Institute of Nursing

Far Eastern University

N. Reyes St., Sampaloc Manila
S.Y. 2020-2021

Community Health Nursing 1 (Family and Individual)

Concept: Family Nursing Process - Family Nursing Care Plan
By: Dr. Judith J. Sugay

I. Module Introduction
This module focuses on the development of the nursing care plan which is the next step
in the application of the nursing process. This comes after conducting an assessment, when
the family nursing problems on wellness state, health deficit, health threat, or foreseeable
crisis have been identified. In planning phase of the family health nursing process, the nurse
enhances his/her foresight for teamwork and coordination to ensure coordination of services
and be able to provide adequate and continuous care to the family.
II. Learning Outcomes:
After an hour of completing this module, students are expected to write a family nursing
care plan, specifically:
• Prioritize health problems
• Establish goals
• Develop objectives
• Write a Family Nursing Care Plan (FNCP)

III. Content
Family Nursing Care Plan
Promotes systematic communication in settings where there is a frequent turnover of staff
or where there are several health workers providing care to the same family. This is also
known as the basis or blueprint of health care services provide to the client.
In Planning phase, the development of a care plan consists of the following: (1) Prioritized
health condition(s)/problems; (2) Goals and objectives of nursing care; (3) Intervention
plan; and (4) Evaluation plan.

Four Steps in Developing a Family Nursing Care Plan (Show a diagram in ppt)
1. Prioritized health condition/s or problems

The bases for the formulation of goals and objectives of nursing care. Given a numerous
family health problems that the nurse can address in a specific period, she can rank the
identified health problems into priorities through the use of the Scale for Ranking Health
Conditions and Problems according to Priorities (Bailon and Maglaya, 1990). This tool aims
to facilitate decision-making in determining the family nursing problems that can be

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 addressed by the nurse with the family. The arithmetic computations utilized in the scale can
guide novice nurses or students who needs to gain the skill in deciding which factors have
more weight over others. The computation aid to systematize priority setting by determining
a specific score for each problem on the list. The nurse considers several factors to be
objective in the decision-making process when setting priorities (see table number 1).

Four Criteria in determining priorities among health condition(s)/problems:

1. Nature of the condition or problem presented: categorized into wellness state/potential,

health threat, health deficit and foreseeable crisis.
2. Modifiability of the condition or problem: refers to the probability of success in
enhancing the wellness state, improving the condition, minimizing alleviating, or totally
eradicating the problem through interventions.
3. Preventive potential: refers to the nature and magnitude of future problems that can be
minimized or totally prevented if an intervention is done on the condition or problem under
consideration.
4. Salience: refers to the family’s perception and evaluation of the condition or problem in
terms of seriousness and urgency of attention needed or family readiness.

TABLE 1. SCALE RANKING HEALTH CONDITIONS AND PROBLEMS ACCORDING TO

PRIORITIES
Criteria Weight
1. Nature of the condition or problem
Scale**Wellness state 3
Health deficit 3 1
Health threat 2
Foreseeable crisis 1
2. Modifiability of the condition or problem
Scale** Easily modifiable 2 2
Partially modifiable 1
Not modifiable 0
3. Preventive potential
Scale** High 3 1
Moderate 2
Low 1
4. Salience
Scale** A condition or problem, 2 1
needing immediate attention
A condition or problem not 1
needing immediate attention
Not perceived as a problem 0
or condition needing change
Scoring
1) Decide on a score for each of the criteria.

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 2) Divide the score by the highest possible score and multiply by the weight:
(Score/Highest Score)x Weight
3) Sum up the scores for all the criteria. The highest score is 5 equivalent to the total
weight.

❖ Developed by Salvacion G. Bailon and Araceli S. Maglaya. For details see article:
“Tools and Guidelines for Nursing at the Family Level:. The Anphi Papers,
22(1):13,1997. Updated by A.S. Maglaya in 2003
❖ Figures (0,1,2,3) for the weights and scale values are arbitrary, dictated more by
convenience in computation.

