COMMUNITY FAMILY CASE STUDY FORMATE

                            

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	Name of the family members	Relation-ship with head of the family	Age/Gender	Educational status	Occup/ Income	Marital status	Nutritional status	Health status	Remarks

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	Weight (kg)	Height (cm)	Body built				BMI (Normal 19-25)
			Thin	Moderate	Well	Obese	Below normal	Normal	Above normal

  C)   Nutritional deficiency: yes/no.  if yes specify: Anemic/Goiter/Night Blindness/ Scurvy/Rickets/PEM/Others

S.no	NAME	AGE	SYMPTOMS	TREATMENT	REMARKS

D)     24 hours diet recall for target group:

Time	Menu	Quantity per serving	CHO (g)	Protein (g)	Fat (g)	Calcium (g)	Iron (mg)	Vitamin	Calories (kcal)

E)     Recommended /Modified Menu Plan

Time	Menu	Quantity per serving	CHO (g)	Protein (g)	Fat (g)	Calcium (g)	Iron (mg)	Vitamin	Calories (kcal)

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	Normal value	Patient value	Remarks
Temperature
Pulse
Respiration
B.P.

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	Client picture	Book Picture

Nursing Diagnosis (Beneficiary and Family)

HEALTH VISIT RECORD

S.no.	Date of visit	Name	Needs	Problems	Treatment details Hospital/home	Referral service if needed,  follow up	Health education	Sign.

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	Name	R/S with head	Age	sex	Education	Occupation	Health status	Remarks

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	Moderate	Well	Obese	Below normal	Normal	Above normal

c) Nutritional deficiency: yes/no.  if yes specify: Anaemic/Goitre/Night Blindness/ Scurvy/Rickets/PEM/Others

S.NO	NAME	AGE	SYMPTOMS	TREATMENT	REMARKS

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	Nursing diagnosis	Expected outcomes	Intervention		Evaluation
			plan	Implementation
Subjective data: Objective data:

 Modified diet plan:

 Health education:

Conclusion:

Bibliography