NCMMCA1 First Grading Notes PDF

UNIT 1 Promoting Family Health 1 The Family and Family Health 2 Family Health Nursing Process 3 Methods of Data Gathering 4 Typology of Nursing Problems in Family Nursing Practice 5 Statement of a Family Health Nursing Problem 6 Developing the Care Plan 7 Categories of Nursing Interventions in Family Nursing Practice 8 Categories of Health Care Strategies and Intervention 9 Evaluation 10 Records in Family Health Nursing Practice 11 Mother And Child Care A Self-Regulated Learning Module 1 CHAPTER 1: THE FAMILY AND FAMILY HEALTH There are different levels of clients in community health nursing: the individual, the family, the population group, and community. The family has traditionally been a central focus of nursing. As the basic unit of society, the family profoundly influences its individual members. In the nursing profession, interest in the family unit and its impact on the health, values, and productivity of individual family members is expressed by family-centered nursing: nursing that considers the health of the family as a unit in addition to the health of individual family members. All nursing care should involve the family. When giving care, nurses must consider the particular needs, circumstances, goals, and priorities of each family and the members within it. This chapter focuses on family concepts: its definition, characteristics, structures and dynamics, roles and functions, stages and development and the level of prevention in family health. Understanding these concepts related to the family and its influence over individuals is essential for providing appropriate nursing care. LEARNING OBJECTIVES: After completing this chapter, you will be able to: 1. Define a family 2. Identify the family structure and family dynamics of a family 3. Describe family stages and tasks of a family 4. Discuss the importance of assessing the family using the family structure, family dynamic, characteristics of a healthy family and Duvall’s family stages 5. Identify levels of prevention in family health A. Definition of family The definitions of family are as diverse as families themselves and the situations they are found in. Viewed simply, the definitions can be categorized in two ways: (1) structural definitions that specify who’s in the family and who’s out according to certain characteristics of family members, and (2) functional definitions that specify the functions family members perform. Structural definitions of the family Structural definitions of the family characteristically define the characteristics of family members such as those who share a place of residence, or who are related through blood ties or legal contracts. A commonly used definition is that of the Census Bureau, “a householder and one or more other persons living in the same household who are related to the householder by birth, marriage, or adoption” (Census 1990). This definition includes many family types commonly regarded as A Self-Regulated Learning Module 2 families including traditional families (breadwinner husband, homemaker wife and their children), remarried families, dual-earner families, and single parent families Another frequently used structural definition is “two or more persons related by birth, marriage, or adoption” (Ooms and Preister, 1988). This definition broadens the scope by counting as “family” people who do not live together, but are related biologically or through legal contracts. Yet, though this definition is more inclusive, some would contend it still excludes some arrangements that many might recognize as legitimate families. For example, long-term foster families are not related by birth, marriage, or adoption, yet carry out many family functions over a significant period of time. Both these structural definitions exclude communal living arrangements and gay and lesbian couples. Functional Definitions of the Family Other definitions move away from blood relationships or a legal definition and focus instead on the functions families perform. According to most functional definitions, a family is any unit in which there exists: ✔ Sharing of resources and economic property ✔ A caring and supportive relationship ✔ Commitment to or identification with other family members ✔ Preparation of children born to or raised by the members to become adult members of the society While this definition is intended to be more inclusive never married couples and homosexual couples would meet these criteria it would exclude family types who do not fulfill these functions. For example, a biological parent who fails to provide care and support would probably not be considered “family” under such a definition. Trying to identify only one definition of the family is like trying to cheat death: it doesn’t work and you end up feeling foolish for trying. Rather than settling for a universal definition, it seems more appropriate to define families according to the particular issue involved. For example, policies concerned with the socialization of children might use a definition of family that includes minor or dependent children (Moen and Schorr, 1987). The UNESCO report stated that a family is a kinship unit and that even when its members do not share a common household, the unit may exist as a social reality. This definition may be too broad to serve the purpose of identification of a family unit for the purpose of assessment as a factor in variables such as health. B. Family dynamics, structures, and functions Family dynamics refer to the patterns of interactions between family members. It also includes the family alignments (closer connections) and A Self-Regulated Learning Module 3 hierarchies (positions of power), roles, and ascribed characteristics. They are influenced by things like the structure of the family, the personalities of each family member, cultural background, values, and personal or family issues (e.g. divorce). Exploring family dynamics helps you to understand the family’s behaviour and difficulties in context and enables more effective interventions. Family structure is the number of children and adults and how they are related. The following are common family structures: TYPES OF FAMILY STRUCTURES: 1. Dyad Family ▪ Consists of two people living together, usually a woman and a man without children Ex) newly married couple ▪ Also refers to single young same sex adults who live together as a dyad in shared apartments, dormitories, or homes for companionship and financial security while completing school or beginning their careers. ▪ Dyad families are generally viewed as temporary arrangements, but if the couple chooses child-free living, this can be a lifetime arrangement. 2. Cohabitation Family ▪ Composed of heterosexual couples and perhaps children who live together but remain unmarried ▪ Although such a relationship may be temporary, it may also be as long-lasting and as meaningful as a more traditional alliance. ▪ A means of knowing a potential life partner before marriage ▪ Statistically, couples who cohabit before marriage have a higher divorce rate than those who do not (Cherlin, 2008). Reason: union without real commitment. ▪ When in place, effective cohabitation arrangements offer psychological comfort and financial security similar to marriage. 3. Nuclear Family ▪ Composed of husband, wife, and children. ▪ Traditionally it is the most common structure seen worldwide ▪ Today, however, in the US, the number of nuclear families have declined to about 49% of families. This is because of the increase in divorce, acceptance of single parenthood, and the greater acceptance of alternative lifestyles (NCHS, 2009). (National Center of Health Statistics) ▪ Advantage: ability to support family members because of its small size, people know each other well and can feel genuine affection for A Self-Regulated Learning Module 4 each other, In time of crisis, this same characteristic may become a challenge to a family a there are few family members to share the burden and offer support; helping nuclear families locate and reach out to support people during a crisis can be an important nursing responsibility. 