FAMILY
FOLDER/FAMILY CASE STUDY
Date of registration: Folder No:
Head of the family:
House No:
House:
Own/ Rented
Address:
Type of house: Pucca/Semi pacca/kaccha
Religion: No of rooms:
Caste :
Ventilation:
well/ ill
Type of family:
Nuclear/Joint/Extended Total monthly
income.................Rs.
No of Family members: Food
pattern: Veg./Non veg.
Family care group members:
New
born/Infant/ under five /School age children /Adolescent
/Antenatal mother /Postnatal mother /Geriatric person
If
morbidity is present specify:
FAMILY
CHARACTERISTICS
S.N
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Name of the family members
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Relation-ship with head of the family
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Age/Gender
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Educational status
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Occup/
Income
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Marital status
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Nutritional status
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Health status
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Remarks
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Family Tree:-
Past Medical History Of Family:-
Past surgical history of family:-
Present history of illness:-
Environmental Condition:-
Electricity facility : Yes/No
Water supply : Tap water/Dug well/Bore
well/Lake/River
Drainage: open/ closed
Latrine: Yes/No
Disposal of waste : Hygienic /Unhygienic
Presence of
Rodents & Pests: If specify…………………
Animals Kept: Yes/No If Yes Specify…………. .Pet animals: Yes/No If Yes Specify………….
Nutritional history:-
A)
Diet
pattern:
Hygienic
practices in cooking followed: yes/no
Food
category: Vegetarian /Non vegetarian/Ova vegetarian
Cooking
practices:--fresh preparation/storing -
Availability
of food items:- fresh/stored or preserved
Cooking
by:
B)
Nutritional
status:
Name
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Weight (kg)
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Height (cm)
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Body built
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BMI (Normal
19-25)
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Thin
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Moderate
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Well
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Obese
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Below normal
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Normal
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Above normal
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C) Nutritional deficiency: yes/no. if yes specify:
Anemic/Goiter/Night Blindness/ Scurvy/Rickets/PEM/Others
S.no
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NAME
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AGE
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SYMPTOMS
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TREATMENT
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REMARKS
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D)
24 hours diet recall for target group:
Time
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Menu
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Quantity per serving
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CHO
(g)
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Protein
(g)
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Fat
(g)
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Calcium
(g)
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Iron
(mg)
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Vitamin
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Calories
(kcal)
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E)
Recommended /Modified Menu Plan
Time
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Menu
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Quantity per serving
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CHO
(g)
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Protein
(g)
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Fat
(g)
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Calcium
(g)
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Iron
(mg)
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Vitamin
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Calories
(kcal)
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BENEFICIARY DATA
Name :
Age:
Sex:
PHYSICAL EXAMINATION
General Appearance:-
Nourishment – Well
nourished / Mal nourished
Body build – Thin
/ Moderate / Obese
Health – healthy /
unhealthy
Activity – Active
/ dull
Vital Signs:
Vital Signs
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Normal value
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Patient value
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Remarks
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Temperature
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Pulse
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Respiration
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B.P.
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Anthropeometric measurement:
Height (cm):
Weight (kg):
1.
Head to toe examination
a)
Skin:
Color: pink/yellow/pale/blue (cyanosed)
Temperature: cold/warmth/hot
Texture: moisture/dry
Turgor: good elasticity/poor elasticity/no
elasticity
Integrity: normal/injury
b). Head:
Scalp: Clean/Unclean, Pediculosis present/not
present, dandruff present/not present
Hair distribution:
equal/alopecia
Hair texture:
soft/hard/brittle/ dryness
Hair color: black/brown/
white.
c). Face: symmetry asymmetry/puffiness/swelling (facial
edema)/flushed /pale/cyanosed/pink
d). Eyes:
Visual acquit:
normal/myopia/hyperopia/blurred vision/double vision/color blindness
Presence of
orbital edema/black
rings/tenderness/inflammation/redness/photophobia/itching/eye injuries etc
e). Nose:
Mucosa: pink/
red//pale
Septum:
medial/deviated
Nasal breath: Rt
nostril/Lt nostril/both nostril/absence
Presence of
crust/nasal discharge/ bleeding/ Sneezing/lopss of smell/obstruction/breathing
problems etc.
f)
Mouth:
Lips: normal/angular
stomatitis/crackled lip/ dry lips
Teeth: dental
carries/loss of teeth/use of dentures
Tongue: normal/pale
Uvula:
pink/pale/red
Larynx: voice
changes
g)
Ear:
Hearing acquit:
normal/conductive hearing loss/sensory hearing loss/mixed hearing loss
Discharge, pain,
tenderness behind the ears
h)
Neck:
Palpable thyroid
gland: yes/no
palpable lymph
node/yes/no
ROM: yes/no
Stiffness/pain/swelling
etc
i)
Chest:
Inspect for Shape:
Normal/Abnormal(specify)
Palpation: mass/nodules/tenderness etc
Percussion:
normal/dull sound
Auscultation: for Lung sounds: normal breath sounds/
crackles/wheezing/grunting etc
j)
Abdomen:
Inspection: scar, rashes etc
Palpation: organ enlargement/mass
Percussion: fluid or gas collection
Auscultation: bowel sound
k)
Back:
Body curves –Normal/
Lordosis / Kyphosis / Scoliosis
Movement – Showing
ROM / inappropriate ROM
l)
Extremities:
Range of motion: yes/no
Presence of any
abnormalities: yes/no If yes Specify…..
