FAMILY FOLDER COMMUNITY WITH IDEAL COMMUNITY DESIGN.docx

A community is a group of people living in a particular area. A community can be made up of a large or small group of people. The land area of a community can also be large or small. A community may be roomy or crowded, depending on the size of its land area and population, or amount of people living there.

1. COMMUNITY HEALTH NURSING
FAMILY FOLDE R
PREPARED BY
Prof.Dr.Anjalatchi Muthukumaran
Professor cum vice principal
Department of community health nursing
Era college of nursing, era university
Lucknow 226003

2. Primary Health Centre:------------------------------------
Sub Centre/HWC :-----------------------------------
Name of The Village :------------------------------------
1.IDENTIFICATION INFORMATION
Head of Family-
Name : --------------------------------------------------
Occupation: ----------------------------------------------------
Address : ---------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------
Type of family: Nuclear Joint Extended
Religion: Hindu: Muslim: Christian: Any other:
2.HOUSING CONDITION
1.TYPE OF HOUSE: Completed: Independent: Tiled: Sheeted:
Hut: Owned: Rented:
2.Rooms : Number : Adequate: Inadequate:
3.Kitchen : Separate: Attached to room:
4.Fuel used : Gas: kerosene Firewood Electricity
5.Ventilation : adequate: Inadequate:
6.Bath room : separate: Common:
7.Lighting : Electricity Oil lamp: Solar
8.Drainage : Open Close
9.Water supply : Tap/ hand pump Well chlorine – yes/no open tank chlorinated
10.Toilet : Own Public: Open field:
11.Disposal of waste : Composing Burning Buying
12.Cattle shed : Separate Within the house

3. 3. PHYSICAL INFRASTRUCTURE COMMUNITY :
4. FAMILY HEALTH STATUS
I) FAMILY TREE
II) FAMILY COMPOSITION
S. N.Name Relationship
with head of the
family
Age SexEducationOccupation Health
status
1
2
3
4
5
6

4. 5. MEDICAL/SURGICAL/HERIDITRY HISTORY OF THE FAMILY
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
6. SOCIOCULTURAL BACKROUND
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
…………………………………………………………………………………………………
7. TRANSPORT AND COMMUNICATION FACILITIES
A.Transport facilities
Type of transport being used : Own or Rented
Personal: Bicycle/Two wheeler/Four wheeler etc.
Public / Private transport facilities:
Bus Tempo E-Rickshaw
AC Bus City bus UPSRTC Private
Autos Taxies Train
B.Communication Media
Telephone/Mobile phone yes/no
Television yes/no
Radio yes/no
Newspaper/magazines yes/no
Post office and telegraph yes/no

5. 8. LANGUAGE KNOWN
Hindi : Able to write/speak/read/don’t know
English : Able to write/speak/read/don’t know
Urdu : Able to write/speak/read/don’t know
Any other : …………………………………………………………………………………..
…………………………………………………………………………………..

9.A) NUTRITIONAL PATTERN
Vegetarian Non vegetarian
Staple food: Rice Wheat Ragi Mixed
Vegetables: grown pur purchased q Quantity used per day:……kg
Milk: quantity used per day:……litres
B) NUTRITIONAL STATUS OF FAMILY MEMBERS
Name of the member Well nourished/ undernourishedMalnutrition

C) Nutritional status (APM):
Name Weight
(kg)
Height
(cm)
Body built BMI (Normal 18.5-24.9)Remarks
ThinModerateWellObese Below
normal
NormalAbove
normal

6.   D)   Nutritional deficiency: yes/no.  if yes specify: Anemic/Goiter/Night Blindness/
Scurvy/Rickets/PEM/Others
S.NoNAME AGESYMPTOMS TREATMENT REMARKS
10.RECORD OF ILLNESS : YES/NO
Name of the
member
AgeIllnessDurationMain
characteristics
Investigatio
n done
Treatment
11.PREGNANT WOMAN : YES/NO
Name Age Gravida/
para
No. of children
living
Whether registered
in hospital/nursing
home
Receiving iron
and folic acid
Danger signs during pregnancy if any-
Convulsions Severe Pain In Abdomen Bleeding Per Vaginum
Excessive Swelling In Legs Fever Weakness
Fatigue Breathlessness