4. Polygamous Family ▪ Polygamy – a marriage in which a spouse of either sex may have more than one mate at the same time ▪ Has been illegal in the US since 1978 ▪ Middle Easterners – may have been raised in this type of family ▪ Tends to occur in nations where women have low social status or are not valued for their individual talents 2 types of polygamy: a. Polygyny – a marriage with having more than one wife b. Polyandry – a marriage with having more than one husband ▪ It can be attractive for men as it allows for sexual variety ▪ It can serve as the mark of a wealthy man as wives cost money ▪ With more than one wife having children, it also increases the chance that the marriage will produce a male heir ▪ Advantage for women: able to have fewer children than if they were a lone wife so it lowers their chance of dying in childbirth---a concern for women where prenatal care is not a high national priority ▪ If differences in wealth are great, women may prefer polygyny to being the wife of a poor man. Problems that can arise are jealousy and rivalry between wives because of perceived favoritism. 5. Extended (Multigenerational) Family ▪ An extended family includes not only the nucleus family but also other family members such as grandparents, aunts, uncles, cousins, and grandchildren. ▪ Advantage: it contains more people to serve as resources during crises and provides more role models for behavior or values. ▪ Disadvantage: family resources, both financial and psychological, must be stretched to accommodate all members. 6. Single-Parent Family ▪ A single parent is a parent who cares for one or more children without the assistance of the other biological parent. Historically, single-parent families often resulted from death of a spouse, for instance during childbirth. Single-parent homes are increasing as married couples divorce, or as unmarried couples have children. A Self-Regulated Learning Module 5 DISADVANTAGE: A health problem in a single-parent family is almost always compounded. If the parent is ill, there is no close support person for child care. If a child is ill, there is no close support person to give reassurance or a second opinion on whether the child’s health is worsening or improving. Low income is often encountered because the parent is most often a woman. Traditionally women’s income is lower than men’s by about 33%. Single parents may also have difficulty with role modeling or clearly identifying their role in the family (i.e. they must provide duplicate roles, or financial support as well as child care). ADVANTAGE: Single-parent families have a special strength in that such a family can offer the child a special parent – child relationship and increased opportunities for self-reliance and independence. 7. Blended Family ▪ A remarriage or reconstituted family, a divorced or widowed person with children marries someone who also has children. ADVANTAGE: increased security and resources for the new family; children of blended families are exposed to different customs or culture and may become more adaptable to new situations. DISADVANTAGES: Childrearing problems may arise in this type of family from rivalry among the children for the attention of a parent; each spouse may encounter difficulties in helping rear the other’s children Often stepparents believe they have been thrust into a limited or challenged role of authority. Children may not welcome stepparent because they have not yet resolved their feelings about the separation of their biologic parents (through either divorce or death). 8. Communal Family ▪ Communal families are formed by groups of people who choose to live together as an extended family. ▪ The relationship between each other is motivated by social or religious values rather than kinship (Cherlin, 2008). ▪ The values of commune members may be more oriented toward freedom and free choice than those of a traditional family. ▪ Some communes are described as cults or composed of a group of people who follow a charismatic leader. ▪ People living in a commune may have difficulty following traditional health care regimens, preferring to use complementary or alternative therapies. ▪ They view healthcare as an established system that’s why they reject it. A Self-Regulated Learning Module 6 9. Gay or Lesbian Family ▪ In homosexual unions, individuals of the same sex live together as partners for companionship, financial security, and sexual fulfillment. ▪ Some lesbian and gay families include children from previous heterosexual marriages or through the use of artificial insemination, adoption, or surrogate motherhood. ▪ Lack of understanding by health care providers of the strength and richness of these unions can further impede health care. 10. Foster Family ▪ Children whose parents can no longer care for them may be placed in a foster or substitute home by a child protection agency. ▪ Foster parents may or may not have children of their own. They receive remuneration for their care of the foster child. ▪ Foster home placement is theoretically temporary until children can be returned to their own parents. Such children can experience almost constant insecurity; concerned that soon they will move again. In addition, they may have some emotional difficulties related to the reason they were removed from original home. ▪ Most foster parents are as concerned with the health care as the biologic parents. When caring for children from foster homes, be certain to determine who has legal responsibility to sign for health care for the child ▪ The child protection agency is the one with legal responsibility. 11. Adoptive Family ▪ Many types of families adopt children today. ▪ No matter what the family structure, adopting bring several challenges to the adopting parents and the child as well as to any other children in the family. (Fontenot, 2007). FAMILY FUNCTIONS ⚫ The primary function of the family is to ensure the continuation of society, both biologically through procreation, and socially through socialization. Family functions have evolved and adapted over time in response to social and economic changes (Freidman, Bowden, & Jones, 2002), the family progresses through it life cycle and continues to carry out certain functions for the well-being of family members and wider society. ⚫ Family functions are described as: 1. Affective A Self-Regulated Learning Module 7 o One of the most vital and focuses on meeting family member’s needs for affection and understanding. 2. Socialization o This refers to the learning experiences provided within the family to teach children their culture and how to function and assume adult social roles and is a lifelong process. 3. Reproductive o This ensures family continuity over the generations and the survival of society. 4. Economic o Involves the family’s provision and allocation of sufficient resources. 5. Health care o This is met by the provision of such physical necessities like food, clothing, shelter, and healthcare. C. UNIVERSAL CHARACTERISTICS OF FAMILIES 1) A family is a social system Although it is a basic unit of society, it is also complex. The family is a group of individuals who are interdependent; the choices and actions of one family member often influence other family members. For example, when one family member is ill, the entire family is affected. In another example, when a mother returns to full-time outside employment after several years of staying at home to care for children, ramifications abound for all members of the immediate, and perhaps the extended, family. 2) A family perform certain basic function Each member of the family has a responsibility towards other family members, towards family and towards society. Sometimes young people start to act as parents to their parents. They provide a lot of practical support (cooking, childcare, helping them fill in forms) and/or emotional support. The roles people play within a family may be many and varied. For example, Siblings can fulfill many roles for each other: protector, supporter, comforter, teacher, social planner, friend, and disciplinarian. 3) A family has structure Family reflects relationships of members of a household who are linked by biological relatedness, marital and partnership status, and living arrangements. 