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Family Nursing Care Plan
Assessment & Diagnosis

Based on Maglaya, Bailon & Maglaya, and Friedman. Prepared by AV & MA Manzano.

Contents — click any section to jump
01The Family 02Nursing Process Overview 03Assessment Data Base 041st Level Assessment 05First-Level Typology 062nd Level Assessment 07Family Coping Index 08Nursing Diagnosis 09Prioritization (NMPS) 10Goals & Objectives 11Intervention 12Evaluation 13Self-Test
01 The Family: Definitions & Forms ▾
Key Definitions
NSCB, 2008A group of persons usually living together, composed of the head and other persons related by blood, marriage, or adoption. Includes nuclear and extended families.
Johnson, 2000A social unit interacting with the larger society.
Friedman, 2003Two or more persons joined by bonds of sharing and emotional closeness who identify themselves as part of the family.
Family Forms

Nuclear

Husband, wife, children (natural or adopted)

Extended

Three generations including married siblings or grandparents

Compound

Man with more than one spouse (PD 1083)

Single Parent

Death of spouse, separation, or pregnancy out of wedlock

Dyad

Newly married couples or "empty nesters"

Blended

Union where one/both spouses bring children from a previous marriage

Cohabiting

"Live-in"; unmarried; common-law spouses

Gay/Lesbian

Same sex living together for companionship, financial security, or fulfillment

02 Family Health Nursing Process ▾
The 4-Phase Cycle
A

Assess

Enter the family system. Identify health conditions and the etiologies of family inaction.

P

Plan

Prioritize vulnerabilities and architect achievable objectives.

I

Implement

Catalyze behavior change by building cognitive, psychomotor, and affective competencies.

E

Evaluate

Measure clinical outcomes against normative standards and adjust the intervention.

Features — "FAMILY" Mnemonic
FFuturistic
AActs on problems
MMethodical / Systematic Process
IIdentifies problems
LLifelong / Continuous
YYields best care
6 Steps of the Family Health Nursing Process
  1. 1st Level Assessment
  2. 2nd Level Assessment
  3. Prioritization of identified problems
  4. Formulation of goals & objectives
  5. Select appropriate nursing interventions
  6. Develop the evaluation plan
3 Types of Nursing Care Plan

Individual Care Plan • Family Care Plan • Community Care Plan

03 Assessment Data Base (ADB) ▾
5 Categories of the ADB

1. Family Dynamics & Structure

Composition, power structures, decision-making patterns, interpersonal conflicts

2. Socio-Economic & Cultural

Income, educational attainment, ethnic background, community roles

3. Home & Environment

Living space adequacy, sanitation, water supply, neighborhood type

4. Health Status of Members

Current/past illnesses, physical assessments, BMI, dietary history

5. Values & Practices

Immunization status, lifestyle practices (sleep, exercise), use of preventive services

Data Gathering Toolkit — 5 Tools
ToolPurpose
1. ObservationAssessing sensory signs and home conditions
2. Physical ExamDirect examination to indicate health deficits
3. InterviewCrucial for 2nd-level assessment. Requires trust and confidentiality. Uses probing questions to assess self-determination.
4. Record ReviewClinical records, immunization logs
5. Lab TestsValidating physiological integrity
Tools Used on Family Assessment
  • Genogram — family tree (1st level assessment); outlines structure over 3 generations; children pictured left to right by age
  • Ecomap — maps external interactions and energy flow; identifies where energy is drained and support is lacking
  • Initial Database — Family Assessment Guide
  • Gordon's Assessment Tool — 11 functional health patterns
  • Family APGAR — Adaptation, Partnership, Growth, Affection, Resolve
  • Family Coping Index — 2nd level assessment tool
Assessment Process Map — 3 Phases
1

Data Collection

Gathering data on status/condition (1st level) and assumption of health tasks (2nd level).

2

Data Analysis

Sorting, clustering, identifying patterns, comparing to norms, drawing inferences.

3

Nursing Diagnoses

Defining the exact health conditions and specifying the family's barriers to performance.

Continuous data validation & update for adequacy of evidence runs throughout all 3 phases.

Data Analysis Pipeline — 7 Steps

Sort → Cluster → Distinguish → Identify Patterns → Relate to Norms → Interpret → Make Inferences

GIPPAT Framework (Building Rapport)
G — GreetFriendly greeting shows respect and warmth
I — IntroduceIntroduce yourself and your role
P — PurposeExplain the purpose of your visit clearly
P — PermissionAsk permission to talk, assess, or provide care
A — Assist/ActProvide care with competence, compassion, respect
T — ThankThank the person and agree on next steps
04 1st Level Assessment ▾
Definition (Maglaya, 2009): Process whereby data about the current health status of individual members, the family as a system, and its environment are compared against norms or standards of personal, social, and environmental health.
Two Levels of Assessment — The Operational Engine

1st Level — "The What"

Identifying the condition. Comparing current health status against established norms.

