FAMILY NURSING ASSESSMENT

Yankes Facility No. Register

Name of nurse who Date of
studies Assessment
1. FAMILY DATA
Name of Head of Family Every day language
Home Address & Tel Distance to the
nearest airport
Religion & Tribe Means of
transportation
2. FAMILY MEMBER DATA
N Name Relation Age gen tribe last Current Nutrition Vital sign Basic Aid /
o ship der education Job al Status (BP, P, T, Immuniza prosthesis
with the (height, B) tion
family weight, Status
BMI)

NEXT
Analysis of
General Current Health
No Name Allergic history Individual Health
appearance Status
Problems

3. ILLNESS INDIVIDUAL ASSESSMENT DATA (attached)

4. FAMILY SUPPORT DATA
 Home and Environmental Sanitation
 House Conditions:.
 Ventilation:
 Home Lighting:
 Waste Dispose Channels:Good /
Enough / Less
 Clean Water Source: Healthy / Unhealthy
 latrines meet requirements:
 Trash Place:
 Ratio of Building Size to Houses with
clean and healthy lifestyle
 If there is Bunifas, Childbirth is
helped by health workers:Yes No
 If there are babies, give exclusive
breastfeeding:Yes No
 Juika have toddlers, weigh toddlers
every month:Yes No
 Use clean water to eat & drink:Yes
No
 Using Drinking Water for Personal
Hygiene: Yes / No
 Number of Family Members: 8 m2 /  Hand Washing with Clean Water &
person: Yes / No: Soap:Yes No
 Disposing of rubbish at its
place:Yes No
 Maintaining a Heated Looked
Home Environment:Yes No
 Take side dishes and brew every
day:Yes No
 Using Healthy latrines:Yes No
 Eradicate Flicking at Home Once a
Week:Yes No
 Eat Fruit & Vegetables Every Day:
Yes / No
 Doing Physical Activity Every Day:
Yes / No No Smoking in the House:
Yes / No

5. FAMILY CAPABILITY TO DO HEALTH MAINTENANCE TASK FAMILY MEMBERS

o Are there family concerns to members who are sick: Ada / No,

o Do families know of health problems experienced by members in their families: Yes / No

o Does the family know the causes of health problems experienced by members in their family:
Yes / No
o Do families know the signs and symptoms of health problems experienced by members in
their family:
o Yes / No
o Is the family aware of the health problems experienced by members in their family if not
treated / treated: Yes / No
o On whom the family used to dig up information about health problems experienced by family
members:
o Family a / Neighbors / Cadres / Health Workers, Namely: ……………
o Family beliefs about health problems experienced by family members: No need to be treated
because they will heal themselves usually / Need to go to the Yankes facility / Do not think
o Do families actively make efforts to improve the health of their family members: Yes /
o No, Explain: The family does not know about efforts to improve health that are experiencing
pain
o Does the family know the treatment needs of health problems experienced by family
members: Yes / No, Explain The family says if they are sick they should seek treatment.
o Can families do how to care for family members with the health problems they experience:
o Yes / No Explain:
o Can the family prevent health problems experienced by family members: Yes /
o No, Explain:
o Is the family able to maintain or modify the environment that supports the health of family
members who have health problems: Yes / No, Explain: ....

o Is the family able to explore and utilize resources in the community to overcome health
problems of family members: Yes / No.
CRITERIA OF FAMILY INDEPENDENCE

1. 1. Receiving puskesmas officers

2. 2. Receiving health care according to plan
3. 3. State health problems correctly
4. 4. Use health facilities as recommended
5. 5. Carrying out simple treatments as recommended
6. 6. Carry out preventive measures actively
7. 7. Implement promotive actions actively
8. CONCLUSION1. Independence I: If it meets criteria 1 & 2
9. 2. Independence II: If it meets criteria 1 & 5
10. 3. Independence III: If it meets criteria 1 & 6
11. 4. Independence IV: If it meets criteria 1 & 7