Department of family and Community Health Nursing, Faculty of Nursing, Khon Kaen University,

Thailand
Family Health Care in Community Nursing Practicum
The Family Health Assessment Form
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Student’s name : Members of Group
1. Dwi Koro Prihantini
2. Dwi Nur Baety
3. Mochamad Chabibi
Informant’s name (Family name): Mr. N
Time period of practice……………………………………………………Setting/Village: Ban Laonadi
Adviser’s name: Asst. Prof.Dr.Lukawee
Part 1 Family Health Assessment
1.1 General data of family
Address No. 11 Ban Laonadi, Banwa sub distric, Muang Distric, Khon Kaen
Health
Relationship Status/Disease
Age Marital
No. Name with Sex Religion Education Career Incom
(year) status
householder
DM and heart 10 yea
1. Mrs. Nuanjan Wife 80 Female Wife Budha Elementary Farmer disease ago
2. Mr. Thongsu Husband 79 Male Husband Budha Elementary Farmer Gloucoma 4 year
3.
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 4.
5.

During last year, does the family loss family member (s)/ or crisis event : in this family don’t have family members
which of dead

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1.2 Family Genogram (Three generations)

Note :

Male :

Female :

Married :

Died male :

Died female :

One home :

Died of Cancer:

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1.3 Family attachment and Ecomap (diagram of the relationships
among family members and with other social capital or
subsystems in the community)

Khon Kaen Hospital

Neighbor

BanWa Health
Promoting Hospital
79 80 Young Brother
DM and Heart Chronic Back
Disease Pain

granddaughter Niece
Relationship
Shop Hawkey

Double Surgery
Herniatomy

Symbols

Strong relationships

Good relationships

Temporary relationships

Having conflict

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1.4 Environment and Sanitation
1.4.1 Indoor environment and sanitation (area in house/water
used/solid waste disposal/ventilation etc.)
Family said: they are used water in this house from ground
water and they are buy a nwater to drink every week, for
solid waste disposal used trash for collected garbage in the
house and in the house there are ventilation for air
sirculation, there are some door at the house
1.4.2 Physical Environment of the community (Housing and
zoning/transportation/ service centers/ solid waste disposal
etc.)
Family said: physical environment of the community around
home seen so dirty and disordered, they are don’t have
transportation at house, service center in the environment
so near with them home like a hospital, shop.
Part 2 Family lifestyle; Family roles and functions

