are you aware of existing organizations in the community?
      .       yes                                                        .     ✓    no
B. List/name all organizations you know
N/A
C. Are you a member of any of these organizations?
      .       yes                                                        .     ✓    no
D. Are you aware of its activities and projects?
      .       yes                                                        .     ✓    no
E. How are you involved in its activities? N/A
      .       attend meeting                                     .        planning
      .       give donation                                         .        implementation
      .       give advice                                            .        others, specify:
F. Name five(5) leaders (formal and non-formal of the community whom you think can
lead the people.
1.  Maam Jona
 
VI. Health status of each family member
A. Medical and nursing history
Present health history (symptoms analysis (PQRST) for a sick member of the
family)
Past Health History

                   Common illness encountered for the past six (6) months and the treatment
applied
Common illness Treatment
 Fever Ambroxol
Cough Amoxicillin
Common colds Solmux

Immunization status of the family members

Name of child Immunization received Date received

Mark Joseph Pagal  Not vaccinated  
Angela Pagal Not vaccinated  
Angelo Paga Not vaccinated  
Baby Shell Not vaccinated  
     

B. Family health status/Health history (genogram)

Marlene Joseph Leni

Junion Pagal Garcia Garcia
Pagal
60yrs old 56 yrs old
 v
Marvin Alvin Michea
Mark Joan Joan Mariss Elna Wendy
Pagal Pagal Pagal a Elmar l
Lenard Pagal Garcia Pagal Garcia
28yrs 26 yrs 23yrs 20 yrs 35 yrs Garcia Garcia 27 yrs
31yrs old 34 yrs
old old old old old 32 yrs old 30 yrs old
old
old

Mark Joseph Angela Baby Shell

Angelo Pagal
Pagal Pagal 4 yrs old
11 yrs old
7 yrs old
7 yrs old

C. Review symptoms of systems for each family member includes 1) past and
present health, 2) checks significant data omitted under present illness (for sick
member), 3)evaluates health promotion (HP)

 
Father Mother Child 1 Child 2
 1hr 1hr  8-10hrs 8-10hrs
SKIN: (HP sun exposure)
    Lice Lice Lice
hair 
     
head
  Yellowish  
Eyes (HP-glasses/contacts)
     
Ears (HP hearing loss, aids, exposure to noise)

      Common
Nose and sinuses Colds
   Missing tooth in canine Missing Missing
Mouth and throat (HP dental care) part molar incisors
above
     
neck
     
Breast (HP BSE)
     
axilla
  Dyspnea  
Respiratory system (HP-chest x-ray)

     
Cardiovascular (HP-WCG/heart tests)

     
Peripheral vascular (HP-sitting/standing-support hose)

    Diarrhea Diarrhea
Gastrointestinal: (HP-antacids, laxatives,diet history)

      Urinary
Urinary system (HP-prevention of urinary tract infection) tract
infection
(UTI)
     
Genitals:

female (HP-GYNE exam,pap smear)

sexual health

     
Musculoskeletal system (HP-interpersonal relationships,
coping)

     
Neurological system (HP-interpersonal relationships,
coping)

     
Hematologic
     
Endocrine

 
D. Functional Assessment
COMPONENTS Father  Mother Child 1 Child 2
    
SELF CARE ABILITIES `

ADL’S
     
PERSONAL HABITS:

Alcohol use:
✓

Tobacco use: ✓
Medications:

(use of illegal drugs)

 
NUTRITION AND METABOLIC PATTERN         

Usual food intake  Rice, Fish,

Rice, Fish, Vegetables  Rice, Fish, Rice, Fish,
Breakfast Vegetables
Vegetables Vegetables
Lunch

Dinner

Preferences

usual fluid intake 2 glasses of 2 glasses of 2 glasses of

water 2 glasses
Any problem with the ability to eat water water of water
 

Any supplements (Vitamin, feeding)   Celin Celin

   

   

 
ELIMINATION PATTERN
3 2 1 1
Bladder
2 2 2 2
Bowel
 
ACTIVITY EXERCISE PATTERN N/A N/A N/A N/A

Usual daily/weekly activities:

   
Any limitations of physical ability:

 
✓
history of dyspnea or fatigue

 
SLEEP REST PATTERN
 

Usual sleep pattern

9 pm 7 pm 7 pm 7 pm
No. of pillows
2 4 1 1
Sleep routines

Any problems regarding sleep

     
COGNITIVE PERCEPTUAL PATTERN

Any deficits in sensory perception (hearing, sight, touch)

Ability to read and write. Any difficulty in learning?

