Review The Nursing Process In Practice: Formulating A Family Care Plan

Formulating a Family Care Plan

Mr. R., an 80-year-old retired pipe fitter, lives with his wife; he has had diabetes for 15 years. Although his diabetes has been moderately controlled with diet and daily insulin, some complications have occurred. He experiences arteriosclerotic cardiovascular disease and peripheral neuropathy, and he recently spent 2 months in the hospital due to circulatory problems in his left leg. The progressive deterioration of circulation resulted in an amputation below the knee. Although fitting him with a prosthesis would be possible, he has refused this and is wheelchair bound. Mr. R. currently depends on someone else to help with transfers. He is cranky, irritable, and demanding to almost everyone. He recently has stopped following his diabetes regimen because he claims, “It just doesn’t matter anymore.”

Mr. R.’s wife, Doris, is a 74-year-old woman who has been a homemaker most of her life. She has always been the “watchdog” for Mr. R.’s health. Mostly through her changes in food preparation and her lifestyle adjustments, Mr. R.’s diabetes has been managed. She schedules his physician appointments, buys his medical supplies, and administers his insulin. He is now refusing to accept her help, and she is anxious and angry about his behavior. They frequently have arguments, after which Mrs. R. retreats to her room.

Mr. and Mrs. R. have three children and four grandchildren who live in the same city. The eldest daughter, Patricia, calls or stops by about once a week. The other children, Tom and Ellen, are busy with their families and see their parents mostly on holidays; they have very little communication with Patricia or their parents. When the children do come to visit, Doris tries to put on a happy expression and pretend that everything is going well to avoid worrying them. She is also embarrassed about Mr. R.’s behavior and does not want anyone from outside the family to see what is happening.

On her initial home visit to this family, the community health nurse notes that Mr. R. appears somewhat drowsy and unkempt. Mrs. R. looks anxious and tired, her skin color is slightly ashen, and she has circles under her eyes. When the nurse asks them what they hope to get out of the nursing visits, Mrs. R. says, “Actually, you don’t need to keep visiting. In a few weeks we’ll be back to normal and doing fine.”

Based on a thorough assessment of the family, the community health nurse may begin to develop a mutually acceptable plan of care with the family.

Assessment

In the initial interview, the community health nurse completes a genogram and an eco-map with the family (see  Figures 13-3  and  13-4 ). After the second family interview, the nurse also completes a family map that describes the members’ interactions with each other (see  Figure 13-2 ). A family guide to help structure a family assessment is presented in  Box 13-7 .

Completing the genogram helps break the ice to get the family to talk about their situation. The genogram provides a safe and thought-provoking way for Mrs. R. to supply appropriate information about the situation. During this process, the nurse obtains information about other family members, their general levels of functioning, and the possibility of acting as resources. She identifies family members’ patterns of closeness and distance.

Box 13-7 Family Assessment Guide

I Identifying Data

· Name: ___________________________________________________________________________________________________

· Address: __________________________________________________________________________________________________

· Phone number(s):_____________________________________________________________________________________________

· Household members (relationship, gender, age, occupation, education):____________________________________________________

· Financial data (sources of income, financial assistance, medical care; expenditures):___________________________________________

· Ethnicity: __________________________________________________________________________________________________

· Religion: __________________________________________________________________________________________________

· Identified client(s):______________________________________________________________________________________________

· Source of referral and reason: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

II Genogram

· Include household members, extended family, and significant others

· Age or date of birth, occupation, geographical location, illnesses, health problems, major events

· Triangles and characteristics of relationships

III Individual Health Needs (for each household family member)

· Identified health problems or concerns: ________________________________________________________________________________

· Medical diagnoses: _____________________________________________________________________________________________

· Recent surgery or hospitalizations: _________________________________________________________________________________

· Medications and immunizations: _________________________________________________________________________________

· Physical assessment data: ______________________________________________________________________________________

· Emotional and cognitive functioning: _______________________________________________________________________________

· Coping: _____________________________________________________________________________________________________

· Sources of medical and dental care: ____________________________________________________________________________

· Health screening practices: ____________________________________________________________________________________

IV Interpersonal Needs

· Identified subsystems and dyads:________________________________________________________________________________

· Prenatal care needed: _________________________________________________________________________________________

· Parent–child interactions:_______________________________________________________________________________________

· Spousal relationships:_________________________________________________________________________________________

· Sibling relationships:_________________________________________________________________________________________

· Concerns about older members:___________________________________________________________________________________

· Caring for other dependent members:________________________________________________________________________________

· Significant others:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

V Family Needs

· A. Developmental

· Children and ages:____________________________________________________________________________________________

· Responsibilities for other members: _____________________________________________________________________________

· Recent additions or loss of members:_____________________________________________________________________________

· Other major normative transitions occurring now:____________________________________________________________________

· Transitions that are out of sequence or delayed:_____________________________________________________________________

· Tasks that need to be accomplished:_______________________________________________________________________________

· Daily health-promotion practices for nutrition, sleep, leisure, child care, hygiene, socialization, transmission of norms and values: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________

· Family planning used:_______________________________________________________________________________________

· B. Loss or Illness

· Nonnormative events or illnesses:______________________________________________________________________________

· Reactions and perceptions of ability to cope:________________________________________________________________________

· Coping behaviors used by individuals and family unit:_________________________________________________________________

· Meaning to the family:_________________________________________________________________________________________

· Adjustments family has made:________________________________________________________________________________

· Roles and tasks being assumed by members:_________________________________________________________________________

· Any one individual bearing most of responsibility:_____________________________________________________________________

· Family idea of alternative coping behaviors available:____________________________________________________________________

· Level of anxiety now and usually:_________________________________________________________________________________