4) A family has its own values and rules Family is bound to run by certain family and social regulations. These various rules called taboos, customs, laws etc., vary in different cultures. An individual is not free to overlook these (family and social) regulations which were rather stricter in olden days as compared to the present-day society. 5) A family moves through stages its life cycle The development of the family consists of the family life cycle, a series of stages that encompass roles and tasks. A family passes stages such as marriage, birth of children, children leaving home, A Self-Regulated Learning Module 8 the “empty nest” period and the dissolution of the marriage through death of one of the spouses. For example, when the son marries he goes out of the family and starts another family which again may give rise to more families. D. Characteristics of a healthy family It is important for the nurse to understand healthy family characteristics and to use a variety of tools so that family assessments are thorough. Healthy families demonstrate seven important characteristics: Physical maintenance: A healthy family provides food, shelter, clothing, and health care for its members. Being certain that a family has enough resources to provide for a new or ill member is an important assessment. Socialization of family members: A healthy family involves preparing children to live in the community and to interact with people outside the family. It means the family has an open communication system among family members and outward to the community. Allocation of resources: In healthy families, there is justification, consistency, and fairness in the distribution of resources. Resources include not only material goods but also affection and space. In some families, resources are limited, so, for example, no one has new shoes. A danger sign would be a family in which one child is barefoot while the others wear $100 sneakers. Maintenance of order: In healthy families, members know the family rules and values and respect and follow them. Example, enforcing common regulations for family members such as using “time out” for toddlers. Division of labor: Healthy families evenly divide the work load among members and are flexible enough that they can change workloads as needed. Pregnancy or the illness of a child may change this arrangement and cause the family to have to rethink family tasks. Placement of members into the larger society: Healthy families realize that they do not have to operate alone but can reach out to other families or their community for help when needed. Because they have the ability to be sensitive to the needs of individual family members they are able to select community activities, such as schools, religious affiliation, or a political group, that correlate with the family’s beliefs and values. Maintenance of motivation and morale: Healthy families are able to maintain a sense of unity and pride in the family. When this is created, a sense of pride helps members defend the family against threats as well as serve as support people for each other during crises. It means that parents are growing with and through the experience of their children the same as children are growing through contact with the parents. Assessing whether this feeling is present tells you a lot about the overall health of a family. A Self-Regulated Learning Module 9 Assessing families for these characteristics is helpful in establishing the extent of stress on a family and empowering the family to move toward healthier behaviors. The seven characteristics of a healthy family provide one assessment framework that community health nurses can use. E. Family stages and tasks The set of predictable steps and patterns families experience over time is referred to as the family life cycle. One of the first designs of the family life cycle was developed by Paul Glick in 1955. In Glick’s original design, he asserted that most people will grow up, establish families, rear and launch their children, experience an “empty nest” period, and come to the end of their lives. This cycle will then continue with each subsequent generation (Glick, 1989). The family life cycle was used to explain the different processes that occur in families over time. Sociologists view each stage as having its own structure with different challenges, achievements, and accomplishments that transition the family from one stage to the next. The problems and challenges that a family experiences in Stage 1 as a married couple with no children are likely very different than those experienced in Stage 5 as a married couple with teenagers. The success of a family can be measured by how well they adapt to these challenges and transition into each stage. This table shows one example of how a “stage” theory might categorize the phases a family goes through. Stage Family Type Children Marriage 1 Childless Family Procreation Children ages 0 to 2 Family 2.5 Preschooler Children ages 2.5 to 3 Family 6 School-age 4 Children ages 6–13 Family Teenage Children ages 5 Family 13–20 Launching Children begin to 6 Family leave home “Empty nest”; adult Empty Nest 7 children have left Family home A Self-Regulated Learning Module 10 Over the years, there have been other attempts to parse out stages of the family life cycle, but most in use today are derivations of the eight posited by Duvall (1957): (1) beginning families (the establishment phase), (2) childbearing families (the transition to parenthood), (3) families with preschool children, (4) families with school children, (5) families with teenagers, (6) families as launching centers, (7) families in the middle years, and (8) aging families These eight stages are described below: Each stage in this family life cycle has its developmental phases, tasks, transitions, and crises, ie, its own physiology, pathology, and behavioral characteristics ***The age of the oldest child marks the stage. Because families are delaying the age at which they have a first child and parents are living longer, the lengths of stages 1, 7, and 8 are growing. 1. Marriage: Beginning Families (childless, newly married) Task: a. establish a mutually satisfying relationship b. learn to relate well to families of orientation c. if applicable, engage in reproductive life planning 👉 Establishing a mutually satisfying relationship includes merging the values that the couple brings into the relationship from their families of orientation. 👉 The illness of a family member or an unplanned pregnancy at this stage may be enough to destroy the still lightly formed bonds if the partners do not receive support from their former family members of health care providers no not recognize a problem exists. 2. The Early Childbearing Family (new parents, having an infant) Task: birth of first child; new role as parents; integrating new family member into the existing family 👉 The birth or adoption of a first baby is usually both an exciting and a stressful event because it requires both economic and social role changes. 👉 Nursing role: to provide health education about well-child care and how to integrate a new member into a family. 👉 It is a further developmental step for a family to change from being able to care for a well baby to being able to care for an ill one. 👉 Parents who have difficulty with this step need a great deal f support and counseling from health care providers to be able to care for an ill child at home or to manage a difficult pregnancy. A Self-Regulated Learning Module 11 3. The Family with a Preschool Child (Child is 3-6 y/o with a possible other siblings) Task: establishing family network; socialization of children; reinforcing independence in children when separating from parents 👉 This is a busy stage for the family because children at this age demand a great deal of time. 👉 The imagination of a preschool child is at its peak that safety considerations become a major health concern. 4. The Family with a School-Age Child (Oldest child is 6-12 y/o) Task: facilitating peer relationships while maintain family dynamics; adjusting to outside influences 👉 Parents of school-age children have the important responsibility of preparing their children to function in a complex world while at the same time maintaining their own satisfying marriage relationship. 