Home Safety Assessment Student: ____________________ Date:_______________________ Assigned Agency:______________ Safety Hazard 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. Are medications safely stored and adequately labeled? Are throw rugs, area rugs, and flooring materials secured? Is there adequate lighting in each room? Are there telephone cords or electrical cords in walkways? Do the entry doors locks with deadbolts? Are combustibles, such as newspapers, stored at least three feet from stove, fireplace or heater? Is there adequate space around space heaters? Are there exposed heating pipes? Is the room/house heated cooled adequately and safely? Is water heater set at 120F or lower? Is there a portable fire extinguisher available in the kitchen? Do occupants who are smokers demonstrate safe handling of cigarettes, lighters and matches? Does the gas at the stove, furnace , and space heater work properly? Are walkways clear, sturdy and wide enough to walk safely (using assistive devices if necessary)? If burglar bars are present on doors and/or windows, will they bend for Emergency exit or is the key close by? Is there a phone within easy reach? Is there a working smoke detector near the kitchen and near each sleeping area? Dos the bathtub have a non-skid surface? If oxygen is in use in the hours, are all occupants aware of oxygen and cord safety? Are all occupants able to safely exit the home in five minutes or less? Are guns or weapons safely stored? Are there secure handrails on stairs? If a ramp is needed, is one present and safely constructed? Sanitation Hazards 1. Is there indoor running water? 2. Is food stored properly? 3. Are there indoor toilet facilities? 4. Do the stove and/or microwave operate properly? 5. Is trash picked up on a regular scheduled basis? 6. Is the water in the kitchen, bathroom and utility are working properly each room? 7. Are there signs of rodent or pest infestation? 8. Is there adequate refrigeration? 9. Comments: Yes No ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ Modifications recommended after your assessment_____________________________________________________________ What surprised you when doing your home safety assessment? Why are home safety assessments important for a public health nurse to know and do? What kind of teaching/topics can you see would be important for a public health nurse to do as a result of a home safety assessment? EVALUATION OF UNDERGRADUATE WRITTEN ASSIGNMENT –Family Assessment Student Name: ____________________________Course: _____________________ Date: __________________ Faculty Signature: ________________________________________________ Grade: ______________________ CRITERIA ASSESSMENT Complete a home safety/home environmental assessment using the tool provided (20) Valu e % 80 Assess and describe the family’s level of Emergency Preparedness (5) Assessment - Provide a brief summary about the family including the following information: Type of family Describe the family functions Describe the family structure Is the family healthy or dysfunctional? (10) Health Risk Appraisal - Conduct a family health risk appraisal assessing for the presence of specific factors in each of the categories that have been identified as being associated with an increased likelihood of an illness (Biological/age-related health risk, Environmental risk, Behavioral risk(5) Identify at least 5 resources/strengths the family possesses. (5) Identify and list at least top 5 family needs. Prioritize the identified needs. (10) INTERVENTION Design a detailed culturally appropriate intervention plan for 1 or more of the needs identified and list specific public/community health nursing roles you would employ in addressing the family need (from intervention wheel - home visits, screening, case management, etc.). Include the level of prevention you used (primary, secondary or tertiary). (10) Review literature and select one article from the literature in support of the identified intervention. Use the article to support your design and attach the article.(5) Implement the intervention with the family, providing appropriate resources as indicated. (5) Evaluation- Develop an evaluation plan for the intervention and include recommendations for the future. Follow-up with the family to conduct an initial evaluation of the intervention. (5) Organization Structure 1. Includes purpose in introduction. 2. Paper is logically arranged with introduction, body, and summary. 3. Subsections and paragraphs reflect the main idea. Transitions occur between thoughts. 10 Literacy and Style 1. 2. Uses professional vocabulary. Uses correct grammar, spelling, punctuation, and capitalization. Maintains economy of expression. 5 % Earne d COMMENT S APA 1. Title page is correct. 2. Page numbering is accurate. 3. Page header is appropriate. 4. Citation of references in text is correct. 5. a. Direct quotes b. Paraphrasing 5 Reference list follows APA format. a. Citations in text are included on reference list b. Reference list citations are included in text Final Grade 100
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