Output: Specific health conditions — WellnessThreatsDeficitsCrises

2nd Level — "The Why"

Identifying the barrier. Specifying the family's inability to perform essential health tasks.

Output: The underlying etiology or cause of the failure to act.

05 First-Level Typology ▾

Wellness States

A clinical judgment about a client in transition to a higher level of wellness.

Potential for Enhanced

Based on current performance/clinical data. No explicit expression of desire to improve.

Readiness for Enhanced

Based on current competencies with explicit expression of desire to achieve higher-level health.

Examples: Enhanced healthy lifestyle, breastfeeding, parenting, spiritual well-being.

Health Threats

Conditions conducive to disease, accident, or failure to realize health potential.

CategoryExamples
Inherent Traits & Medical HistoryHealth history (e.g., previous difficult labor), inherent characteristics (poor impulse control), risk factors (metabolic syndrome, smoking), lack of immunization
Behavioral Choices & Daily HabitsSmoking, alcohol, poor hygiene, self-medication, inadequate sleep, lack of exercise, faulty nutritional habits, unsanitary food handling
Relational Friction & Family StructureFamily disunity, stress-provoking factors, inappropriate role assumption, resource constraints
Physical Environment HazardsAccident hazards (broken stairs, fire risks), poor environmental sanitation (polluted water, vector breeding sites), threat of cross-infection

Health Deficits

Instances of actual failure in health maintenance.

  • Illness States — diagnosed or undiagnosed illness
  • Failure to Thrive — failing to develop at a normal rate
  • Disability — transient (e.g., aphasia after CVA) or permanent (e.g., amputation, blindness)

Stress Points / Foreseeable Crises

Anticipated periods of unusual demand requiring adjustment to family resources.

Early Life

Pregnancy, labor, parenthood, newborn, school entrance, adolescence, illegitimacy

Adulthood

Marriage, loss of job, divorce/separation

Later Life

Menopause, hospitalization, resettlement, death of a member

06 2nd Level Assessment & The 5 Inabilities ▾
Definition (Maglaya, 2009): Defines the nature or type of nursing problems that the family encounters in performing health tasks, and the etiology or barriers to the family's assumption of these tasks.
The 5 Breakdowns in Family Action
#InabilityBroken ByKey Interview Question
1 Recognize the condition Lack of knowledge, denial of severity, social stigma, philosophy in life "What does the family think about the situation?"
2 Decide on health action Failure to comprehend magnitude, low salience, feeling helpless, lack of knowledge of alternatives "What has been done to improve the condition?"
3 Provide Care Lack of knowledge/equipment, inadequate resources (financial, manpower), role strain/conflict "What barriers were encountered in implementing care?"
4 Maintain Environment Limited physical resources, failure to see long-term benefits, ineffective communication "How are other members affected by this problem?"
5 Utilize Resources Lack of knowledge of resources, lack of trust, previous bad experiences, physical/financial inaccessibility "Are you aware of the free health services at your barangay?"
Interview Principles
  • Validation: Relate verbal responses with non-verbal cues to ensure accuracy.
  • Etiology Focus: If a family gives a negative answer, always explore WHY rather than skipping the question.
  • Refining the Diagnosis: Final product = nursing diagnosis stating the unhealthful response (inability) + the factors maintaining it (etiology).
07 Family Coping Index ▾

Purpose: Assess the family's overall capacity to cope rather than focusing on individual problems.

Scoring: 1 = No Competence • 3 = Moderate Competence • 5 = Complete Competence

9 Areas of Assessment
  1. Physical Independence
  2. Therapeutic Independence
  3. Knowledge of Health Condition
  4. Application of Hygiene
  5. Health Attitude
  6. Emotional Competence
  7. Family Living
  8. Physical Environment
  9. Use of Community Facilities
08 Formulating the Nursing Diagnosis ▾
[1st-Level Condition] + [2nd-Level Etiology] = Family Nursing Diagnosis
Example

Condition: Inability to utilize community resources for health care

Etiology: ...due to inadequate family resources (financial, manpower, time)

Key Takeaway: A diagnosis is a clinical judgment about the family's response to actual or potential health problems. The more specific the etiology, the more precise the nursing intervention.
09 Prioritization of Problems (NMPS) ▾
N.URSES M.UST P.RIORITIZE S.MARTLY

Uses the Scale for Ranking Health Conditions and Problems by Bailon and Maglaya.

