First Level Assessment
I. Presence of Wellness Condition-stated as potential or Readiness-a clinical or nursing judgment about a client in transition from a specific level of wellness or capability to a higher level. Wellness potential is a nursing judgment on wellness state or condition based on client’s performance, current competencies, or performance, clinical data or explicit expression of desire to achieve a higher level of state or function in a specific area on health promotion and maintenance. Examples of this are the following
A. Potential for Enhanced Capability for:
B. Readiness for Enhanced Capability for:
II. Presence of Health Threats-conditions that are conducive to disease and accident, or may result to failure to maintain wellness or realize health potential. Examples of this are the following:
A. Presence of risk factors of specific diseases (e.g. lifestyle diseases, metabolic syndrome)
B. Threat of cross infection from communicable disease case
C. Family size beyond what family resources can adequately provide
D. Accident hazards specify.
E. Faulty/unhealthful nutritional/eating habits or feeding techniques/practices. Specify.
F. Stress Provoking Factors. Specify.
G. Poor Home/Environmental Condition/Sanitation. Specify.
H. Unsanitary Food Handling and Preparation
I. Unhealthy Lifestyle and Personal Habits/Practices. Specify.
J. Inherent Personal Characteristics-e.g. poor impulse control
K. Health History, which may Participate/Induce the Occurrence of Health Deficit, e.g. previous history of difficult labor.
L. Inappropriate Role Assumption- e.g. child assuming mother’s role, father not assuming his role.
M. Lack of Immunization/Inadequate Immunization Status Specially of Children
N. Family Disunity-e.g.
O. Others. Specify._________
III. Presence of health deficits-instances of failure in health maintenance.
A. Illness states, regardless of whether it is diagnosed or undiagnosed by medical practitioner.
B. Failure to thrive/develop according to normal rate
C. Disability-whether congenital or arising from illness; transient/temporary (e.g. aphasia or temporary paralysis after a CVA) or permanent (e.g. leg amputation secondary to diabetes, blindness from measles, lameness from polio)
IV. Presence of stress points/foreseeable crisis situations-anticipated periods of unusual demand on the individual or family in terms of adjustment/family resources. Examples of this include:
B. Pregnancy, labor, puerperium
D. Additional member-e.g. newborn, lodger
F. Entrance at school
H. Divorce or separation
J. Loss of job
K. Hospitalization of a family member
L. Death of a member
M. Resettlement in a new community
O. Others, specify.___________
I. Inability to recognize the presence of the condition or problem due to:
B. Denial about its existence or severity as a result of fear of consequences of diagnosis of problem, specifically:
C. Attitude/Philosophy in life, which hinders recognition/acceptance of a problem
D. Others. Specify _________
II. Inability to make decisions with respect to taking appropriate health action due to:
A. Failure to comprehend the nature/magnitude of the problem/condition
B. Low salience of the problem/condition
C. Feeling of confusion, helplessness and/or resignation brought about by perceive magnitude/severity of the situation or problem, i.e. failure to breakdown problems into manageable units of attack.
D. Lack of/inadequate knowledge/insight as to alternative courses of action open to them
E. Inability to decide which action to take from among a list of alternatives
F. Conflicting opinions among family members/significant others regarding action to take.
G. Lack of/inadequate knowledge of community resources for care
H. Fear of consequences of action, specifically:
I. Negative attitude towards the health condition or problem-by negative attitude is meant one that interferes with rational decision-making.
J. In accessibility of appropriate resources for care, specifically:
K. Lack of trust/confidence in the health personnel/agency
L. Misconceptions or erroneous information about proposed course(s) of action
M. Others specify._________
III. Inability to provide adequate nursing care to the sick, disabled, dependent or vulnerable/at risk member of the family due to:
A. Lack of/inadequate knowledge about the disease/health condition (nature, severity, complications, prognosis and management)
B. Lack of/inadequate knowledge about child development and care
C. Lack of/inadequate knowledge of the nature or extent of nursing care needed
D. Lack of the necessary facilities, equipment and supplies of care
E. Lack of/inadequate knowledge or skill in carrying out the necessary intervention or treatment/procedure of care (i.e. complex therapeutic regimen or healthy lifestyle program).
F. Inadequate family resources of care specifically:
G. Significant persons unexpressed feelings (e.g. hostility/anger, guilt, fear/anxiety, despair, rejection) which his/her capacities to provide care.
H. Philosophy in life which negates/hinder caring for the sick, disabled, dependent, vulnerable/at risk member
I. Member’s preoccupation with on concerns/interests
J. Prolonged disease or disabilities, which exhaust supportive capacity of family members.
K. Altered role performance, specify.
L. Others. Specify._________
IV. Inability to provide a home environment conducive to health maintenance and personal development due to:
A. Inadequate family resources specifically:
B. Failure to see benefits (specifically long term ones) of investments in home environment improvement
C. Lack of/inadequate knowledge of importance of hygiene and sanitation
D. Lack of/inadequate knowledge of preventive measures
E. Lack of skill in carrying out measures to improve home environment
F. Ineffective communication pattern within the family
G. Lack of supportive relationship among family members
H. Negative attitudes/philosophy in life which is not conducive to health maintenance and personal development
I. Lack of/inadequate competencies in relating to each other for mutual growth and maturation (e.g. reduced ability to meet the physical and psychological needs of other members as a result of family’s preoccupation with current problem or condition.
J. Others specify._________
V. Failure to utilize community resources for health care due to:
A. Lack of/inadequate knowledge of community resources for health care
B. Failure to perceive the benefits of health care/services
C. Lack of trust/confidence in the agency/personnel
D. Previous unpleasant experience with health worker
E. Fear of consequences of action (preventive, diagnostic, therapeutic, rehabilitative) specifically :
F. Unavailability of required care/services
G. Inaccessibility of required services due to:
H. Lack of or inadequate family resources, specifically
I. Feeling of alienation to/lack of support from the community, e.g. stigma due to mental illness, AIDS, etc.
J. Negative attitude/ philosophy in life which hinders effective/maximum utilization of community resources for health care
K. Others, specify __________