m)
Genitalia:-
DISEASE CONDITION
Sr. No
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Client picture
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Book Picture
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Nursing Diagnosis (Beneficiary and Family)
HEALTH VISIT RECORD
S.no.
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Date of visit
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Name
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Needs
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Problems
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Treatment details
Hospital/home
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Referral service if needed, follow up
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Health education
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Sign.
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FAMILY HEALTH CARE STUDY
1.
INTRODUCTION:
I am ______________, ____B.Sc (N), as a part
of my community requirement I posted in __________village from -------------to
------------. And I took care of one
family from______ to ________ and target
group is __________ for my care study.
Community Profile:
State:
District:
Village:
Transport: Own/Private/Government/Other
Communication:
telephone/TV/radio/newspaper/post/websites
Health
care facilitY: PHC/SC/CHC/Private/Govt Aided
Educational
Facility: Balwadi/Schools/Colleges/Universities
Presence Of
Organization: GOVT ORGANIZATIONS/ NON GOVT. ORGANISATION (NGOS)
Religious
facilities: Temple/Church/Gurudwara/ Masjith
/Others:
Recreational
facilities: Cinema theatres/Park/Zoo:
2.
BIO-DEMOGRAPHIC
DATA:-
Name
of the head of the family:
Name
of the client:
Age:-_______years
Gender:
Classification;
Address
of the family:-
Education:-
Occupation:
Marital
status:
Religion:
Date
of care started:
Date
of care ended:
Problems
identified:
Family history:
Type
of family:
Family
tree:
Family
composition:
S.no
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Name
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R/S with head
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Age
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sex
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Education
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Occupation
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Health status
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Remarks
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Past health history:
Previously
hospitalized, duration of illness, treatment had, and effects of treatment.
Personal history:
Habit
of smoking, chewing pan leaves, alcoholic, or any other habits.
Present health problems:
Health
problems or any complaints,
constipation, or pain or diarrhea and its duration of the complaints.
Socio economic history:
Economic
status of the family:
Housing:
own/rent
Total
income of the family:
Farms: present/absent
Environmental history:
Type
of house: kuttcha/pucca/semipucca
Number
of living room:
Living
room space: Adequate/Inadequate
Kitchen
condition: separate/corner of the house/verandas
Occupancy:
Tenant/Owner/Monthly rent
Ventilation:
adequate/inadequate/no ventilation
Electricity
facility: yes/ no
Water supply : Tap water/Dug well/Bore well/Lake/River
Latrine: Yes/No
Sullage
water disposal: open drainage/closed drainage/soakage pit/kitchen garden
Refusal
disposal: indiscriminate throwing/composting/burning/municipality collection
Excreta
disposal: open air defecation/separate latrine/shared latrine/ public toilet
Accident
place environment: Sharp stone/Slippery floor/Open drainage/others
Presence of Rodents & Pests: If
specify…………………
Cattle Kept:
Yes/No If Yes Specify…………. .
Pet animals: Yes/No If Yes Specify………….
Floor map of the house:
Nutritional history:
F)
Diet
pattern:
Hygienic
practices in cooking followed: yes/no
Food
category: Vegetarian /Non vegetarian/Ova vegetarian
Cooking
practices:--fresh preparation/storing -
Availability
of food items:- fresh/stored or preserved
Cooking
by: Coal/ Wood/ Cow dung/ Kerosene oil stove/LPG
Gas
G)
Nutritional
status:
Name
|
Weight (kg)
|
Height (cm)
|
Body built
|
BMI (Normal
19-25)
|
Thin
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Moderate
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Well
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Obese
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Below normal
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Normal
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Above normal
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c) Nutritional deficiency:
yes/no. if yes specify:
Anaemic/Goitre/Night Blindness/ Scurvy/Rickets/PEM/Others
S.NO
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NAME
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AGE
|
SYMPTOMS
|
TREATMENT
|
REMARKS
|
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d) 24 hours diet recall of target
group:
Physical assessment
Disease condition:
List of individual, family and community
diagnosis
Nursing process:
Assessment
of family health problems
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Nursing
diagnosis
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Expected
outcomes
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Intervention
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Evaluation
|
plan
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Implementation
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Subjective
data:
Objective
data:
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Modified diet plan:
Health education:
Conclusion:
Bibliography