A. Nature of the Problem (Weight: 1)
ClassificationScore
Wellness State3
Health Deficit3
Health Threat2
Stress Point / Foreseeable Crisis1
B. Modifiability of the Problem (Weight: 2)

Factors: Knowledge/Technology, Family resources, Nurse resources, Community resources

ClassificationScoreFactors Present
Easily Modifiable24 factors
Partially Modifiable11–3 factors
Not Modifiable00 factors
C. Preventive Potential (Weight: 1)

Depends on: Gravity (severity) • Duration • Current Management • Vulnerable Groups

ClassificationScoreCriteria
High3Early stage, low gravity, vulnerable group; action can totally prevent complications
Moderate2Moderate severity; intervention can only partially minimize damage
Low1Chronic, very severe, or advanced; little potential to prevent further magnitude
Remember: Higher severity = lower preventive potential (inverse). Good current management = higher preventive potential (direct). Presence of vulnerable group = increases preventive potential.
D. Salience (Weight: 1)

Family's perception and evaluation of the problem's urgency.

StandardScore
Needing immediate attention2
Not needing immediate attention1
Not perceived as a problem0
Scoring Formula
(Assigned Score ÷ Highest Possible Score) × Weight = Actual Score

Sum all 4 criteria. Maximum total = 5 (the total of all weights: 1 + 2 + 1 + 1).

The problem with the highest total score gets first priority.

Quick-Reference Weighting Table
CriterionWeightHighest Possible Score
Nature13 (Wellness/Deficit)
Modifiability22 (Easily)
Preventive Potential13 (High)
Salience12 (Immediate)
10 Goals & Objectives ▾
Goal vs. Objective

Goal

Broad desired outcome. Tells "where the family is going." Must be set jointly with the family (cardinal principle).

Objective

Specific, measurable milestones to reach the goal. Criteria for evaluating care effectiveness. Must be SMART.

SMART Framework
S — SpecificClear, significant, sensible
M — MeasurableHave means to monitor progress or evaluate results
A — AttainableFlexible and possible
R — RealisticHave available resources at hand
T — TimelyDeadline, designated time parameter
Objectives Timeline
S

Short-term / Immediate

Few nurse contacts, short observation period.

M

Medium-term / Intermediate

Requires time to demonstrate, bridges the gap.

L

Long-term / Ultimate

Sustained behavior change, high investment of resources.

Behavioral Verbs — Use These in Objectives
CognitiveAffectivePsychomotor
Teach, Discuss, Identify, Describe, List, Report, Distinguish, Compare, Recall, State, Define, Name, Classify Express, Explain, Share, Listen, Communicate, Relate, Contrast Demonstrate, Practice, Participate, Perform, Exhibit, Record, Verbalize, Arrange, Modify, Construct, Use
Do NOT use non-measurable verbs: Know, Think, Appreciate, Accept, Feel
Barriers to Joint Goal Setting (Freeman)
  • Perception — failure to see the problem
  • Preoccupation — consumed by daily survival over preventive care
  • Trivialization — recognizing the problem but dismissing severity
  • Refusal to Act — fear of stigma, traditions, mismatched economic goals
  • Trust Deficit — failure to develop a mutual, respectful working relationship
11 Intervention ▾
3 Primary Decision-Making Areas
  1. Select nursing action/intervention — choose from alternatives
  2. Determine contact method — most effective/efficient nurse-family contact
  3. Specify resources needed — material and human
5 Vectors of Intervention
1

Recognize the Problem

Enhance knowledge of magnitude, causes, consequences. Affirm capabilities.

2

Decide on Health Actions

Explore available courses of action and analyze consequences of inaction.

3

Provide Nursing Care

Develop commitment through demonstration, practice, and creative contracting.

4

Enhance the Home Environment

Teach environmental modification (e.g., eliminating vector breeding sites).

5

Utilize Community Resources

Facilitate maximum use of available socio-economic resources and referral systems.

Guidelines for Selecting Interventions
  1. Analyze the Situation with the Family — "Look-Think-Act" participatory approach. Deconstruct mindsets to find workable options.
  2. Develop Family Competencies — as Thinker (cognitive), Doer (psychomotor), Feeler (affective).
  3. Focus on Health Tasks — minimize/eliminate reasons they can't perform essential tasks.
  4. Catalyze Behavior Change — provide motivation (information) and support (experiences) for self-directed change.
Interventions Focus
FocusGoalSample Verbs
AssessmentDetermine family health status, problem, capabilityAssess, determine, identify, examine, observe
Direct Care / ManagementHelp family perform health tasksImplement, assist, perform, facilitate, promote, guide
Health EducationEmpower family for self-reliant managementExplain, teach, demonstrate, encourage, reinforce, verify
Methods of Nurse-Family Contact (3 Criteria: Effectivity, Efficiency, Appropriateness)
MethodKey Points
1. Home VisitBest for accurate appraisal of family relationships & home environment. Expensive in time/logistics.
2. Clinic/OfficeLess expensive. Access to specialized equipment. Emphasizes empowerment.
3. TelephoneFor immediate data access, monitoring acute illness, schedule changes.
4. Written CommunicationFor motivated/independent families. Reminders, referrals. Less time-consuming.
5. Specialized ContactsSchool visits (child/adolescent health), industrial/job site visits (occupational health).
Resources