Any complaints? (e.g. pain)

     
SELF PERCEPTION PATTERN: Health goals: Effect of
present illness on the self (for sick member)

How does the client see/feel about self?

ROLE RELATIONSHIP PATTERN  

Language spoken Tagalog  Tagalog Tagalog Tagalog

Manner of speaking

Significant person to client Parents

Complaints regarding family

Living with (member of the family)

      
SEXUALITY SEXUAL FUNCTION 

anticipated change in sexual relations because of illness (for

ill member)

knowledge of sexual functioning  ✓ 2x in a

week

COPING STRESS MANAGEMENT PATTERN      

       

Decision making ability      

       

any significant stress in the past year    3rd party  Bullying Bullying

     

management of stress    “Chismisan”  

   

expectations from nurses  

     
VALUE BELIEF SYSTEM

 
God
Source of strength or meaning

 
E. Development assessment of infants, toddlers, and preschoolers (MMDST)
F. Physical assessment of each member of the family.

AREAS METHOD NORMAN DEVIATIONS ACTUAL ACTUAL Child 1 Child 2

ASSESSE FINDINGS FROM FINDINGS FINDINGS
D NORMAL Angela Angelo
   Mother
Hair /scalp Inspection  Hair must be Patchy areas, Scalp is  Scalp is Scalp is Scalp is
moisturized and loss hair, brittle, symmetrical and symmetrical symmetrical symmetrical
palpation  evenly dry and no no presence of and no and no and no
distributed presence of lesions. presence of presence of presence of
parasite lesions. (+) lesions.(+) lesions. (+)
lice lice lice
 

Scalp must be
symmetrical,
smooth, firm,
and no presence
of lesions,

Head Inspection Skull is Uneven Skull is  Skull is Skull is Skull is

normocephalic, molding, symmetrical. symmetrical symmetrical symmetrical
Palpation symmetrical, asymmetrical
features masses,
appropriate enlarged head,
for the size, the hydrocephalus,
head may have microcephaly
odd shape due
to the molding
of childbirth

Face and Inspection  Shape may be face a bump or Face shape is Face shape is Face shape is Face shape
cranial oval soft, lumps on asymmetrical;Has asymmetrical asymmetrical is
nerves V Palpation or rounded; the lesions no involuntary ;Has no ;Has no asymmetric
and VII face is observed, movements. involuntary involuntary al;Has no
symmetrical: no asymmetrical, movements. movements. involuntary
involuntary distorted movements.
movements features.

Nose Inspection Nose is Lesions, Nose has no  Nose has no Nose has no Nose has
symmetric and asymmetrical, presence of presence of presence of (+)
Palpation straight, there is redness, discharge and is discharge discharge and discharg
no discharge dryness, or symmetrical. The and is is e and is
present and the cracked, color is the same symmetrical. symmetrical. symmetri
color is the tenderness as the face  and The color is The color is cal. The
same as the has no lesions. the same as the same as color is
face, no the face  and the face  and the same
tenderness and has no has no as the
lesions were lesions. lesions. face  and
observed and has no
palpated. The lesions.
nasal system is He has a
intact and in the nevi
midline. A red
glow is seen in
the maxillary
and frontal
sinus during
light
illumination. 
Eyes and Inspection (+) PERRLA, (-) PERRLA, (+) PERRLA  (+) (+) PERRLA (+)
Vision the sclera is asymmetrical PERRLA PERRLA
Palpation white no edema blink, The sclera is The sclera is
or tearing, incomplete white. (+)yellowish white. The sclera is
palpebral closure, rapid . white.
conjunctivae are blinking, The eyes has no The eyes has
smooth and irregular shape, involuntary The eyes has no The eyes
pinkish red, no inconsistent movements and no involuntary has no
discharge and color, cloudy are symmetrical involuntary movements involuntary
tenderness lens, jerky eye when blinking. movements and are movements
noted upon movements.  and are symmetrical and are
palpation of the symmetrical when symmetrical
lacrimal sac, the when blinking. when
cornea is blinking. blinking.
transparent,
shiny smooth
and blinks when
it is touched.