Factors affecting Priority- Setting

1. Nature of the condition/problem:

• the biggest weight is given to wellness or potential state to recognize the client’s
effort or desire to sustain/maintain high level wellness.
• The same weight is assigned to health deficit because of its sense of clinical
urgency which may require immediate intervention.
• Foreseeable crisis is given the least weight because culture linked variables
usually provide our families with adequate support to cope with
developmental/situational crisis.
2. Modifiability of a health condition/problem: The nurse considers the following factors:
• Current knowledge, technology, and intervention to enhance the wellness state
or manage the problem.
• Resources of the family: physical, financial, and manpower
• Resources of the nurse: Knowledge, skills, and time
• Resources of the community: facilities and community organization or support
3. Preventive potential
• Gravity or severity of the problem – refers to the progress of the
disease/problem indicating the extent of damage of the patient/family. This
indicates prognosis, reversability, or modifiability of the problem. In general,
the more severe or advanced the problem is, the lower is the preventive
potential of the problem.
• Duration of the problem – refers to the length of time the problem has been
existing. Generally, the duration of the problem has a direct relationship to
gravity of the problem. The nature of the problem is a variable that may alter
this relationship. Duration has also a direct relationship to preventive potential.
• Current Management – refers to the presence and appropriateness of
intervention measures instituted to enhance the wellness state or remedy the
problem. The institution of appropriate intervention increase the condition’s
preventive potential.
• Exposure of any vulnerable or high – risk group increases the preventive
potential of a condition or a problem.

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 4. Salience: The nurse evaluates the family’s perception of the condition or problem. As a
general rule, the family’s concerns, felt needs and/or readiness increase the score on
salience.

Let’s try it!

Family Nursing Problem: Hypertension of Aling Kim Tsoy due to inability to

recognize the problem because of lack of knowledge.

Criteria Weight Score

1. Nature of the condition or problem
Scale**Wellness state 3
Health deficit 3 1 1
Health threat 2
Foreseeable crisis 1
2. Modifiability of the condition or problem
Scale** Easily modifiable 2 2 1
Partially modifiable 1
Not modifiable 0
3. Preventive potential
Scale** High 3 1 1
Moderate 2
Low 1
4. Salience
Scale** A condition or problem, 2
needing immediate attention 1 .5
A condition or problem not 1
needing immediate attention
Not perceived as a problem 0
or condition needing change
TOTAL SCORE 3.5

This is how the score was computed:

Nature of the condition or problem: 3 (score)/3 (highest possible score) = 1x 1 (weight) = 1
This applies to all criteria given, and then add all the scores to get the total score.

2. Goals of nursing care

Specify the expected health/clinical outcomes, family response(s), behavior, or competency

outcomes.

Nature of Goal:

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 ✓ Wellness state goal reflects the client’s desire to function at a higher level of health, and go
beyond merely maintaining health.
Example:
Health Problem: Readiness on enhanced capability for breastfeeding of Mrs. Tiwala
Goal: After two weeks on nursing intervention, Mrs. Tiwala will breastfeed more
competently.

✓ Health deficit related goal is appropriate when the client’s situation or health condition
interferes with the promotion and/or maintenance of health and recovery from illness or
injury.
Example:
Health Problem: Diabetes Mellitus of Mr. Garcia as Health deficit
Goal: After one month of nursing intervention, the family will be able to maintain the blood
sugar of Mrs. Garcia within normal level.

✓ Health threat related goal is appropriate when the client’s situation or health condition is
conducive to disease or may result to failure to maintain wellness.
Example:
Health Problem: Presence of accident hazard, particularly broken stairs in the hallway of Mr.
and Mrs. Juan Dela Cruz as Health threat.
Goal: After one week of nursing intervention, Mrs. & Mrs. Cruz will be able fix the stairs in
the hallway.

✓ Presence of Stress Points/Foreseeable – crisis related goal is appropriate when the client
has anticipated periods of unusual demand on the individual or family.
Example:
Family Nursing Diagnosis: Presence of Foreseeable crisis on loss of job of Mr. Gomez
Goal: After two weeks of nursing intervention, the family will be able to decide on taking
alternative job for Mr. Gomez which is appropriate to his skills and capabilities.