👉 Important nursing concerns during this family stage are monitoring children’s health in terms of immunization, dental care, and health care assessments; monitoring child safety related to home or automobile accidents; and encouraging a meaningful school experience that will make learning a lifetime concern. 5. The Family with an Adolescent (oldest child 16-20 y/o) Task: Increase in children’s independence and autonomy; parents concern shift to aging parents, career, and marital relationships 👉 Family must loosen family ties to allow adolescents more freedom and prepare them for life on their own. 👉 As technology advances at a rapid rate, the gap between generations increases. 👉 Violence, accidents, homicide, and suicide is the major cause of death in adolescents (NCHS, 2009). As adolescents become sexually active, they risk contracting sexually transmitted infections such as HIV and gonorrhea. 👉 A responsibility of the nurse working with families at this stage is to spend time counseling members on safety (driving defensively and not under the influence of alcohol; safer sex practices) and the dangers of chemical abuse. 👉 If there is a “generation gap” between the parents and an adolescent, the adolescent may not be able to talk to the parents about these problems, especially those of a controversial nature such as sexual responsibility. 👉 A nurse can be a neutral person to assist families at this stage when communication can be difficult while maintaining confidentiality between the family members. A Self-Regulated Learning Module 12 6. The Launching Stage Family: The Family with a Young Adult (from departure of first child to last child) Task: Readjustment of marital relationships; parents and children establish separate identities outside the family unit 👉 This is the stage where children leave to establish their own households and is seen by many families as the most difficult because it represents the breaking up of the family. 👉 The stage may represent a loss of self-esteem for parents who feel themselves being replaced by other people in their children’s lives.. 👉 A nurse can serve as an important counselor at this stage. She can help the parents see that what their children are doing is what they have spent a long time preparing them to do, or that leaving home is a positive, not a negative, step in family growth. 7. The Family of Middle Years (after children have left home) Task: 1. Adjusting to the body’s physical and physiological changes. 2. Adjusting to the reality of the work situation 3. Helping children leave home and become responsible adults 4. Maintaining contact with children and grandchildren 5. Reorganizing own living arrangements 6. Readjusting to being a couple again 7. Assuring own economic security for old age 8. Maintaining and even increasing participation in community life 9. Assuring adequate and satisfactory medical supervision for old age 10. Making adequate living arrangements for own parents (some couples, even at this age, have this responsibility). Renewed marital relationships, new outside interests, fewer family responsibilities, and new roles as grandparents and as in-laws, increased concern for aging parents, death, and disability of older generation. 👉 This is the period when child launching is completed (ie, the last child leaves home and the nuclear family is contracting in the sense that the parents are left alone) 👉 This stage is often called the “empty-nest” period, but the connotation that it is an empty or negative period is not always true. On the contrary, many couples feel that it is a “second honeymoon” and others that it is the “ age of fulfillment”. This stage spans about 20 years and lasts until approximately the age of retirement of one or both partners. It is during this stage that the important transitions of the menopause and the “midlife (50) crisis” occur. 👉 The partners may view this stage either as the prime time of their lives (an opportunity to travel, economic independence, and time to spend on hobbies) or as a period of gradual decline (lacking the A Self-Regulated Learning Module 13 constant activity and stimulation of children at home, finding life boring without them, or experiencing an “empty nest: syndrome), 8. The Family in Retirement or older Age (after retirement) Task: End of career, shift to retirement functioning during the aging process, maintain marital relationship, adjust to potential loss of spouse, friends, and siblings, prepare for eventual death. 👉 Families of retirement age account for approximately 15% to 20% of population (NCHS, 2009). 👉 They remain important in maternal and child health because they can offer a great deal of support and advice to young adults who are just beginning their families. 👉 Many grandparents care for their grandchildren while the parents are at work. This can be a strain on older adults as they struggle to meet young children’s needs in relation to both energy level and finances needed. This developmental task concept gives rise to certain principles which may be listed as follows: a) At each stage of the life cycle everybody faces responsibilities and adjustments of maturation. b) The developmental tasks of any given period must be accomplished before going on to the next level of maturation. (If the tasks are not accomplished, the person/family is at a disadvantage at all subsequent levels.) c) Very few developmental tasks can be mastered in isolation, but are always influenced by the family, the subculture, and society. d) No one else can accomplish these tasks for the individual. e) A parent, physician, or other “provider” who assists an individual/family in these tasks is promoting individual and family development. FAMILY ROLES: o An important part of the family assessment is to identify the roles of family members such as the following: ▪ Nurturing figure– primary caregiver to children or any dependent member. ▪ Provider – provides the family’s basic needs. ▪ Decision maker– makes decisions particularly in areas such as finance, resolution, of conflicts, use of leisure time etc. ▪ Problem-solver– resolves family problems to maintain unity and solidarity. A Self-Regulated Learning Module 14 ▪ Health manager– monitors the health and ensures that members return to health appointments. ▪ Gate keeper- Determines what information will be released from the family or what new information can be introduced. Ex.) If a hospitalized child will need continued care after he or she returns home, it would be important to identify and contact the nurturing member of the family, because this person is probably the one who will supervise or give the needed care at home. Be careful not to make assumptions about role fulfillment based on gender or stereotyping, because every family operates differently. Although nurturing has been typically thought of as a female characteristic, many men fill this role today. F. LEVELS OF PREVENTION IN FAMILY HEALTH Primary Prevention— is the action taken before the onset of the disease. It does this by eliminating or reducing factors that reduce good health, and promoting factors that are protective of health. Ex.) ✔ programs to discourage the uptake of smoking, ✔ health education about preventing illness ✔ Immunization/vaccinations programs, ✔ increasing opportunities for physical activity and healthy eating, and ✔ banning substances known to be associated with a disease or health condition. Secondary Prevention— is the action which halts the disease at the earliest stage and prevents complication. It can be done thru: early diagnosis (thru screening tests and case findings) e.g. mammography and regular blood pressure testing. early treatment (treating before irreversible pathological changes take place) Ex.) ✔ regular hearing tests for workers exposed to industrial noise. ✔ Breast self-examination Secondary prevention targets individuals who may show no symptoms, but are exposed to or have known risk factors for a particular condition. Tertiary Prevention— is the action available to reduce or limit impairments and disablilities, and to improve quality of life. - it is used when the disease process has advanced beyond its early stages. This is to slow or stop disease progression through measures such as chemotherapy, rehabilitation, and screening for