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Utilize the Box 13-7 Family Assessment Guide, pages 364-368.
Make sure to use all of the VI steps of the assessment.
Fill out the assigment
Box 13-7 Family Assessment Guide
I Identifying Data
Household members (relationship, gender, age, occupation, education):____________________________________________________
Financial data (sources of income, financial assistance, medical care; expenditures):___________________________________________
Source of referral and reason: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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: _______________________________________________________________________________
Sources of medical and dental care: ____________________________________________________________________________
Health screening practices: ____________________________________________________________________________________
IV Interpersonal Needs
Identified subsystems and dyads:________________________________________________________________________________
Prenatal care needed: _________________________________________________________________________________________
Concerns about older members:___________________________________________________________________________________
Caring for other dependent members:________________________________________________________________________________
V Family Needs
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?_______________________________________________________________________
Type of dwelling:________________________________________________________________________________________________
Number of rooms, bathrooms, stairs; refrigeration, cooking:_______________________________________________________________
Water and sewage:______________________________________________________________________________________________
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.:________________________________________________________________
Degree of cohesiveness and loyalty to family members:___________________________________________________________________________________________________________________________________________________________________________
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.”
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.
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.
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.
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.
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.
The community health nurse and the family together develop both long-term and short-term goals.
•Will monitor and record blood glucose levels every morning
•Will accept administration of insulin by Mrs. R
•Will begin range-of-motion and strengthening exercises to promote mobility for eventual transfer of self to chair
•Will communicate to Mrs. R. his ability to take care of any of his own needs as each opportunity arises
•Will demonstrate improved blood glucose levels within 1 month
•Will have her cardiac status evaluated within 2 weeks
•Will self-monitor her health and record her health status for 1 week
•Will decide on one goal to take care of herself within 2 weeks
•Will practice this behavior for 1 month
•Will allow Mr. R. to care for himself when he desires
Mr. and Mrs. R. together:
•Will experience decreased frequency of arguments within 1 month
•Will spend some relaxed time together every evening
•Will discuss new ways of coping with this situation as a group
•Will try out two behaviors that use different family members within 2 weeks
•Will accept one resource to help within 1 month
The community health nurse is aware that the disturbances in the family’s coping ability are fairly recent. The behaviors they have used in the past—self-reliance, appropriate action, distancing, and some denial of the problem—are not working in this situation. The first goal for nursing implementation addresses individual health needs. The second goal involves helping Mr. and Mrs. R. think about the crisis and identify their present coping strategies. Because the nurse knows that the family style is distant, she will proceed slowly with this step, adjusting to suit the family’s pace. She will initially keep the discussion focused on thoughts and facts rather than feelings. Mr. R. perceives the situation as hopeless. It is important to help the family reframe this perception so that the current crisis is seen as being able to be modified. Subsequent plans with regard to family coping would include identifying alternative coping behaviors and practicing them. Because significant strengths are present and the family level of functioning is fairly high, the community health nurse would expect the family to use information to appropriately problem-solve in this crisis. The family may also use the situation as a way of growing into new behaviors that foster family health.
Connecting the family with resources must be done in a way that allows this family to make the choice about outside care. Providing information about the extent to which other modern families use these resources may help them accept this intrusion into their world. Internal resources that are available to the family include the adult children, who may be able to offer instrumental or emotional support simply by being made aware of the extent of the need.
The internal dynamics of the family, in which the couple’s roles are unbalanced, given that the wife has assumed more and more responsibility for the husband, are likely to be long-term patterns. Expecting a family at this stage of life to change a formerly effective pattern of relating to each other is unrealistic and ill advised. Instead, helping Mrs. R. focus on herself more so that she can care for her own needs and helping Mr. R. increase his awareness about his responsibility for his health and to his wife are more appropriate interventions.
The community health nurse reviews the care plan periodically with the family and at the end of the contact. This evaluation includes examination of goals. As the family crisis subsides, goals are quickly accomplished and revised weekly.
The family also examines the effect of the interaction on the member who is ill (Mr. R.). His hyperglycemia is modified the first week, and his blood glucose levels drop to a normal range within several weeks of contact. He accepts his insulin and even expresses interest in administering it himself. His stance with regard to eating whatever he wants also changes, and he begins to follow his diet recommendations more closely. He continues to resist attempts to be fitted for a prosthesis but eventually learns to assist with his transfers. When the community health nurse leaves this family, a goal still to be accomplished is Mr. R.’s learning to use a walker.