3. Objectives of nursing care

• Objectives are short-term in nature and is usually attainable while the client is in the
direct care of an institution.
• Objectives flow from an etiological clause.
• Objectives describe an intended result of a particular action (Mager, 1984).
• Usually three to six objectives are necessary for each goal.
• Objectives are useful tools in the design, implementation, and evaluation of care.

Characteristics of Objectives
1. Performance
A performance or outcome is any activity engaged in by the client.

Types of Performance/Activity:

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 ✓ Overt client performances
Example of Overt and Covert Objective
• The client will demonstrate proper insulin administration according to the
American Diabetic Association within 1 week.

Covert Objective
• The client will identify three complications of bed rest within a day.
2. Conditions
Conditions may include the experiences that the client is expected to have had
before completing the following which the client will carry out the performance:
• Objective
• Resources available for using the performance of the objective
• Environmental conditions
Example of Condition:

3. Criterion
The criterion is the standard by which a performance is evaluated. Criteria within
the objectives may be stated in four ways:
a. Speed: Set a time limit that is reasonable, given the client’s health state, as well
as the nurse’s capabilities and limitations.
b. Accuracy: Identify a specific degree of performance quantitatively.
c. Quality: Indicate the standard that is expected in terms of given acceptable
procedures.
d. Criterion: referenced: Use a book, pamphlet, or other resources . They also
provide a measure for meeting the objective.

Example of Criterion:

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 Domains of Objective

Objectives related to client learning situations can be classified into three domains,
which provide direction for selecting and individualizing the strategies and orders.
This is a classification of the intended behaviors, or the way people are expected to
think, feel, or act as a result of participating in a given learning experience.
1. Cognitive Domains are associated with changes in knowledge or intellectual abilities and
skills. Learning in this domain involves acquiring information and addressing the
development of the learner’s intellectual abilities, mental capacities, and thinking processes
(Eggen & Kauchak, 2012).
Levels of Cognitive Domain:
Category Example
Knowledge level: Recall, define, or After 30 minutes of teaching session, the
identify specific information. client will be able to state with accuracy the
definition of Asthma.

Comprehension level: Understand, or After watching a 5 – minute video on

demonstrate comprehension of what is nutrition following gastric bypass surgery,
being communicated by recognizing its the client will be able to give at least three
translated form. examples of food choices that will be
included in his diet.

Application level: Use ideas, principles, Upon completion of a cardiac rehabilitation

abstractions, or theories program, the patient will modify three
exercise regimes that can fit his lifestyle at
home.

Analysis level: Recognize and structure After reading handouts provided by the
information nurse educator, the family member will
calculate the correct number of total grams
of carbohydrate included on daily average of
the family’s diet.

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 Synthesis level: Put together parts into Given a sample list of foods, the patient will
unified whole create a menu to include foods from the 3
basic food groups in the recommended
amount of daily intake.

Evaluation level: Judge the value of After three teaching sessions, the learner
something by applying the appropriate will assess his readiness to function
criteria independently in the home setting.

1. Affective Domain
Learning in this domain involves increasing internalization of commitment to feelings
expressed as emotions, interest, beliefs, attitudes, values, and appreciations.
Levels of Affective Domain:

Category Example
Receiving level: Awareness of idea or During a group discussion session, the
fact patient will admit to any fears he may have
about needing to undergo repeat
angioplasty.

Responding level: to respond to an At the end of one-to-one instruction, the

experience, and later on willingly child will verbalize feelings of confidence in
respond with satisfaction. managing their asthma using the peak-flow
tracking chart.

Valuing level: Regard or accept the After attending a grief support group
worth of a theory, idea, or event meeting, the patient will complete a journal
demonstrating commitment to an entry reflecting her feelings about the
experience that is perceived as having experience.
value.