Mouth Inspection Lips are moist, Asymmetrical Lips are moist and  Lips are Lips are Lips are
red and smooth, mouth, dry, smooth, gums are moist and moist and moist and
Palpation gums are pink, pale lips, pink, and the smooth, smooth, smooth,
tongue is at the bleeding, white tongue is at the gums are gums are gums are
center and patches, broken center and moves pink, and the pink, and the pink, and
slightly rough teeth, dental freely. tongue is tongue is the tongue
on top, it moves caries ulcers at the center at the center is at the
freely, teeth are present presents   and moves and moves center and
not yet of lesions. freely. freely. moves
completely Note: Cavity on Missing Missing freely.
erupting, soft the left 2  molar
nd
tooth in tooth in Missing
palate is color tooth. canine molar. tooth in
pink and hard incisors
palate is lighter above.
in color and
positioned in
the midline.
Pink and
soothing and no
discharge;
Consistency is
even.
 Ears and Inspection Ears must be Pinna Ears are equal in  Ears are Ears are Ears are
Hearing equal in size positioned size and similar in equal in size equal in size equal in size
Palpation and similar in below a line appearance and and similar and similar in and similar
appearance, from a comet of have no presence in appearance in
auricles have auricles have of discharge. appearance and have no appearance
the same color the same color and have no presence of and have no
with the facial with the facial presence of discharge. presence of
skin. They are skin. They are discharge.. discharge.
symmetrical symmetrical
and aligned and aligned
with the outer with the outer
canthus of the canthus of the
eye; they are eye;they are
firm and not firm and not
tender, no tender, with no
presence of presence of
discharges. discharges.

Neck Inspection Muscles equal Muscles equal The Head is at the  The Head is The Head is The Head is
in size head in size head center. at the center. at the center. at the
Palpation centered. centered. center.
Coordinated Coordinated Coordinated
    muscle movement muscle muscle Coordinated
and there's no pain movement movement muscle
coordinated Coordinated when moving. and there's and there's no movement
muscle muscle no pain when pain when and there's
movement movement and moving. moving. no pain
and there’s no there’s no pain when
pain when when moving moving.
moving.
 
 
Lymph nodes
Lymph nodes are not
are not palpable.
palpable.

There is no
tenderness, no
palpable lumps
or masses, color
is the same as
the face.

 
UPPER EXTREMITIES

AREAS METHOD NORMAL DEVIATION ACTUAL ACTUAL Child 1 Child 2

ASSESSED FINDINGS FROM FINDINGS FINDINGS
NORMAL Angela Angelo
   Mother

Musculoskeletal Inspection Able to Bone Able to  Able to Able to Able to perform

structure perform deformity, perform ROM perform ROM perform ROM ROM
Palpation ROM muscle exercises. exercises. exercises. exercises.Bone
 exercise, the atrophy, not deformity in
ches is able to right forearm.
symmetric, perform ROM
spine exercises;
vertically limited ROM
aligned chest asymmetrical.
wall intact,
no
tenderness,
no masses. 

Number of
fingers per
each hand is
five

Skin Inspection Uniform in Presence of Skin is  Skin is Skin is Skin is uniform

color, no lesions, uniform in uniform in uniform in in color and has
Palpation lesion, no deformities color and has color and has color and has no presence of
deformities, no presence of no presence of no presence of lesions and (+)
same color lesions and lesions and lesions and scars.
and deformities. deformities. deformities.
temperature Same
as other Same Same Same temperature.
body parts, temperature. temperature. temperature.
skin springs
back to
previous 