complications. Ex.) A Self-Regulated Learning Module 15 ✔ self-management programs for those with chronic illness ✔ rehabilitation programs for those recovering from accident or illness. ✔ teaching someone with Diabetes Mellitus how to identify and prevent complications CHAPTER 2: FAMILY HEALTH NURSING PROCESS In 1958, Ida Jean Orlando started the nursing process that still guides nursing care today. Defined as a systematic approach to care using the fundamental principles of critical thinking, client-centered approaches to treatment, goal-oriented tasks, evidence-based practice (EDP) recommendations, and nursing intuition. Holistic and scientific postulates are integrated to provide the basis for compassionate, quality-based care (Toney-Butler & Thayer, 2018). The nursing process functions as a systematic guide to client-centered care with 5 sequential steps. These are assessment, diagnosis, planning, implementation, and evaluation. This important process continues to be used as a model today when providing patient care. Nursing practice in the community entails the utilization of a number of processes to respond to health needs and problems of clients, manage health programs and resources, and influence decisions that affect the delivery of health services. One of the processes includes the nursing process. Ahdella said that by providing nurses with a strong knowledge base, the nurse can focus on the patient problem using the nursing process. The following is a discussion on the use of this nursing process to family nursing practice. LEARNING OBJECTIVES: After completing this chapter, you will be able to: 1. Differentiate family health nursing and family nursing process 2. Integrate knowledge of family nursing with nursing process to promote quality maternal and child health nursing care. 3. Gather initial assessment of the family using the initial data base tool A. DEFINITION FAMILY HEALTH NURSING is a nursing aspect of organized family health care services which are directed or focused on family as the unit care with health as the goal. It is thus synthesis of nursing care and health care. It helps to develop self-care abilities of the family and promote, protect and maintain its health. Family health nursing is generalized, well balanced and integrated comprehensive and continuous planning to accomplish its goal. The goals of the family health nursing include optimal functioning for the individual and for the family as a unit. FAMILY NURSING PROCESS is an orderly, systematic steps to assess the health needs, plan, implement and evaluate the services to achieve the health. It is a systematic approach to help family to develop and strengthen its capacity to meet its health needs and solve health problems. A Self-Regulated Learning Module 16 B. PRINCIPLES OF FAMILY HEALTH NURSING 1. Provide services without discrimination 2. Periodic and continuous appraisal and evaluation of family health situation 3. Proper maintenance of record and reports. 4. Provide continuous services 5. Health education, guidance and supervision as integral part of family health nursing. 6. Maintain good IPR. 7. Plan and provide family health nursing with active participation of family. 8. Services should be realistic in terms of resources available. 9. Encourage family to contribute towards community health. 10. Active participation in making health care delivery system. C. STEPS OF FAMILY NURSING PROCESS The family nursing process, consists of the following steps adapted specifically with family as the focus group. (Carnevali and Thomas, 1993): a.) Assessment of client’s problem b.) Diagnosis of client response needs that nurse can deal with c.) Planning of client’s care d.) Implementation of care e.) Evaluation of the success of implemented care 1. Assessment (of client’s problem) The nurse assesses not only the health care demand of the client and family but also the home and community environment. Assessment actually begins when the nurse contacts the client for the initial home visit and reviews documents received from the referral agency. The goal of the initial visit is to obtain a comprehensive clinical picture of the client’s need. During the initial home visit, nurse gathers data by obtaining a health history from the client, examining the client, observing the relationship of the client and caregiver, and assessing the home and community environment. Data to be collected during assessment phase includes: family structure and characteristics, life style, culture and socio economic factors, health and medical history, health behavior and environmental factors. Once assessment is complete, review all the data, compile the risk factors and formulate nursing diagnosis. Since assessment is an ongoing process, it should be periodically reviewed, deleted and revised as per need. It is important to look at assessment data in totality and compile as overall functioning and health of the family. The final step of family assessment is formulation of nursing diagnosis. 2. Diagnosis (of client response needs that nurse can deal with) The nurse formulates nursing diagnosis based on assessment data with complete data available. She can formulate more accurate and scientific diagnosis. This forms the foundation for development of a health care plan. Analyzed data can be categorized as health deficit, health threats and foreseeable crisis situations. Health threats and foreseeable crisis are potential problems while health deficit is an actual problem. Family nursing diagnosis is the written statement of family health problems which are assessed from A Self-Regulated Learning Module 17 analysis of data collected. Examples of common nursing diagnoses include Deficient Knowledge, Impaired Home Maintenance, and Risks for caregiver Role strain. If the focus of assessment is the individual and family, the nurse formulates a family nursing diagnosis but if it is a community, a community diagnosis should be made. 3. Planning (of client’s care) During the planning phase the nurse needs to encourage and permit client’s to make their own health management decisions. Alternatives may need to be suggested for some decisions if the nurse identifies potential harm from a chosen course of action. The nurse has to assist the family in making a clear goal statement by achievable means. Be sure that neither nurse nor families are too ambitious. Goal should be clear and concise statement. Clearly written goals give a sense of direction in how to proceed in the care of the family. This increases the self-confidence and trust of the family in the ability of the nurse to provide care. At this phase of family nursing process, health problems are prioritized, goals and objectives are established, nursing interventions are decided both by the family and the nurse. All these components put together for the schematic representation of the care plan (or the FAMILY NURSING CARE PLAN) Family Nursing Care Plan should be: realistic, consistent with the goals, agreeable to the family, need active involvement of the family members and in written form. 4. Implementation (of care) To implement the plan, the nurse performs nursing interventions, including teaching, coordinates and uses referrals and resources, provides and monitors all levels of technical care; collaborates with other disciplines and providers; identifies clinical problems and solutions from research and other health literature, supervises ancillary personnel, and advocates for the client’s right to self –determination. Technical skills commonly performed by nurses include blood pressure measurement; body fluid collection (blood, urine, stool, and sputum), wound care, etc. Implementing the health care requires home visits, working closely with families, community leaders, health workers, and other related agencies like social welfare and educational institution, etc. for comprehensive system to care. As the implementation process goes on, it may be necessary to change or omit certain strategies according to situation. During this phase, the nurse reviews the family nursing care plan, motivates the family to implement actions of care, and helps the family to utilize the community resources. 