Organization level: Organize, classify, After 45 – minute group discussion session,

and prioritize values by integrating a the patient will be able to explain the
new value into general set of values. reasons for anxiety about self-care
management responsibilities.

Characterization level: Display Following a series of teaching sessions, the

adherence to a total philosophy, learner will display consistent interest in
showing firm commitment into the maintaining good handwashing technique to
values system. control the spread of infection to the
members of the family.

1. Psychomotor Domain

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 Learning in this domain involves acquiring fine and gross motor abilities such as walking,
handwriting, or performing a procedure.

Levels of Psychomotor Domain

Category Example
Perception level: Awareness on cues After a 20-minute teaching session on
or objects associated with some tasks aspiration precautions, the family caregiver
performed. will describe the best position to place the
patient in during mealtimes to prevent
choking.
Set level: Exhibit readiness to take Following a demonstration of how to do
certain kind of action and express proper wound care, the patient will express
willingness to take action willingness to practice changing the dressing
on his leg using the correct procedural steps.
Guided level: Exert effort via overt After watching a 15-minute video on the
actions under the guidance of an procedure for self-examination of the breast,
instructor/mentor the patient will perform the exam on a
model with 100% accuracy.
Mechanism level: repeatedly perform After a 20 minute teaching session, the
steps of a desired skill with a certain patient will demonstrate the proper use of
degree of confidence crutches while repeatedly applying the
correct three-point gait technique.
Complex overt response level: After 20-minute teaching session, the
Automatically perform a complex patient will demonstrate the correct use of
motor act with independence and a crutches while accurately performing
high degree skill different tasks such as going up stairs, or
using the toilet.
Adaptation level: Modify or adapt a After reading handouts on healthy food
motor process to suit the individual or choices, the patient will replace unhealthy
various situations, indicating mastery of food items with healthy alternatives.
highly developed movements.

Origination level: Create new motor After simulation training, the parents will
acts, such as novel ways of respond correctly to a series of scenarios
manipulating objects or materials, as a that demonstrate skill in recognizing
result of understanding a skill and respiratory distress in their child with
developed ability to perform skills. asthma.
Guidelines in Writing SMART Objectives
✓ Write objectives that are specific about what is to be achieved.
✓ Write objectives that relate to the goal.
✓ Quantify/Qualify objectives by including numeric, cost, or percentage amount or the
degree/level of mastery expected.
✓ Write realistic objectives given the ability of the client.
✓ Indicate when the objectives will be achieved.
Remember to be:
Specific
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 Measurable
Attainable
Realistic
Timely/Time bound

IV. Writing a Nursing Care Plan

Family Nursing Care Plan
✓ A written guide that organizes about client’s care into a meaningful whole.
✓ The tool for documenting and communicating the client’s nursing diagnoses, expected
outcomes, nursing orders, strategies, and evaluation.

Purposes of FNCP
• Care plans provide direction for individualized care of the client
• For continuity of care
• Helps to teach proper documentation
• Serves as guide for assigning staff to care for the client
• Care plans serve as guide for reimbursement of health insurance

Guidelines for Writing Family Nursing Care Plans

1. Date and sign the plan
• The date plan is essential for evaluation, review, and future planning.
• The nurse’s signature demonstrates accountability to the client, and to the
nursing profession since the effectiveness of nursing actions can be
evaluated.
2. Use category headings. Example: Nursing diagnoses, Goals, Nursing Intervention and
Evaluation
3. Be specific.
• Write the specific time during the shift when the procedure was done to
avoid any miscommunication.
4. Refer to procedure books or other sources of information rather than including all
the steps on a written plan.
• Example: “ See unit procedure for post partum care”