7. 12.POST NATAL / LACTATING MOTHER : YES/NO
Name of mother: Age :
Name of husband : Duration of marriage :
Number of children : Space between children :
GTPAL : Date of delivery :
Abdominal Girth : Lochia :
Details of the baby
Name of baby AgeSex of
baby
TermType of
delivery
Alive/
dead
Wt
of
baby
Place of
delivery
Conducted
by whom
Health
of the
baby
oWeight of the baby:
oImmunization status :
oFeeding pattern:
oProblems related to feeding:
oCondition of breast:
oCondition of suture in case of caesarean / normal delivery:
oPerineal care
Health education given to the mother regarding ___________________________________
___________________________________________________________________________
13.UNDER FIVE ASSESSMENT:YES/NO
ANTHROPOMETRIC MEASUREMENT:-
Measurement Remark
Height
Weight
Head Circumference
Mid Arm Circumference
Chest Circumference
Signs Of Malnutrition If
Any……………………………………………………………………………………………
Health Education/Suggestion to the Parents……………………………..…………………
………………………………………………………………………………………………….

8. 14. IMMUNIZATION SCHEDULE
Type of group
New born: Early/Late :………………………………………….
Infant 1year:…………………………………………………………..
Toddler 2-3:……………………………………………………………..
Preschool 3-6:…………………………………………………………………
School children 6-12:………………………………………………………………
Adolescence 12-18 :……………………………………………………
Vaccine When to give DoseRouteDon
e
Not
done
Remarks
BCG At birth or as early as
possible till one year
of age
0.1
ml
Intra
dermal
Hepatitis B- birth dose At birth or as early as
possible within 24
hours
0.5
ml
Intra
muscular
OPV-0 At birth or as early as
possible within the
first 15 days
2
drops
Oral
OPV 1,2 & 3 At 6 weeks, 10 weeks
& 14 weeks ( OPV
can be given till 5 year
of age)
2
drops
Oral
Pentavalent 1,2 & 3 (Diptheria,
Pertussis,Tetanus,Hib,Hepatitis
- B
At 6 weeks, 10 weeks
& 14 weeks ( can be
given till one year of
age)
0.5
ml
Intra
muscular
Rotavirus At 6 weeks & 14
weeks ( can be given
till one year of age)
5
drops
Oral
PCV At 6 weeks, 10 weeks
& 14 weeks ( can be
given till one year of
age)
0.5
ml
Intra
muscular
IPV Two fractional dose at
6 and 14 weeks of age
0.1
ml
Intra
dermal
MR 1
st
Dose 9 completed months-
12 months (can be
given till 5 years of
age)
0.5
ml
Sub
cutaneous
PCV booster 9 completed months-
12 months
0.5
ml
Intra
muscular
JE- 1 9 completed months-
12 months
0.5
ml
Intra
muscular
Vitamin -A (1
st
dose) At 9 completed
months with measles-
Rubella
1
ml(1
lakh
IU)
Oral
DPT booster 1 16- 24 months 0.5
ml
Intra
muscular
MR 2
nd
Dose 16- 24 months 0.5
ml
Sub
cutaneous
OPV Booster 16- 24 months 2
drops
Oral
JE- 2 16- 24 months 0.5
ml
Intra
muscular

9. Vaccine When to give DoseRouteDon
e
Not
done
Remarks
Vitamin- A (2
nd
to 9
th
dose) 16-24 months with
MR and remaining at
an interval of 6
months up to the age
of 5 years
2
ml(2
lakh
IU)
Oral
DPT booster – 2 5-6 years 0.5
ml
Intra
muscular
Td 10 years & 16 years0.5
ml
Intra
muscular
Findings:
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
………………………………………………………………………………………..
15.PERFORMA FOR ADOLECENT :YES/NO
Name of adolescent:---------------------------------------- age:-------------- sex:---------------------
Education:----------------------------------- Occupation if any: -----------------------------------------
Marital status: -----------------------------
H/O any addiction Yes/No, if yes specify
Signs of puberty: 1. 4.
2. 5.
3. 6.
Menstrual history (only in case of female):
Menarche- ----------------------------
Cycle
Duration--------------------------
Flow: less/adequate/heavy
H/o dysmenorrhea: yes/no
Menstrual hygiene followed: yes/no
H/O passage of white discharge P/V:Yes/No
Influence of peer group :
Complete Immunization history: Yes/No, if no reason
What are you doing to protect and promote your health?