Examination of the intervention’s effect on individuals includes looking at Mrs. R.’s health status and that of the adult children. Mrs. R.’s cardiovascular status has deteriorated. She begins some cardiotonic medication and is urged to moderate her activity and stress level. All three of the adult children begin sharing in the care of their father. Although the children are busier than before, the impact on them is manageable.
Examination of the effects on the subsystem includes effects on the interactions of the marital couple. Mr. and Mrs. R. both begin to assume more appropriate responsibility for themselves. The arguments and anger lessen, although their long-term way of relating to each other does not change a great deal.
The effect on the whole family is also examined. Incorporating additional resources lead to a decreased perception of the crisis and an increased calm in the family. As the members begin to renew connections with each other, they discover new sources of emotional support. Following Mr. R’s death due to a pulmonary embolus several months later, the children are able to support their mother during the time of loss.
In examining the family’s interaction with the environment, it becomes apparent that the family members have become more aware of the community resources available to them. The family members are still very private but begin to use available resources appropriately. Their home environment is relatively safe.
As she is working with this family, the community health nurse continually seeks feedback to evaluate her own performance. She carefully monitors the family’s reactions to her interventions and her reactions to the family. She is frustrated at the need to proceed slowly with the family but is satisfied with her choice when she sees that the strategy has worked. Her contact with the family leads her to enroll in a course about client nonadherence. She learns to be patient during this experience and takes these behaviors with her in her future contacts with families.
Learning by Experience and Reflection
1. Choose one of the family assessment tools and apply it to a family you know. In what ways does the tool help you identify information to collect? Would you have considered this information important without the guidance of the tool? In what ways does the tool restrict your thinking about the family? What important information was not included?
2. Trace the origins of one of the assessment tools back to the original theoretical concepts from which it evolved. Is the theory appropriate for thinking about this family? Would different concepts seem to fit better?
3. Draw a structural–functional map of an ideal family. Then draw a structural–functional map of a family you know from television programs such as “The Simpsons,” “The Bernie Mac Show,” “George Lopez,” or “Everybody Loves Raymond.” In what ways does the television family match your ideal?
4. Complete a genogram of your own family for at least three generations. What was it like to ask family members questions about your family? Did you find out information that was not known to you before you began? How did family members respond to thinking about past generations? Can you figure out the relationships, as well as the facts, of the family? Where would you go to find the missing information?
5. What categories of needs exist within your family of origin? What data support your analysis? What developmental and health-promotion issues are relevant in your family? In what ways does your family experience needs related to illness or loss, inadequate resources and support, family dynamics, and environmental threats?
6. What style would you assign to your family of origin? What data support your analysis? What suggestions would you give to a community health nurse about how to interact with your family?
7. What are the strengths within your family of origin? How are these strengths valuable to your family, especially in stressful times?
8. What functional level would you assign to your family of origin? What data support your analysis?
9. Think about a patient you have known in an inpatient capacity. Can you apply some of the family concepts to her or his situation? How might knowing more about the family have helped you with her or his care?
10. Think about the family you have in your community/public health clinical practicum. What categories of needs does this family have? Do the family needs fit into more than one category? Which category of needs do you believe you are most prepared to deal with as a nurse? In which category are you the least informed? What do you need to learn to prepare yourself to deal with these types of needs?
11. Assess your clinical family’s environment. How does the environment affect your thinking about your care planning?
12. How many different dyads (two-person groups [e.g., mother–infant]) can you conceive that might occur in a family? Where do health priorities and problems fit into these dyads?
13. In a student group, role-play an initial encounter with a family. Introduce yourself, engage the family, make some initial assessment, and set up a contract for your repeated visits.
14. In a student group, role-play a visit in which you and the family are planning mutual goals. Have an observer set up the situation so that the goals of the family and the goals of the nurse are slightly different. Can you negotiate and come to an agreement?
15. Think of three examples of summative evaluation and three examples of formative evaluation in your clinical area. What formative and summative evaluation methods would be appropriate for your clinical family?
16. Identify the family style of one family that you know. Try different interpersonal approaches with this family. Which ones seem to work best? Does the family give you any clues about how they would like you to interact with them?
17. Watch a movie that demonstrates family interaction (e.g., Soul Surfer, My Family, One True Thing, Smoke Signals, Arranged, The Debaters, Into the Wild, The Tree of Life, or The Descendants). Try to apply family assessment tools to the family in the film. Can you make a care plan that addresses that family’s needs, style, strengths, and level of functioning?
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