5. Tailor the plan to the unique characteristics of the client by ensuring that the client’s
choices, such as preferences about the times of care and the methods used are
included.
• “Provide cranberry juice to at breakfast rather than other juice”
• This indicates that the client was given other beverages.
6. Ensure that the NCP incorporates preventive and health maintenance aspects as
well as restorative ones.
• Example: “ Provide active range of motion (ROM) exercises to affected limbs
q2h” prevents joint contractures and maintains muscle and strength and
joint mobility.
7. Ensure that the plan and contains interventions for ongoing assessment of the
client.
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 • Example: Inspect incision q8h
8. Include collaborative and coordination activities in the plan.
• Example: The nurse may write orders to ask a nutritionist about specific
aspects of the client’s care.
9. Include plans for the client’s discharge and home care needs.
10. Use this format when writing a Family Nursing Care Plan (see example).
Head of the Family: _____________________
Name of the Client: _____________________
Address: ______________________
Family Number: ______(Reference: Rural Health Unit’s Family Health Record)
Health Family Analysis Goal & Interven Ratio Evalua
Problem Nursing Objectives tions nale tion
and Cues Problem
Health Second level Scientific Goal
Problem: assessment Analysis: -Either Long term
First level Brief or Short term goal.
Assessme Descriptio A statement that
nt n/Pathoph leads to the desired
Relevant ysiology of outcome)
Cues: the Health
Subjective Problem. Objectives
and - nursing care
Objective Situational objectives that
analysis: addresses
This management of the
includes second level
Predisposi assessment.
ng and -Format of
other statement: SMART
related -Indicate the
factors on domains of each
the objective, reflecting
occurrence the characteristics
of the as well on each
health objective
problem. statement.
(Reference
–
journals/b
ooks,
exclude
wiki, blogs,
and the
like)

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 Now, let us prioritize and develop goal(s) and objectives based on
the information below:

CUES/DATA Family Nursing Problems

• Rina, three years old, B. Malnutrition as a health deficit:

weighs 10 kgs; looks
pale, lethargic and
apathetic; markedly 1. Inability to recognize the presence pf
underweight malnutrition in a dependent member
due to lack of knowledge.
• Mother verbalized,
"Rina is really small in 2. Inability to decide about taking
built since she was a appropriate health action due to failure
baby. She is not fond of to comprehend the nature, magnitude
eating too.. .", and scope of the problem.

• Three preschool 3. Inability to provide adequate nursing

members usually are care to a member suffering from
left to the care of eight- malnutrition due to:
year old sister when
a. Lack of knowledge about health
parents are working
condition;
and older children are
in school; b. Lack of knowledge on the nature and
extent of nursing care needed
• Mother is very busy
helping earn a living c. Inadequate resources for care, i.e.,
that she could hardly responsible family member and
see to the needs of the financial constraints.
children;

• Family income is
P500.00 a day.

• Three preschoolers C. Scabies as a health defiicit

have scabies;

• Mother verbalized, " ...I

have such a lot of
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 things to attend to as a 1. Inability to provide adequate nursing
fish vendor that i could care to preschoolers with scabies due to:
hardly see to the needs
a. Lack of knowledge about the health
of the children...Nieves
condition;
is the only older child
who is left to take care b. Inadequate knowledge of the nature
of the younger ones and extent of nursing care needed;
when we are not
around. But I can't c. Inadequate family resources for
expect her to do care, specifically:
everything. That's the • Responsible family members
reason why the scabies
of Andres and Lita have • Financial resources
not improved... I was
• Physical resources, i.e., water
able to buy medicine...
supply facilities
but it was quite
expensive that I was
not able to buy another
one when it was
consumed. This
(scabies) must be due
to the weather. Quite a
lot of children in the
neighborhood have
this. See, even Rina got
it, too.";

• Family income is
P500.00 a day;

• Water supply is taken

from a public well 1/2
km form the house;

• Rina contracted the

scabies of the two
older siblings;

• Mother believes that

scabies is due to
weather condition

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 • Family lives in a two-
room house, each room
with a dimension of 3
meters by 3 meters,
and;

