Scribd
Upload
126 views9 pages

Initial Data Base Form Revised

This document contains a template for collecting data on family nursing practice. It includes sections to gather information on household members, family characteristics, socioeconomic/cultural factors, cultural influences, the family environment, family health/behaviors, and potential health problems or needs. The goal is to obtain a holistic understanding of the family to guide nursing care. Information ranges from demographics, relationships, health histories, living conditions, resources, beliefs, and lifestyle habits.

Uploaded by

Mavelle Patindol
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
126 views9 pages

Initial Data Base Form Revised

This document contains a template for collecting data on family nursing practice. It includes sections to gather information on household members, family characteristics, socioeconomic/cultural factors, cultural influences, the family environment, family health/behaviors, and potential health problems or needs. The goal is to obtain a holistic understanding of the family to guide nursing care. Information ranges from demographics, relationships, health histories, living conditions, resources, beliefs, and lifestyle habits.

Uploaded by

Mavelle Patindol
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 9

UNIVERSITY OF CEBU – BANILAD

COLLEGE OF NURSING

INITIAL DATA BASE FOR FAMILY NURSING PRACTICE


Family Surname :
Barangay : Municipality/ City: ________
Source (s) of Information: - Contact No: ____ Date:

Data Gathering: __________ Type of Family:

A. HOUSEHOLD MEMBERS (all who resides in the family home)

RELATIONSHIP HIGHEST NUTRITIONAL


CURRENT
NAME GENDER AGE TO HEAD OF EDUCATIONAL OCCUPATION ASSESSMENT
HOUSEHOLD HEALTH PROBLEMS
ATTAINMENT (Healthy/At Risk)

Note: Insert genogram, family tree (indicating health problems of individual members)

11 | P a g e
GENOGRAM OF FAMILY
(NAME)

Grandparent Grandparent Grandparent


Grandparent

Aunts and Uncles


Parent Parent

Child Child

2|Page PMV- lanie / joy (edited) 06/27/2016


FAMILY HEALTH TREE OF FAMILY
(NAME)

1. Causes of death of deceased family members

2. Genetically linked diseases:


( ) Heart Disease
( ) Cancer
( ) Diabetes
( ) Hypertension
( ) Allergies
( ) Asthma
( ) Mental retardation
3. Environmental and occupational diseases

4. Psychological problem (mental illness/ obesity)

5. Infectious diseases
( ) TB
( ) Hepatitis
( ) Chicken Pox
( ) Measles
( ) Others:

6. Family’s methods of illness Prevention


( ) Exercise
( ) Periodic physical examination
( ) Pap smear
( ) Immunizations

7. How family cope with stress


______________________
______________________
______________________

3|Page PMV- lanie / joy (edited) 06/27/2016


B. FAMILY CHARACTERISTICS

1. Family members living outside the household

Relationship Frequency and


Means of
Name Age to the Location operating
Communication
Household contact

2. Family Mobile
2.1 Length of the current address
2.2 Address of Previous Residence
2.3 Frequency of geographic moves

3. Family dynamics
3.1 Emotional bonding of family members
3.2 Distribution of authority and power
3.3 How members communicate
3.4 How problems are solved
3.5 How conflict is handled
3.6 Division of labor
3.7 Decision making ________________________________

C. SOCIOECONOMIC AND CULTURAL CHARACTERISTICS

1. Family Social Integration


1.1 Language(s) or dialect(s) spoken
1.2 Literacy (ability to read or write in language)
1.3 Network with religious organization
1.4 Network with social organization

4|Page PMV- lanie / joy (edited) 06/27/2016


D. CULTURAL INFLUENCES: Values, Attitudes & Beliefs about:
1. Spirituality
2. Rituals (holidays & celebrations)
3. Dietary habits
4. Health
5. Traditional healers

E. FAMILY ENVIRONMENT

1. Home
1.1. Ownership ( ) owned ( ) rented ( ) rent-free
1.2. Construction materials used ( ) light ( ) mixed ( ) strong
1.3. Adequacy of Size (# of bedrooms)
1.4. Lighting Facilities ( ) electricity ( ) kerosene
( ) others (specify)
1.5. General Sanitary Condition

2. Water Supply
2.1. Drinking water
2.1.1. Ownership ( ) individual (private) ( ) municipal (city owned)

2.1.2. Source ( ) Level 1 (point source)


( ) Level II (communal faucet system or standposts)
( ) Level III (waterworks system or individual
house connections)
( ) open dug wells
( ) unimproved springs
( ) wells not need priming
( ) rain water

2.1.3. Storage ( ) None (direct from faucet or pipe)


( ) jar or can with faucet
( ) jar or can without faucet
( ) others (specify) _

2.2. Water for household use


2.2.1. Ownership ( ) individual / private water system
( ) municipal / city water system

5|Page PMV- lanie / joy (edited) 06/27/2016


2.2.2. Source ( ) ground water (specify) _
( ) surface water (specify)
( ) rain water

2.2.3. Storage ( ) home (direct from faucet or pipe)


( ) jar or can
( ) others (specify) _

3. Kitchen
3.1. Cooking Facility ( ) electric stove ( ) gas stove
( ) firewood / charcoal
3.2. Sanitary Condition
3.3. Drainage Facility ( ) none ( ) open drainage
( ) blind drainage

4. Water Disposal
4.1. Refuse and Garbage
4.1.1. Container ( ) covered ( ) open
( ) none

4.1.2. Methods of Disposal ( ) hog feeding ( ) open dumping


( ) open burning ( ) burial in pit
( ) burial in pit ( ) composting
( ) incineration ( ) collection by government
( ) collection from private
( ) others (specify) _

4.2. Toilet ( ) none ( ) pail system


( ) open pit private ( ) closed pit private
( ) bored hole latrine ( ) overhung latrine
( ) antipolo system ( ) water sealed latrine
( ) flush type
( ) others (specify) _

4.2.1. Distance from the house

4.3. Sanitary Condition

6|Page PMV- lanie / joy (edited) 06/27/2016


5. Domestic Animals

KIND NUMBER WHERE KEPT

F. FAMILY NEIGHBORHOOD
1. Location
(urban, rural, subdivision, slum area)
2. Type
(residential, semi commercial, commercial)
3. Safety
3.1. Traffic pattern
3.2. Lighting
3.3. Security
4. Population density
(crowding)
5. Sources of pollution
5.1. Air
5.2. Water
5.3. Soil
5.4. Noise
6. Transportation available _______________________
7. Social facilities _______________________

G. FAMILY HEALTH & HEALTH BEHAVIOR


1. Healthy lifestyle practices (Activities of Daily Living)
____________________
____________________
____________________

2. Hours of sleep/rest per day ______________________________

7|Page PMV- lanie / joy (edited) 06/27/2016


3. Health Problems
3.1 Health Deficit / Need: (condition that can be alleviated with medical or social technology)

3.2 Health Threats (conditions that will promote or cause disease(s) or injury(ies))

3.3 Foreseeable crisis (stressful conditions)

4. Home Remedies

5. Health Care Resources

6. Eating/ feeding habits/ practices


____________________________
____________________________
____________________________

7. Protective measures used


____________________________
____________________________
____________________________

8. Vaccination (vaccinations received)


____________________________
____________________________
____________________________

8|Page PMV- lanie / joy (edited) 06/27/2016


9|Page PMV- lanie / joy (edited) 06/27/2016

You might also like