11. Hobbies :
Is suffering from any disease? Specify : …………………………………………………….
Health advice given regarding: ………………………………………………………………...
16.PROFORMA FOR GERIATRIC ASSESSMENT : YES/NO
Name: Age: Sex:
Health status:
Height :
Weight :
A. Activities of Daily LivingSelf / Helped / Unable
1.Brushing :
2.Bathing
3.Dressing :
4.Climbing Stairs :
5.Feeding :
B. Physical Health
1. Do you have cough?
2. Do you have pain in the legs?
3. Do you have swelling in the Body?
4. Do you have pain in the chest?
5. Blood Pressure?
6. Blood Sugar?
7. Urine Sugar?
8. Specific Physical Problems:
9. Vision:
10. Hearing ability:
11. Vital Signs :

12. C. Mental Health
1. Appearance: 2. Mood :
3. Communication: 4. Any Psychological Problem :
(Worry, Anxiety etc.)
5.History of addiction :
1.Smoking 2. Alcohol 3. Drugs 4. Tablets
D. Social Health
1. Whether he / she is living with the family.
3. Whether he / she is having good relations with his / her friends.
4. Whether he / she is taking part in a Social Organization.
E. Economic Status:
Occupation: Income:
Saving :
Insurance :
Standard of Living:
Identified:
1.Actual Problems
2.Potential Problems
3.Need for Health Education ( Patient Oriented )
Immediate planned list of Nursing diagnosis:

13. 17.ELIGIBLE COUPLES
Name AgeFamily
planning
method
adopted
Not interested in
family planning
Willing to use family
planning method
18.IN CASE OF SICKNESS, WHERE TO VISIT THE HEALTH FACILITIES
SC/HWC Private nursing home/clinic
PHC /CHC/District Hospital Indigenous Doctor/AYUSH
Private/Corporates hospital/ESIC/Health Insurance
HEALTH EDUCATION PLAN FOR FAMILT:
1
2
2
3
5
VITAL STATICS STATUS :
No Of Male:
No Of Female:
No Of Children:
New-born
Infant
Toddler
Preschool
School Children
Adolescence
No Of Target Couple:
No Of ANC
No Of PNC
No Of Elders

14. DISEASE STATUS OF THE FAMILY:
No Communicable Diseases:
No Of Non communicable Diseases:
No Of Hereditary Diseases:
No Of Disabilities:
If Any Others:
COMMUNITY FAMILY ASSESSMENT
Identification of problems
1.
2.
3
4
5
Identification of needs
1
2
3
4
5
Community diagnosis of the family
1
2
3
4
5
19.Plan for the next visit/Follow up

15. IMMEDIATE PLANNED LIST OF NURSING ACTIVITIES

NUMBER OF VISIT: DATE OF VISIT:
Existing Problems:
Objectives of Visit (According To Need of Priority):
Activity Performed:
Nursing Diagnosis:
Date of Next Visit planned on :

16. NURSING CARE PLAN
ASSESSMENT NURSING
DIAGNOSIS
OBJECTIVE/
GOALS
NURSING
INTERVENTION
EVALUATION
OUTCOME

17. 20. VITAL GRAPHIC SHEET

18. 21. BODY MASS INDEX.

20. 22.COMMUNITY HEALTH NURSING OFFICER / NURSING STUDENT NOTES
DATE TIME NURSING INTERVENTION /NOTES SIGNATURE

21. 23.Home Visit
House No………
Objective of family visit
DateAssessment of family members Intervention Remarks
Next
visit
plan
Sign of student Sign of teacher

22. Summary :
Planning for next visit :
SUSTAINABLE COMMUNITY AREA
IDEAL COMMUNITY AREA