2.1. Family economy (income/ expenditure/ debt/ family

saving/ financial support etc.)
Wife said: income the family from the goverment around 1500
bath / mounth for her husband and 700 bath for her self.
Besides that it is also assist by her young brother for daily
needs.
2.2. Responding to the basic needs of family members (food
management / residence/ cloth/ other basic factors related to
family members’ living)
Wife said: the wife always manage pattern eating with how to
reduce food that contain a lot of glucose for eating her
husband. Every day her husband only consumption like a
frish, chicken and sometimes sticki rice. Him dont consume
vegetable.
2.3. Exercise, Activities and Recreation (Characteristics of
each family member's activities and family activities,
frequency, etc.)
Wife said: Mr.T could’t walk, him can’t go and do activities
anywhere only lie at the bed, the wife still do activities like a
take care her husband and tidy up the house. The wife can’t
walk away because her have experienced physical
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 weakness. They are don’t doing exercise because they are
have a physical weakness
Every day young brother came to visit and bring some food
for eating her self and her husband
2.4. Interaction, relationships and communication (the
interactions and relationships between family members such
as husband-wife, parents-children, grandparents-
grandchildren etc.)
Wife said: Mr. T suffering from DM since 10 years ago and
can’t do activities since 4 years ago. Communication on the
family tend be pasisive because her husband can’t talk, the
wife communication with her husband if the husband ask for
something like a eating, drink, take a bath, etc
2.5. Problems, coping and stress management (e.g., how to
face with the problems and how to manage the stress of
family stress. People with primary and secondary roles in the
family, etc.)
Wife said: if they family get sick, they come to the fasillity
health to treathment her self and her family. She said her
husband get sick DM 10 years ago . and her self get problem
at helth eyes. Her left eyes can’ t see clearly.
2.6. Perception, awareness, and family health care (i.e.,
caring methods of family members, including health
promotion, disease prevention, curing, rehabilitation, and
seeking treatment methods etc.)
Wife said: the family know the disease from doctor, a nurse or
other health workers and they are only goes to hospital once
a month, they no treatment in other ways just routine
comsumption of drugs from hospital
2.7. Family parenting (how to nurture/raise the children, people
with primary and secondary roles)
Wife said : in family the have not son or children, only some
cousin often help in their daily lives
2.8. Sleeping pattern of the family members (e.g., bed time,
quality of sleep, sleeping pill use of family members)
Wife said: her husban sleep every day 4 times around 2-3
hours, at the morning until evening he sleep on the terrace of
the house, at the night he has sleep in the house.
And quality of sleep her self is irregular, she often wake up
because she has always standby when her husband call to
ask for sometimes.
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 2.9. Activities with communities (e.g., participation in
community activities, taking role as a community group/
organization leader (s))
Wife said: they are have been inactive in community
actrivities because they are old and experience physical
weakness.
2.10. Family beliefs and values (i.e., religion, alternative
treatment beliefs, beliefs in ghost, family inherits and
practices from generation to generation, morale support
resources)
Wife said: they are budhis religion, they are now rarely go to
temple because they are alredy unable to walk away.
Part 3 Health Assessment and 11 Functional health pattern
Assess family member: Mr. Thongsu
3.1. General appearance : Composmentis
3.2. Vital Sign :
BP : 120/80 mmHg
PR : 68 x/minuts
RR : 22 x/minuts
T : 36 0 C
BW : 51 Kg. HT : 160 cm. BMI : 19,92 kg/m2
3.3. Physica examination
1) Head : head shape mesochepal, no injuri, no palpeble of
limph, no tenderness
2) Hair : white hair, dirty hair, has a dandraff, even
distribution of hair,
3) Face : simetris shape, no tenderness, normal facial nerve
and trigeminus nerve, can move the jaw, has a
temporoandibular.
4) Eyes : can see can see with a distance of one inch, 6
cardinal test can’t to move up and down, simetris eye
level, no visus, refleklight isokor, diameer pupil 2-3 mm,
retina normal, konjungtiva anemis, slera ikterik.
5) Hear: seen so dirty hear, can hear but decreased
hearing, no buildup of cerumen,no tenderness
6) Nose : no tenderness, normal olfaktorius nerve, no nasal
polyp, dirty nose
7) Mouth : no wound, white tongue, there four theet, dirty
mouth,
8) Neck : stiff neck, can turn the right and the left, no shrug,
good reflek swallow
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 9) Chest
Lung I : no injuri, chest see simetris, no
respiratory distres,
P : no tenderness, no edema,
P : good skin integrity, simetris exspansion,
normal lung resonance sounds (dug dug dug)
A : vesicular breath sounds,

Heart I : appears ictus cordis, no injuri,

P : the heart is felt 2-3 cm behind the

midclavicularis line
P :
A : a heartbeat,
10) Abdomen
I : No injuri, simetris, No ascites,
A : intestinal peristalyic not assessed,
P : Tenderness, the stomach feels hard,
P : Hypertympani
11) Nail : no lession, no clubing finger, no spoon finger,
12) Ekstremitas : 5 5
5 5 upper extremity : normal, normal
bisep refleks
Lower extremity : can’t up the leg,
normal tendon refeks
13) Skin : color skin a dark brown, skin turgor > 2 sec,
mosturaiser dry skin, no injuri, no pitting edema.
14) Genetalia: no review
3.4. Health Perception and Health Management Pattern

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 Husband said that what is meant by health is a condition
where the patient can move normally as usual without any
complaints
3.5. Nutritional-Metabolic Pattern
Husband said they eat four times a day with a small portion
of the composition of stiki rice, chiken, fish and Her
husband's body weight 5.1 kg every day he drinks 5 glasses
of water (250 ml) more or less he meets the needs of only
1.5 liters while the fluid needs must be fulfilled 2.1 liters, he
lacks fluid needs
3.6. Elimination Pattern
Husband said defecate once a day with a consistency of soft
and yellow stool. BAK five times a morning, five times a
night with clear yellow urine