5. Evaluation and Documenting (of the success of implemented care) During evaluation, the last step of the nursing process, the nurse and client jointly measure how well the client has achieved the goals that were specified in the plan of care. Any factors that contributed to the client’s success or failure are identified, and the plan of care is revised as necessary. The client’s A Self-Regulated Learning Module 18 responses to the plan of care determine whether the plan continues as is, is modified, or is ended. The evaluation is based on the set objectives for family. For success in evaluation, it is better to involve family in setting the objectives to bring the desired changes in attitude. The nurse should observe for change in attitude during and after the intervention of care. If she notices the failure brings to the desired change, then she needs to go back to reset the objective, replan and reimplement the programming. D. INITIAL ASSESSMENT/ INITIAL DATABASE Initial data base (IDB) is the first type of data taken during the first-level assessment. Through this IDB, the nurse can identify existing and potential wellness states, heath threats, health deficits and stress points/foresseable crises in a given family. A tool used for gathering IDB is presented below: 1. Family Structure, Characteristics and Dynamics Family structure, characteristics & dynamics: Include the composition and demographic data of the members of the family/household, their relationship to the head and place of residence; the type of, and family interaction/communication and decision-making patterns and dynamics Ex.) The Arizala Family is a typical nuclear type of family consist of the father, Mr. Jonas (not his real name) who is a construction worker. Mrs. Jessica (not his real name), a full time housewife and their 1 year-old baby girl Jane (not his real name). Mrs. Jessica is currently 7 months pregnant and is expected to give birth on the first week of June. Mr. and Mrs. XXXX don’t have a hard time in terms of decision making because each of them tend to consider each others opinion first before coming up with the final decision especially regarding health matters. The father is the head and breadwinner of the family while the mother takes care of the household chores and their first born baby girl Jane. 2. Socio-Economic and Cultural Characteristics Socio-economic & cultural characteristics: Include occupation, place of work, and income of each working member; educational attainment of each family member; ethnic background and religious affiliation; significant others and the other role(s) they play in the family’s life; and, the relationship of the family to the larger community. Ex.) Low educational background seems to be an obstacle for Mr Jonas to get a good job. He never finished elementary education and was forced to work as a construction worker receiving only P250 per day. On the other hand, Mrs. Jessica was fortunate enough to finish second year high school but decided to stay at home to take good care of their first born child. Mr. Jonas’ monthly income is approximately P5,000 per month just enough to pay for their monthly rent, electricity bill, food and milk allowance and transportation expense. Most of the time, the budget for health maintenance is being sacrifice and not given enough priority due to lack of money. According to Mrs. Jessica, she spends P150 per day to meet their daily basic needs. The XXX’s are basically from Antique, Aklan. They migrated to Manila hoping for a better life, but unfortunately they found out that the lifestyle in urban offers very little opportunities. The family is not a member of any social organization in the community nor an active member of the catholic church. A Self-Regulated Learning Module 19 3. Home and Environment Home and environment: Include information on housing and sanitation facilities; kind of neighborhood and availability of social, health, communication and transportation facilities in the community. Ex.) The family resides in a depressed area in Brgy. Pasong Tamo, Area 3, Quezon City. Their house is made up of wood and light materials. The floor area is approximately 6 sq. meters. The family sleeps together in a wooden bed with foam situated near the entrance door which also serves as their receiving area. They usually sleep very early at around 8 p.m. and wakes up at 7 a.m. The house is not well ventilated and there is inadequate lighting. Breeding sites for mosquitoes, flies, cockroaches, and rodents are inevitable due to open drainage and poor environmental sanitation. Their toilet facility is located at the back of their house which they share with all the families in the compound. There is no water supply in the area so Mr. Jonas is force to fetch water 20 meters away from their house and costs 2 pesos per container. Mrs. Jessica buys their food in the market and stores it in an uncovered cabinet leaving it exposed to germ and bacteria. She usually cooks vegetable and fish dishes. The garbage is collected twice a week by a DPS truck. Tricycles roam around as their means of transportation while public phone for communication are available at the sari-sari store. Carinderia’s and mini-market are also visible within the vicinity. The overall surrounding of the family is unhygienic and the drainage system is open and very proximate to the houses. Only wooden walls separate them from their neighbors and the electrical connections are entangled and hazardous. 4. Health Status of Each Family Member Health status of each member: Includes current and past significant illness; beliefs and practices conducive to health and illness; nutritional and developmental status; physical assessment findings and significant results of laboratory/diagnostic tests/screening procedures Ex.) Mrs. Jessica is in a critical stage since she is seven months pregnant to her second child and is expected to give birth on the first week of June. Her first pre-natal check-up was done three months ago and was never repeated due to lack of time and awareness. According to her, she had a hard time delivering her first child due to hypertension. She gave birth at home with the help of a ”hilot“ and plans to do the same with the second child. Her first baby Jane is quite small for her age, though, she was able to walk and stand at the age of 9 months. As of now she is already learning how to speak. She had already taken vitamins during the first three months of her pregnancy but wasn’t able to sustain it due to lack of money. She had her first dose of TT1 last February during her pre-natal check-up. She feeds her baby girl Jane 3 times a day with condensed milk and small amounts of solid foods like a mashed potato and rice with soup. Her husband Mr. Jonas sometimes complain of severe pain at the back of his neck maybe as a sign of hypertension and over fatigue but has no family history of hypertension in the family. The family doesn’t use herbal medicine and goes to the health center when need arises. 5. Values, Habits, Practices on Health Promotion, Maintenance and Disease Prevention Values and practices on health promotion/maintenance & disease prevention: Include use of preventive services; adequacy of rest/sleep, exercise, relaxation A Self-Regulated Learning Module 20 activities, stress management or other healthy lifestyle activities, and immunization status of at-risk family members. Ex.) The family sleeps early to have enough rest and energy for the next day. Mrs. Jessica goes out every morning to walk and exercise outside together with Jane. The family uses bed nets at night to protect them from mosquitoes and other insects while they are sleeping. The first born baby is complete with all the immunization required. Pa-BINGO is held every month at their compound as a form of their relaxation and entertainment. CHAPTER 3: METHODS OF DATA GATHERING There are several methods of data gathering that the nurse can select from. A combination of methods will ensure the validity, reliability, adequacy and quality of assessment data. For instance, a combination of interview and observation will confirm the presence of environmental hazards. This chapter describes the common methods of data gathering about a family, its health status and state of functioning. LEARNING OBJECTIVES: After completing