Nails Inspection Symmetrical, Pallor Nails are Nails are Nails are Nails are
equal in cyanotic nails: symmetrical symmetrical symmetrical symmetrical and
length, yellow and equal and equal and equal equal in length.
pinkish in discoloration;  in length. in length. in length.
color. Capillary refill
Capillary beau lines; Capillary refill Capillary refill Capillary refill is normal.(Turns
refill; prompt clubbing;  is normal. is normal. is normal. to pinkish color
return of (Turns to (Turns to (Turns to in less than 3
pink (less thickened pinkish color pinkish color pinkish color seconds when
than 3 sec) nails in less than 3 in less than 3 in less than 3 pressed)
seconds when seconds when seconds when
pressed) pressed) pressed)

 
ANTERIOR CHEST 

AREAS METHOD NORMAL DEVIATION ACTUAL ACTUAL Child 1 Child 2

ASSESSED FINDINGS FROM FINDINGS FINDINGS
NORMAL Angela Angelo
   Mother
 Breast  Inspection  Breast even Gynecomastia, Symmetrical Symmetrical Symmetrical Symmetrical
with chest wall swelling chest wall. chest wall. chest wall. chest wall.
Palpation  symmetrical, ulcerations,
color, varies irregular hard
from light pink modules. 
to dark brown,
no discharge,
no masses, no
modules, no
tenderness

Axilla  Inspection No masses, Hair nodules No mass No mass No mass No mass

tenderness, or masses,
Palpation  modules  tenderness
noted upon
palpation

Precordium  Inspection Absence of Murmurs, Absence of  Absence of Absence of Absence of

abnormal heart tachycardia, murmurs and murmurs and murmurs and murmurs and
Auscultation  sounds, bradycardia, abnormal abnormal abnormal abnormal
rhythm, and snap split heart sound. heart sound. heart sound. heart sound.
Palpation  murmurs sounds, thrills
upon palpation 
 

Point of
maximal
impulse is
taping, 7 cm
lateral to the
midsternal line
in the 5th
intercostal
space 

 
ABDOMEN

AREAS ASSESS METHOD NORMAL DEVIATION ACTUAL ACTUAL Chold 1 Child 2

ED FINDINGS FROM FINDINGS FINDINGS
NORMAL Angela Angelo
   Mother

Abdomen Inspection Flat, rounded Generalized No scars and the  There has a No scars No scars
(convex) or abdominal color of the skin scars of and the and the
Palpation scaphoid distention, is the same. stitch due to color of color of
(concave) in asymmetrical cesarean the skin is the skin is
Percussion  shape with organ section the same. the same.
symmetric enlargement  delivery
contour, same and the
color with the color of the
body, no scars, skin is the
good same.
 skin turgor, no
masses, no
lumps, no
tenderness

Liver, spleen, Percussion  Liver span is 6 Liver span is Liver span is Liver span Liver Liver
kidneys to 12 cm in the greater than greater than is greater span is span is
right MCL. 12cm in the right 12cm in the right than 12cm greater greater
Liver span is 4 MCL with MCL with in the right than than
to 8 cm in enlarged liver. enlarged liver. MCL with 12cm in 12cm in
midsternal Dullness extends Dullness extends enlarged the right the right
line: non above the 6th above the 6th liver. MCL MCL
tender, no rib.  rib.  with with
masses enlarged enlarged
    liver. liver.
  Enlarged spleen.
Enlarged spleen. percussed note
Spleen; small percussed note become dull;
area of become dull; painful upon
dullness and painful upon palpation,
6th  to 10th palpation, superficial
ribs: tympanic superficial masses,  spleen
on inhalation; masses,  spleen enlargement 
not normally enlargement 
palpable;
nontender 

Kidneys: not
normally
palpable,
nontender, no
masses, no
increase in
abdominal
girth, level of
dullness does
not change 

 
POSTERIOR CHEST 

AREAS METHOD NORMAL DEVIATION ACTUAL ACTUAL Child 1 Child 2

ASSESSED FINDINGS FROM FINDINGS FINDINGS
NORMAL Angela Angelo
   Mother
 Musculoskeletal Inspection  Skin is intact; Pallor, cyanosis, Skin is Skin is Skin is Skin is
structures  spine is bulging intact and intact and intact and intact and
vertically retracting spine is spine is spine is spine is
aligned; shoulder intercostals vertically vertically vertically vertically
and hips are at spaces, aligned. aligned. aligned. aligned.
same height   asymmetrical;
depressed or
projecting
sternum; spine
not aligned.