3.7. Activity-Exercise Pattern

Husband said the patient said he could not move as usual
because his condition was weak, he could only sit since four
years ago
3.8. Sleep-Rest Pattern
Husband said sleep every day 4 times around 2-3 hours, at
the morning until evening
3.9. Cognitive/ Perception Pattern
Husband said they want to do activities and go wherever
they want but their bodies are weak
3.10. Self-concept Perception Pattern
Husband said he had suffered from diabetes for ten years
ago and since four years ago was unable to walk, his legs
were not functioning properly only to be able to stand up
unable to walk, every time he wanted to move had to crawl
3.11. Role-Relationship Pattern
Husband said at this time he could not carry out his role as
hoursholder of the family because of the illness he suffered
3.12. Sexuality/Reproductive Pattern
Husband said he had been married twice, the first marriage
had one child, the second marriage had no children
3.13. Coping Stress Tolerance Pattern
(Stressors/Coping/outcome)
Husband said they usually complain if they feel sick
3.14. Value and Belief Pattern

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 A religious patient Budha, since he cannot move the patient
says he has never worshiped nine tempel

Assess family member: Mrs. N

3.1. General appearance : Composmentis
3.2. Vital Sign :
BP : 100/70 mmHg
PR : 70 x/minuts
RR : 22 x/minuts
T : 36,4 0 C
BW : Kg. HT : cm. BMI : kg/m2

3.3. Physical Examination

3.4. Health Perception and Health Management Pattern
Wife said that what was meant by health was a condition
where you could move
3.5. Nutritional-Metabolic Pattern
Wife said they eat four times a day with a small portion of the
composition of stiki rice, chiken, fish. Drink about 5 glasses
per day
3.6. Elimination Pattern
Wife said defecate once a day with a consistency of soft and
yellow stool. BAK 3 times a morning, 3 times a night with
clear yellow urine
3.7. Activity-Exercise Pattern
wife said she could not move as usual because there was a
problem in the spine which resulted in being unable to move
3.8. Sleep-Rest Pattern
Wife said: her husban sleep every day 4 times around 2-3
hours, at the morning until evening he sleep on the terrace of
the house, at the night he has sleep in the house.
And quality of sleep her self is irregular, she often wake up
because she has always standby when her husband call to
ask for sometimes.
3.9. Cognitive/ Perception Pattern
wife said pain in the spine and was unable to walk
3.10. Self-concept Perception Pattern
The wife said that she had a spinal problem and felt pain
when moving
3.11. Role-Relationship Pattern
Wife said acting as the head of the wife
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3.12. Sexuality/Reproductive Pattern
Wife said first marriage and not having children
3.13. Coping Stress Tolerance Pattern
(Stressors/Coping/outcome)
Patients say they usually complain if they feel sick
3.14. Value and Belief Pattern
A religious patient Budha, since he cannot move the patient
says he has never worshiped nine tempel

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Part 4 Nursing diagnosis

Problem list Nursing diagnosis Supportive data (subjective &

objective data)
Constipation 2. Constipation S: wife said her husband had
Cause : associated with difficulty defecating and defecating
1. Don’t consumtion Nutrition only once a day
vagetables and fruits O: - Result of physical examination
2. Less drink water. stomach so hard
3. He has history double - Sounds hypertimpany
surgery herniatomy
4. Less physical activity, and
they are rarely moving the
body
5. The husband continuous
consumption of drugs

Environment
Couse :
1. Has a dirty environment
around them house
2. They can’t clean them
house by self beause they
has a problem with the
activities
3. The nieces rarely help the
3. Environment S: -
associated with O: the house looks so dirty, in the
kitchen there is a lot of garbage, in
the home environment there are
many mosquitoes, toilet is so
rundown

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 family for clean the house
and the environment
around home
Ineffective Health Management 4. Ineffective
Cause :
1. The husband has Chronic
Kidney Disease, has DM,
has anemia, visual, has
Hearth Disease, wekness
2. The wife have Chronic
Low Back Pain, Kiphosis,
problem of visual, she
also have a bad stress
koping
3. They ara of the aging
process 5. Disturbed sleep pattern
Sleeping Pattern
Cause:
1. The wife complain about
the sleeping pattern,
2. The wife have a problem
self health
3. The wife think about
income economic not
Health S: S: wife said she could not do
Management homework because of his old age
and limited activities, they complain
about them self heath
O: -
S: wife said her husban sleep
associated with every day 4 times around 2-3
disorders due to the hours, at the morning until evening
way a partner sleeps he sleep on the terrace of the
house, at the night he has sleep in
the house.
And quality of sleep her self is
irregular, she often wake up
because she has always standby
when her husband call to ask for
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 enough for daily needs.
4. The wife woried about her
husband health.
5. The wife always get up
every night if the husband
get up o ask something
6. The wife always sleep at
the sleep in front of the house every a
day
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sometimes.
O:
- She looks sleepy during a day
and she feel so tired, she
looks so pale,
- the amount of sleep less than
the number of hours of sleep
needed is according to age
 6. Ineffective coping S: - wife said she confuse
Coping Strees aboout they condition,
Cause: - she looks surrender to his
1. The husband has bed self condition
health aging proscess, - The husband has Chronic
Anemia, Heart disese, Kidney Disease, has DM, has
CKD, Diabetic, Weakness, anemia, visual, has Hearth
Back paint, econimic Disease, wekness
income - The wife have Chronic Low
2. The wife always think Back Pain, Kiphosis, problem
about her husband health of visual, she also have a bad
and her self health stress kopingshe looks not
3. Both of them no have the fresh, she looks pale,
care giver O : the score of depression
4. Problem on the ecomonic scores 9
income (ecomony crisis)