Prioritization of Family Nursing Problem

This table of scoring pertains to Family Nursing Problem:
Malnutrition of Rina as a Health Deficit
Criteria Weight Score
5. Nature of the condition or problem
Scale**Wellness state 3
Health deficit 3 1 1
Health threat 2
Foreseeable crisis 1
6. Modifiability of the condition or problem
Scale** Easily modifiable 2 2 2
Partially modifiable 1
Not modifiable 0
7. Preventive potential
Scale** High 3 1 1
Moderate 2
Low 1
8. Salience
Scale** A condition or problem, 2
needing immediate attention 1 0.5
A condition or problem not 1
needing immediate attention
Not perceived as a problem 0
or condition needing change
TOTAL SCORE 3.5

This table of scoring pertains to Family Nursing Problem:

Scabies of the three children as a Health Deficit
Criteria Weight Score
9. Nature of the condition or problem
Scale**Wellness state 3
Health deficit 3 1 1
Health threat 2
Foreseeable crisis 1
10. Modifiability of the condition or problem
Scale** Easily modifiable 2 2 1

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 Partially modifiable 1
Not modifiable 0
11. Preventive potential
Scale** High 3 1 1
Moderate 2
Low 1
12. Salience
Scale** A condition or problem, 2
needing immediate attention 1 0.5
A condition or problem not 1
needing immediate attention
Not perceived as a problem 0
or condition needing change
TOTAL SCORE 3.5

Writing the Family Nursing Care Plan

Health Family Analysis Goal & Objectives Inter Ratio Evalua

Problem Nursing venti nale tion
and Cues Problem ons
Malnutriti Malnutrition Goal:
on of Rina 1.Inability is prevalent After a month,
as a to among October 29, 2020, of
Health recognize children under home visit, the family
Deficit the five years old. of Rina would be able
Cues: presence pf According to to manage the
-Rina, malnutritio UNICEF(2019) malnutrition of Rina
three n in a nearly all of and maintain normal
years old, dependent deaths under Body Mass Index.
weighs 10 member five are due to
kgs; looks due to lack undernutrition Objectives:
pale, of putting them
lethargic knowledge. at risk of dying After nursing
and 2.Inability from common intervention, the
apathetic; to decide infections, and family, esp the Rina’s
markedly about delays mother will be able
underweig taking recovery. to recognize
ht appropriate Malnutrition. Malnutrition as a
-Mother health health problem given
verbalized action due Situational the following
, "Rina is to failure to Analysis: objectives:
really comprehen
small in d the The most 1. After discussion,
built since nature, common risk Rina’s mother would
she was a magnitude factor of be able to define
baby. She and scope Malnutrition is malnutrition using

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 is not fond of the parental her own words in 2-3
of eating problem. illiteracy, non- minutes. (Cognitive).
too.. .", 3.Inability exclusive 2. Given a food
-Three to provide breastfeeding, pyramid chart , Rina’s
preschool adequate recurrent mother would be
members nursing diarrhea, and able to identify 3 out
usually care to a lack of of five foods high in
are left to member nutritious protein,
the care suffering food intake, carbohydrates, and
of eight- from particular vitamins and
year old malnutritio Protein- minerals in 3 to 5
sister n due to: energy rich minutes (Cognitive).
when a. foods, and 3. Given a sample
parents Lack of with low menu, Rina’s mother
are knowledge socio- will be able to list
working about economic down a 3 day sample
and older health status. menu which is
children condition; (UNICEF 2019, economical but
are in b.Lack of Maglaya nutritious, in 5-10
school; knowledge 2009). If left minutes.
-Mother is on the untreated (Psychomotor)
very busy nature and would cause 4. After reading the
helping extent of medical handouts on benefits
earn a nursing complications of proper nutrition,
living that care such as vision Rina’s mother will be
she could needed problem, able to verbalize
hardly see c.Inadequat longer healing confidence in
to the e resources time for preparing nutritious
needs of for care, wound, but economical food
the i.e., anemia, high for the
children; responsible risk for family.(Affective)
-Family family infection and
income is member the like.
P500.00 a and
day. financial
constraints.

V. References

Christensen P. and Kenney, J. (1990). Nursing Process: Application of Conceptual Models, 3rd
Ed. The C.V. Mosby Company.

Maglaya, A. (2009). Nursing Practice in the Community, 5th Ed. Argonauta Corporation.

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