· C. Resources and Support

· General level of resources and economic exchange with community:_________________________________________________________

· External sources of instrumental support (money, home aides, transportation, medicines, etc.):____________________________________

· Internal sources of instrumental support (available from family members):___________________________________________________

· External sources of affective support (emotional and social support, help with problem solving):_____________________________________

· Internal sources of affective support (who in family is most helpful to whom?): _________________________________________________

· Family more open or closed to outside?______________________________________________________________________________

· Family willing to use external sources of support?_______________________________________________________________________

· D. Environment

· Type of dwelling:________________________________________________________________________________________________

· Number of rooms, bathrooms, stairs; refrigeration, cooking:_______________________________________________________________

· Water and sewage:______________________________________________________________________________________________

· Sleeping arrangements:_____________________________________________________________________________________________

· Types of jobs held by members:_______________________________________________________________________________________

· Exposure to hazardous conditions at job:___________________________________________________________________________

· Level of safety in the neighborhood:____________________________________________________________________________________

· Level of safety in household:________________________________________________________________________________________

· Attitudes toward involvement in community:___________________________________________________________________________

· Compliance with rules and laws of society:____________________________________________________________________

· How are values similar to and different from those of the immediate social environment?_____________________________________

· E. Internal Dynamics

· Roles of family members clearly defined?______________________________________________________________________

· Where do authority and decision making rest?_____________________________________________________________________

· Subsystems and members:__________________________________________________________________________________

· Hierarchies, coalitions, and boundaries:________________________________________________________________________

· Typical patterns of interaction:_______________________________________________________________________________

· Communication, including verbal and nonverbal:__________________________________________________________________

· Expression of affection, anger, anxiety, support, etc.:________________________________________________________________

· Problem-solving style:________________________________________________________________________________________

· Degree of cohesiveness and loyalty to family members:___________________________________________________________________________________________________________________________________________________________________________

· Conflict management:________________________________________________________________________________________

__________________________________________________________________________________________________________

VI Analysis

· Identification of family style:__________________________________________________________________________________

· Identification of family strengths:_____________________________________________________________________________

· Identification of family functioning:____________________________________________________________________________

· What are needs identified by family? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

· What are needs identified by community/public health nurse?______________________________________________________________________________________________________________________________________________________________

The eco-map presents a picture to both the nurse and Mr. and Mrs. R. of a family that is not well connected to outside resources. Little energy is coming in or going out of the immediate family system, with the exception of intervention by the health care system, which the family wants to discontinue. When the community health nurse later completes a family map, she becomes aware of Mrs. R.’s tendency to act as a parent and Mr. R.’s tendency to act as a child. This blurring of boundaries has set up a behavior pattern in which Mr. R. gives away responsibility for his own health. At the same time, however, the rigidity of these boundaries keeps the children out of these interactions. After assessing the family, the nurse tries to guide her practice with some questions. She asks herself about the family’s needs, strengths, functioning, and style. She examines the family’s priorities and the resources they are using or are potentially able to use. She looks at her own skills and abilities and attempts to define her responsibility to the family system. These questions help her begin to analyze the family data. This analysis leads to several determinations.

Family Health Needs

The family needs help coping with this illness and connecting with resources and sources of support. Some minor disturbances in internal dynamics are influencing the way the family is dealing with the problem. The nurse assigns the family the nursing diagnosis of “Family Coping: Compromised.”

Family Style

This family is a distancing family that prefers to keep its problem-solving activities to itself. However, this isolation limits family members’ ability to support each other. The community health nurse must adjust her nursing interactions to accommodate this family’s style of operating. The nurse should respect the family’s need for distance, approach them cautiously, and observe for cues that indicate that they are becoming anxious.

Family Strengths

This family has some ability to organize activities that need to be accomplished to maintain Mr. R.’s health. Family members are concerned about each other and may be able to adjust schedules or routines. Mrs. R. is committed to Mr. R.’s health care and will try to do what is required. The family has a long history together and in the past has developed a sense of identity and common purpose.

Family Functioning

Even though the family is currently stressed, long-term functioning is fairly healthy. No one member has consistently been a problem or has failed to fulfill her or his role. The adult children are not acting in their age-appropriate roles of support to parents. This status seems to reflect the family style but can possibly be modified.

Targets of Care

The community health nurse believes several levels of this family— the individuals with health problems (both Mr. and Mrs. R.), the couple, and the family as a unit—are potential targets for care. When she reviews who the most likely person in the family is to be able to change behavior, she looks for someone who seems willing to change. She decides this person is Mrs. R. and potentially the children.

Nurse’s Contribution

The community health nurse reviews her own caseload and her available time and attempts to make an accurate assessment of her skills. She is fairly comfortable in dealing with families and decides she will intervene on three levels: individual, subsystem, and family unit. Her contribution will be to offer information, counseling, and connection with other resources. She can visit one time per week and will try to schedule these visits when some of the children can be present.

Priorities

The family has several needs. Which one is the most crucial? Any life-threatening situation must be top priority, but nothing will be accomplished without the family’s agreement that this is their concern. After discussing these ideas with the family, the nurse and the family decide to first address individual health concerns. Mr. R.’s hyperglycemia is noted, and he admits it is making him feel bad. Mrs. R.’s cardiac status is to be assessed next week at an appointment with the family physician. Although Mr. R. seems agreeable to resuming his insulin injections, he has no desire to change his diet or learn how to walk with a prosthesis. The community health nurse puts aside these problems for the time being and addresses Mrs. R. She wonders if Mrs. R. would be interested in exploring her current care for herself. Mrs. R. tentatively agrees. Using additional resources to help Mr. R. transfer in and out of his wheelchair is something that can be accomplished, but the family is still reluctant about this course of action. This problem, too, is put off to a later time.