this chapter, you will be able to: 1. Utilize the different methods of data gathering during family assessment 2. Utilize the Genogram, Ecomap and family assessment guide as a tool in assessing the family. METHODS OF DATA GATHERING: A. Physical Examination of each family member Significant data about the health status of individual family members can be obtained through direct examination. This is done through inspection, palpation, percussion, auscultation, measurement of specific body parts and reviewing the body systems. Community health nurse may require to do physical examination of each family member to find individual’s physical state of health. This may help her early diagnosis and treatment and appropriate referral. The data gathered thru this method constitute a substantive part of first-level assessment which may indicate presence of health deficits (illnesses state) B. Interview Another major method of data gathering is the interview. One type of interview is completing the health history of each family member. The second type of interview is collecting data by personally asking significant family members or relatives questions regarding health, family life experiences and home environment to generate data on what wellness condition and health problems exist in the family. Productivity of the interview process depends upon the use of effective communication techniques to elicit the needed responses. The nurse can interview her colleagues who provide direct health services to the family as well as school A Self-Regulated Learning Module 21 personnel, employers, community workers, and significant others who can give reliable and relevant information about the family’s life and experiences. C. Observation This method of data collection is done through the use of sensory capacities- sight, hearing, smell and touch. Through direct observation, the nurse gathers data about the family’s state of being and behavioral responses. Data gathered through this method have the advantage of being subjected to validation and reliability testing by other observers. Many things can be learnt by observation such as: how mother holds the infant; communication pattern of the family members; and conditions in the home and environment. D. Review of record/reports and laboratory results The nurse may gather data by reviewing existing records and reports pertinent to the client. These include the Individual clinical records of the family members; laboratory & diagnostic reports; immunization records; reports about the home & environmental conditions. Family records are important sources of all family members’ health information. E. Assessment of home environment Assessment tools to aid the nurse in appraising the health of families include the eco-map and the genogram. (sample genogram is shown below: A genogram is composed of visual representations of gender and lines of birth descent through the generations. Employment of a genogram will help the nurse visualize how all family members are genetically related to each other and to grasp how patterns of chronic conditions are present within the family unit. An ecomap provides a visualization of how the family unit interacts with the external community environment such as schools, religious commitments, occupational duties, and recreational pursuits. A Self-Regulated Learning Module 22 To construct such a map, first draw a circle in the center to represent the family. Around the outside draw circles that represent the family’s community contacts such as church, school, neighbors, or other organizations. Families that “fit” well into their community usually have many outside circles or community contacts. A mark of abusive families is that they have few community contacts as they deliberately keep outside people remote from them. Constructing such a map helps you assess the emotional support available to a family from the community. A family whom you assess as having few connecting lines between its members and the community may need increased nursing contact and support to remain a well family. A sample ecomap is shown below: Another tool that can be used for family assessment is the Family Assessment Guide which an example is shown below: A Self-Regulated Learning Module 23 Family Assessment Guide Initial Data Base Initial data base (IDB) is the first type of data taken during the first-level assessment. Through this IDB, the nurse can identify existing and potential wellness states, heath threats, health deficits and stress points/foresseable crises in a given family. (CI’s note: pls refer to the previous discussion of IDB in chapter 2) CHAPTER 4: TYPOLOGY OF NURSING PROBLEMS IN FAMILY NURSING PRACTICE Typology of nursing problems in family nursing practice is a classification system of family nursing problems that was developed and field-tested in 1978. The most recent revision of this tool was made in year 2003 which includes wellness diagnosis. The importance of this system is to facilitate the process of defining family nursing problems. The organizing principle of the typology is Freeman’s family health tasks. The rationale for adopting Freeman’s as framework of the typology is the fact that in community health nursing A Self-Regulated Learning Module 24 practice, the nurse deals mostly within the improvement of behavior of clients to achieve optimum health. The typology contains 6 categories of problems in family nursing care. The first category refers to the presence of wellness states, health threats, health deficits and foreseeable crisis situations. This was taken from the analysis of the first level of assessment. The remaining five categories of problems contain statements of the family’s incapabilities to perform the health tasks. This was taken from analysis of second level assessment. This chapter further introduces you to the typology of nursing problems, the first level of assessment and the second level assessment. Please take note of the given examples which guide you in formulating family nursing diagnosis in the next chapter of this manual. LEARNING OBJECTIVES: After completing this chapter, you will be able to: 1. Identify the significance of typology of nursing problem in Family Nursing Practice 2. Differentiate the first level assessment and second level assessment. 3. Analyze the family assessment findings using the typology of nursing problems. A. FIRST LEVEL ASSESSMENT The nurse uses this assessment to determine the existing and potential health conditions or problems of the family. The types of data taken during the first level assessment are the following: ✔ Family structure, characteristics and dynamics ✔ Socio-economic and cultural characteristics ✔ Home and environment ✔ Health status of each member ✔ Health Values and practices The above data will be collected using the IDB (Initial Database) tool. Through this IDB, the nurse can check the presence of health problems and conditions. These health problems/conditions are categorized as WELLNESS STATE, HEALTH DEFICITS, HEALTH THREATS AND FORESEEABLE CRISIS SITUATION which will be described below: 1. Wellness state 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. Wellness State includes: A. Potential for Enhanced Capability for: Healthy lifestyle-e.g. nutrition/diet, exercise/activity Healthy maintenance/health management A Self-Regulated Learning Module 25 Parenting Breastfeeding Spiritual well-being-process of client’s developing/unfolding of mystery through harmonious interconnectedness that comes from inner strength/sacred source/God (NANDA 2001) Others (Specify) B. Readiness for Enhanced Capability for: Healthy lifestyle Health maintenance/health management Parenting Breastfeeding Spiritual well-being Others (Specify) 2. Health Deficits Health deficits refer to instances of failure in health maintenance and development. Health deficits includes: 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, blindness from measles, lameness from polio) 3. Health Threats Health threats refers to conditions which predispose to disease, accident, poor or retarded growth and development and personality disorder and a failure to realize one’s health potentials. These situations are incomplete immunization among children, environmental