Material

Essential supplies & equipment, teaching aids & kits, indigenous/locally available substitutes

Human/Manpower

Professional health team, community leaders, auxiliary/village health workers, the family itself

12 Evaluation ▾

Serves as a blueprint for determining changes in a family's health status and verifying the achievement of desired outcomes. The nursing process is cyclical — evaluation data feeds back into assessment.

4 Core Components
Criteria / IndicatorsObjective, measurable markers derived from stated objectives.
StandardsDesired or acceptable condition against which actual condition is compared.
Evaluation MethodsDirect observation, interviews, record reviews, physical exams (e.g., vital signs).
Tools & Data SourcesInstruments (scales, thermometers, checklists) and resulting records/reports.
Evaluation of Goals
StatusMeaning
Goal MetAll objectives achieved within timeframe. Family is independent.
Goal Partially MetSome objectives achieved (partial independence). Further intervention needed.
Goal Not MetNo planned objectives met. Interventions may need revision; barriers must be re-assessed.
13 Self-Test: Click to Reveal Answers ▾
What are the 4 outputs of the 1st Level Assessment?reveal →
Wellness States, Health Threats, Health Deficits, and Stress Points/Foreseeable Crises.
What are the 5 Inabilities (2nd Level Typology)?reveal →
1) Recognize the condition, 2) Decide on health action, 3) Provide adequate care, 4) Maintain a health-conducive environment, 5) Utilize community resources.
What is the prioritization scoring formula?reveal →
(Assigned Score ÷ Highest Possible Score) × Weight = Actual Score. Sum all four criteria. Maximum total = 5.
What are the 4 pillars of prioritization and their weights?reveal →
Nature (wt. 1), Modifiability (wt. 2), Preventive Potential (wt. 1), Salience (wt. 1). Mnemonic: Nurses Must Prioritize Smartly.
What score does a Health Threat receive under "Nature of the Problem"?reveal →
Score of 2. (Wellness State and Health Deficit both get 3; Stress Point/Foreseeable Crisis gets 1.)
What is the difference between "Potential" and "Readiness" for Enhanced wellness?reveal →
Potential: Based on current data but NO explicit expression of desire to improve. Readiness: Same + WITH explicit expression of desire to achieve higher-level health.
What are the 9 areas of the Family Coping Index?reveal →
1) Physical Independence, 2) Therapeutic Independence, 3) Knowledge of Health Condition, 4) Application of Hygiene, 5) Health Attitude, 6) Emotional Competence, 7) Family Living, 8) Physical Environment, 9) Use of Community Facilities.
What 4 factors affect Preventive Potential?reveal →
Gravity (severity), Duration, Current Management, and Exposure of Vulnerable/High-Risk Groups.
What does GIPPAT stand for?reveal →
Greet, Introduce, Purpose, Permission, Assist/Act, Thank/Set Contract — the framework for building rapport in community nursing.
Name the 5 categories of the Assessment Data Base (ADB).reveal →
1) Family Dynamics & Structure, 2) Socio-Economic & Cultural, 3) Home & Environment, 4) Health Status of Members, 5) Values & Practices.
What is the "cardinal principle" in family nursing goal setting?reveal →
Goals must be set jointly with the family.
What verbs should you NOT use in objectives?reveal →
Know, Think, Appreciate, Accept, Feel — these are non-measurable verbs.
What are the 5 Vectors of Intervention?reveal →
1) Recognize the problem, 2) Decide on health actions, 3) Provide nursing care, 4) Enhance the home environment, 5) Utilize community resources.
What are the 3 evaluation outcomes for a Goal?reveal →
Goal Met (all objectives achieved, family independent), Goal Partially Met (some achieved, further intervention needed), Goal Not Met (none achieved, revise interventions).
How do you determine if a problem is "Easily Modifiable"?reveal →
All 4 factors must be present: 1) Knowledge/technology available, 2) Family has physical/financial means, 3) Nurse has skills/time, 4) Community has supportive facilities. If 1-3 factors = Partially Modifiable; 0 = Not Modifiable.