Posterior thorax Palpation  Symmetrical, Pain, tenderness No No No No

and lungs  fair complexion, asymmetrical, deformities deformities deformities deformities
no deformities, tactile fremitus and no and no and no and no
no lesion, skin is increased or lesions. lesions. lesions. lesions.
intact, uniform decreased
temperature. asymmetrical
Bilateral expansion
symmetrical of adventitious
vocal fremitus sounds 
and it is heard
most clearly at
the apex of the
lungs. No
adventitious
sounds. 

 
LOWER EXTREMITIES 

AREAS METHOD NORMAL DEVIATION ACTUAL ACTUAL Child 1 Child 2

ASSESSED FINDINGS FROM FINDINGS FINDINGS
NORMAL Angela Angelo
   Mother

Musculoskeletal Inspection  Equal in Asymmetrical, Asymmetrical Asymmetrical Asymmetrical Asymmetrical

structures  length, deformities, in length, no in length, no in length, no in length, no
Palpation  symmetrical, lesions, lesions. lesions. lesions. lesions.
no lesions, no masses
deformities,
minimal or
moderate hair
distribution 

Skin Inspection Uniform in Presence of Uniform in  Uniform in Uniform in Uniform in

color, no lesions, color, no color, no color, no color, (+)
Palpation lesions, no deformities; lesions, no lesions, no lesions, no lesions and
deformities, pallor, deformities. deformities. deformities. (+)abrasion,
same color flushed; Has presence Has presence no
and bluish; loss of Same of scars. of scars. deformities.
temperature
 temperature red tones; as other body Same Same Has presence
as other body generalized parts. temperature temperature of scars.
parts, skin pale yellow; as other body as other body
springs back pigmented parts. parts. Same
to previous areas; rough, temperature
state thick as other body
immediately parts.
when pinched

Nails  Inspection Symmetrical, Pale or Symmetrical, Symmetrical, Symmetrical, Symmetrical,

equal in cyanotic nails, equal in equal in equal in equal in
length, yellow length, length, length, length,
pinkish in discoloration, pinkish in pinkish in pinkish in pinkish in
color beau lines, color color color color
clubbing,
thickened
nails 

Musculoskeletal Inspection  Able to do Bone Limited Limited Limited Limited

functions  flexions and deformity, ROM. ROM. ROM. ROM.
ROM muscle
atrophy, not
able to
perform ROM
exercises,
limited ROM,
asymmetrical 
 
Genitals  Inspection  Pubic skin Nodules, Pubic skin
intact, no growths, intact, no
lesions, no lesions, lesions, no
inflammation, drainage inflammation,
no swelling, chancres, no swelling,
no discharge  enlarged with no discharge
tenderness as described
purulent by the client.
discharges 
 
Anus/rectum Inspection Intact anal Sphincter Intact anal
skin, anal tightens, skin, anal
sphincter has tenderness, sphincter has
good tone hemorrhoids, good tone as
nodules, described by
hardness the client.
 
G. Laboratory and diagnostic findings supportive to assessment findings (if any).

VII. DATA ANALYSIS
CLASSIFICATION SIGNIFICANT DATA SECOND FAMILY
LEVEL ASSESSMENT NURSING PROBLEM
PRESENCE OF WELLNESS   Active in health center    
CONDITION (potential/readiness)  Balanced meal
HEALTH DEFICIT   Dislocated arm    
 Lice infestation
HEALTH THREAT   Risk for fall    
 Environmental hazard (fire
 and flashflood)
 Possible skin diseases
 Animal attack
 Pest infestation
 Dental cavities
STRESS POINT/FORESEEABLE   3rd party    
CRISIS  Picky in food
 Unvaccinated
 Alcoholic and smoker
 Bullying
 

VIII. Family nursing health condition

a. Prioritizing health condition
   Health condition/problem #: 
criteria computation Actual score justification
Nature of the problem      
Modifiability of the problem      
Preventive potential      
Salience of the problem      
 
b. Family nursing care plan
Family nursing problem goals objectives Intervention plan Evaluation plan
Nature of the problem        
Modifiability of the problem        
Preventive potential        
Salience of the problem