First Level of Assessment

FIRST LEVEL OF ASSESSMENT
I. Presence of Health threats, Health deficits, Foreseeable crisis/ stress points

of the family.
A. Health Threats (Color the applicable vertical scrolls)
Family history of hereditary diseases
Specify disease/s: Hypertension
Family size beyond family resources
Threats of cross-infection from a communicable disease
Specify disease/s: cough and colds, fever
Inappropriate immunization status especially of children:
Poor environmental situation
Inadequate living space
Inadequate personal belongings/utensils
Lack of food storage
Polluted water supply
Presence of breeding places of insects and rodents
Improper refuse disposal
Improper drainage system
Poor ventilation and lightning
Noise pollution
Unsanitary food handling and preparation
Others, please specify: ____________________________
Inherent personality characteristics

Short temper
Others, please specify: _______________________________
Inappropriate role consumption
Child assuming mother’s role
Accident hazards
Broken stairs
Pointed sharp objects
Poison and medicines improperly kept
Fire hazards
Fall hazards
Others, please specify: Unprotected stairs
Nutritional
Inadequate food intake both in quality and quantity
Excessive intake of certain nutrients
Faulty eating habits
Others, please specify: _________________________
Stress provoking factors
Strained marital relationship
Immature parents
Interpersonal conflicts between family members
Personal habits/practices
Excessive smoking
Walking barefooted
Eating raw fish and meat
Poor personal hygiene
Self-medicated
Health history that may precipitate the occurrence of a health

problem
Specify: Hypertension
Family disunity
Self-oriented behaviour
Unresolved conflicts
Intolerable disagreements
B. Health Deficits (Enumerable and discuss briefly)
• Malnutrition – The children shows signs and symptoms of

malnutrition (underweight, poor skin integrity)
• Diarrhea – one their children shows impending characteristics of
diarrhea that predisposes him in dehydration that may alter the
normal functioning of his body. Some of the manifestation are
frequent defecation in just one day and watery stool.
C. Stress points/foreseeable crisis situations
SECOND LEVEL OF ASSESSMENT

I. Inability to recognize the presence of a problem due to:
Ignorance of facts
Fear of consequences of diagnosis of problem
Social (Stigma, loss of respect of peer/significant others)
Economic (Cost)
Physical/Psychological
Attitude/Philosophy in life
II. Inability to make decisions with respect to taking appropriate health actions
due to: (Color applicable horizontal boxes)
Failure to comprehend the nature, magnitude or scope of the

problem
Low salience of the problem
Feeling of confusion and resignation brought about by failure to

breakdown problems into manageable units of attack
Lack of knowledge/insight as to alternative course of action open

to them
Inability to decide which action to take among the list of

alternatives
Conflicting opinion among members regarding action to take
Ignorance of community resources for health care
Fear of consequences of action
Social
Economic
Physical/Psychological
Negative attitude toward the health problem
Lack of trust/confidence in health personnel/agency
Misconception of erroneous information about proposed course/s

of action
Inability of appropriate resources of care
Pregnancy, labor, puerperium
Parenthood
Additional member of the family
Abortion
Entrance at school
Adolescence
Loss of job
Death of a member
Illegitimacy
Resettlement in a new community
Others, please specify: ______________________________
Physical (location)
Cost
III. Inability to provide nursing care to the sick, disabled, or dependent member
of the family due to: ( Color the applicable horizontal scrolls)
Ignorance of the facts about the disease/health condition
(Nature, severity, complications, prognosis, and management)
Ignorance of the nature and extent of the nursing care needed
Lack of necessary facilities (equipment and supplies) for care

Lack of knowledge and skill in carrying out the necessary
treatment/procedure/care
Inadequate resources for care
Responsible family member
Financial
Physical resources (e.g. isolation room)
Failure to see benefits (especially long term ones) of investments

in home environment improvement
Present of physical/psychological conflicts
Identify crisis/psychological conflicts
Jealousy/rivalry
Guilt feelings
Ignorance of preventive measures
Attitude/philosophy on life
Family disunity
Self-oriented behaviour of members
Intolerable disagreements
Lack of support to members in crisis
IV. Inability to utilize community resources for health due to: ( Put Color Green
to the applicable horizontal scrolls)
Ignorance of lack of awareness of community resources for health

care
Failure to perceive benefits of health care/services

Lack of trust/confidence in health agency/personnel
Previous unpleasant experience with health worker
Fear of consequences of action
Physical/psychological
Financial
Social
Unavailability of required care/services
Inaccessibility of required care/services
Cost
Physical
Inadequate family services
Manpower
Financial
Feelings of alienation/lack of support form from the community
Attitude/philosophy in life:

First Level of Assessment

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FIRST LEVEL OF ASSESSMENT

I. Presence of Health threats, Health deficits, Foreseeable crisis/ stress points

A. Health Threats (Color the applicable vertical scrolls)

Family history of hereditary diseases

Specify disease/s: Hypertension

Family size beyond family resources

Threats of cross-infection from a communicable disease

Specify disease/s: cough and colds, fever

Inappropriate immunization status especially of children:

Poor environmental situation

Inadequate living space

Inadequate personal belongings/utensils

Lack of food storage

Polluted water supply

Presence of breeding places of insects and rodents

Improper refuse disposal

Improper drainage system

Poor ventilation and lightning

Unsanitary food handling and preparation

Others, please specify: ____________________________

Inherent personality characteristics

Others, please specify: _______________________________

Inappropriate role consumption

Child assuming mother’s role

Others, please specify: _______________________________

Pointed sharp objects

Poison and medicines improperly kept

Others, please specify: Unprotected stairs

Inadequate food intake both in quality and quantity

Excessive intake of certain nutrients

Faulty eating habits

Others, please specify: _________________________

Stress provoking factors

Strained marital relationship

Interpersonal conflicts between family members

Others, please specify: _________________________

Eating raw fish and meat

Poor personal hygiene

Others, please specify: _________________________

Health history that may precipitate the occurrence of a health

Others, please specify: _________________________

B. Health Deficits (Enumerable and discuss briefly)

• Malnutrition – The children shows signs and symptoms of

C. Stress points/foreseeable crisis situations

SECOND LEVEL OF ASSESSMENT

Fear of consequences of diagnosis of problem

Social (Stigma, loss of respect of peer/significant others)

Failure to comprehend the nature, magnitude or scope of the

Low salience of the problem

Feeling of confusion and resignation brought about by failure to

Lack of knowledge/insight as to alternative course of action open

Inability to decide which action to take among the list of

Conflicting opinion among members regarding action to take

Ignorance of community resources for health care

Fear of consequences of action

Lack of trust/confidence in health personnel/agency

Misconception of erroneous information about proposed course/s

Inability of appropriate resources of care

Pregnancy, labor, puerperium

Additional member of the family