Medication Management
Cause:
1.

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Part 5 Nursing Care plan and Implementation

No. Nursing Objectives/ Nursing activities Results of care

diagnosis Evaluation criteria
1. Constipation 1. Maintain passage 1. Educating about Nutrition
associated with of soft 2. Educate about fluid
Nutrition 2. Formed stools requirements in the body
every 1 to 3 days 3. Education for exercise,
without straining such as : imobilisasi on
3. State relief from the bed , move, walk,
discomfort of exercise axtermitas
constipation 4. Education about medicine
4. Identify measures 5. Motivation for consum
that prevent or water around 2000-3000
treat constipation cc per day
6. Motivation the patien for
reguler defecation and not
hold back defecation.
2. Environment 1. 2. Education with nephews
about environmental
hygiene so that patients
are more comfortable
staying at home

1. Describe daily food 1. Discuss with family about

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3. Ineffective and fluid intake the diit necessary for
Health that meets patients.
Management therapeutic goals 2. Do a weight check

2. Describe activity 3. Evaluation of edema

petterns that meet 4. Monitoring vital signs and
therepeutic goals fluid balanceRever to the
3. Describe care plan for in effective
scheduling of family healht
medications that management.
meets therapeutic
goals
4. Verbalize ability to
manage
therapeutic
regimens
5. Collaborate with
health
professionals to
decide on a
therapeutic
regimen that is
congreunt with
health goals and
lifestyle
4. Distributed 1. Describe factors 1. Discuss with family about
sleep pattern that prevent or the diit necessary for

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 associated with inhibit sleep patients.
disorders due to 2. Identifies 2. Do a weight check

the way a techniques to 3. Evaluation of edema

partner sleeps induce sleep 4. Monitoring vital signs and
fluid balance
5. discuss the reasons for
differing individual sleep
requirenments, including
age lifesyle, activity level,
and other possible factors
6. explain sleep insufficiency
may be a consequence of
a reduced amount of
duration and/or sleep
quality
7. explain the effects of
sleep deprivation(
cognition, strees
management)

1. Use effective 1. Support the family about

5. Inffective coping coping them viability
strategies 2. Give them fasilitation if
2. Use behaviors the wife want talking
to decrease about the problem
strees 3.

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 3. Remain free of 4. Observe for contributing
destructive factors of inffective
behahavior coping such as poor self-
toward self or concept, grief, lack of
others problem-solfing skills,
4. Report decrease lack of support
in physical 5. Encourage the client to
sympotoms of describe previous
stress stressor and the coping
5. Report increase mechanisms used
in psychological 6. provide opportunites for
comfort the client to discuss the
6. Seek help from maaning the situation
a health care might have for that client
prefosional as 7. assist the client to set
appropriate realitic goals and identify
personal skills and
knowledge
8. provide information
regrding care before care
is given
6 Medication 1. name of the correct 1. do education related to
Management medicine the use of good drugs
2. drug side effects according to what has
3. correct use of the been prescribed and the
drug that has been types of drugs consumed

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prescribed by the client. Types of
drugs:
- glipizide ½ x 1
- manidipine ½ x1
- CaCo2 1x1
- ASA 1x1
- Simvastin 1x1
- Sodamin 1x2
- Folria 1x1

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Part 6 Summary of family care
(time of visits/total number of the family member and health status/
problems and needs of family/nursing
activities/results/continuing care/barrier)

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Part 7 References (APA style)

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Part 8 lesson learned/Learning reflection
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