hazards, poverty, family history of chronic illness, eg., diabetes. Health threats are as follow: A. Presence of risk factors of specific diseases (e.g. lifestyle diseases, metabolic syndrome, smoking) B. Threat of cross infection from communicable disease case C. Family size beyond what family resources can adequately provide D. Accident hazards specify. ▪ Broken chairs ▪ Pointed /sharp objects, poisons and medicines improperly kept ▪ Fire hazards ▪ Fall hazards ▪ Others specify. A Self-Regulated Learning Module 26 E. Faulty/unhealthful nutritional/eating habits or feeding techniques/practices. Specify. ▪ Inadequate food intake both in quality and quantity ▪ Excessive intake of certain nutrients ▪ Faulty eating habits ▪ Ineffective breastfeeding ▪ Faulty feeding techniques F. Stress Provoking Factors. Specify. ▪ Strained marital relationship ▪ Strained parent-sibling relationship ▪ Interpersonal conflicts between family members ▪ Care-giving burden G. Poor Home/Environmental Condition/Sanitation. Specify. ▪ Inadequate living space ▪ Lack of food storage facilities ▪ Polluted water supply ▪ Presence of breeding or resting sights of vectors of diseases ▪ Improper garbage/refuse disposal ▪ Unsanitary waste disposal ▪ Improper drainage system ▪ Poor lightning and ventilation ▪ Noise pollution ▪ Air pollution H. Unsanitary Food Handling and Preparation I. Unhealthy Lifestyle and Personal Habits/Practices. (Specify.) o Alcohol drinking o Cigarette/tobacco smoking o Walking barefooted or inadequate footwear o Eating raw meat or fish o Poor personal hygiene o Self medication/substance abuse o Sexual promiscuity o Engaging in dangerous sports o Inadequate rest or sleep o Lack of /inadequate exercise/physical activity o Lack of/relaxation activities o Non use of self-protection measures (e.g. non use of bed nets in malaria and filariasis endemic areas). J. Inherent Personal Characteristics o e.g. poor impulse control A Self-Regulated Learning Module 27 K. Health History, which may Participate/Induce the Occurrence of Health Deficit o e.g. previous history of difficult labor. L. Inappropriate Role Assumption o e.g. child assuming mother’s role, father not assuming his role. M. Lack of Immunization/Inadequate Immunization Status Especially of Children N. Family Disunity o Self-oriented behavior of member(s) o Unresolved conflicts of member(s) o Intolerable disagreement O. Others. Specify._________ 4. Foreseeable Crisis or Stresses Foreseeable crisis situations or stress points, refers to anticipated periods of unusual demands on the individual or the family in terms of adjustment or family resources. These demands may be pregnancy, retirement from work and adolescence. Though these conditions are expected but still lead to various types of crisis in family. Foreseeable Crisis Situations include: A. Marriage B. Pregnancy, labor, puerperium C. Parenthood D. Additional member-e.g. newborn E. Abortion F. Entrance at school G. Adolescence H. Divorce or separation I. Menopause J. Loss of job K. Hospitalization of a family member L. Death of a member M. Resettlement in a new community N. Illegitimacy O. Others, specify.___________ B. SECOND LEVEL ASSESSMENT ⮚ The nurse uses this assessment to determine the family’s abilities to perform the FIVE HEALTH TASKS on each the health problems/conditions: ▪ ability to recognize the presence of health problems ability to make decisions for taking appropriate health action ability to provide desired care to the sick disabled ability to maintain environment conducive to health promotion maintenance and personnel development Ability to utilize community for health care ⮚ The types of data to be taken during the second level of assessment include: A Self-Regulated Learning Module 28 ✔ Family’s perception of the problem ✔ Decisions made and appropriateness (if none, the family’s reasons) ✔ Actions taken and results (if none, family’s reasons) ✔ Effects of decisions and actions on other family members The result of the analysis of data taken during the second level assessment is reflected as statements of the family nursing problems which categorized into five, namely: 1. Inability to recognize the presence of health problems 2. Inability to make decisions for taking appropriate health action 3. Inability to provide desired care to the sick disabled 4. ability to maintain environment conducive to health promotion maintenance and personnel development 5. Inability to utilize community for health care These 5 categories are listed below along with the factors that lead to the non-performance of the health tasks. The list serves as the guide in classifying the family nursing problems: I. Inability to recognize the presence of the condition or problem due to: A.) Lack of or inadequate knowledge B.) Denial about its existence or severity as a result of fear of consequences of diagnosis of problem, specifically: Social-stigma, loss of respect of peer/significant others Economic/cost implications Physical consequences Emotional/psychological issues/concerns 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 break down 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. A Self-Regulated Learning Module 29 G. Lack of/inadequate knowledge of community resources for care H. Fear of consequences of action, specifically: ▪ Social consequences ▪ Economic consequences ▪ Physical consequences ▪ Emotional/psychological consequences I. Negative attitude towards the health condition or problem-by negative attitude is meant one that interferes with rational decision-making. I. In accessibility of appropriate resources for care, specifically: ▪ Physical Inaccessibility ▪ Costs constraints or economic/financial inaccessibility J. Lack of trust/confidence in the health personnel/agency K. Misconceptions or erroneous information about proposed course(s) of action i. 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: ▪ Absence of responsible member ▪ Financial constraints ▪ Limitation of luck/lack of physical resources 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 A Self-Regulated Learning Module 30 J. Prolonged disease or disabilities, which exhaust supportive capacity of family members. K. Altered role performance, specify. ▪ Role denials or ambivalence ▪ Role strain ▪ Role dissatisfaction ▪ Role conflict ▪ Role confusion ▪ Role overload L. Others. Specify._________ IV. Inability to provide a home environment conducive to health maintenance and personal development due to: A. Inadequate family resources specifically: ▪ Financial constraints/limited financial resources ▪ Limited physical resources-e.i. lack of space to construct facility 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 adequate competencies in relating to each other for mutual growth and maturation Example: 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 : A Self-Regulated Learning Module 31 ▪ Physical/psychological consequence ▪ Financial consequences ▪ Social consequences F. Unavailability of required care/services G. Inaccessibility of required services due to: ▪ Cost constraints ▪ Physical inaccessibility H. Lack of or inadequate family resources, specifically: ▪ Manpower resources, e.g. baby sitter ▪ Financial resources, cost of medicines prescribe 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 __________ CHAPTER 5: STATEMENT OF A FAMILY HEALTH NURSING PROBLEM If the focus of assessment is the individual and family, the nurse formulates a family nursing diagnosis but if it is a community, a community diagnosis should be made. On this chapter, you will be introduced to the statement of a family nursing diagnosis. This is the continuation of the Typology of Nursing Problems discussed from the previous chapter. LEARNING OBJECTIVES: After completing this chapter, you will be able to: 1. Identify the components of family nursing problems 2. State a family nursing problem correctly THE FAMILY NURSING DIAGNOSIS: The end result of the second-level assessment is a set of family nursing problems for each health condition or problem. This is called family nursing diagnosis. Family Nursing Diagnosis represents the clinical judgment about health conditions/problems and life processes occurring with the family. A family nursing problem consists of two parts: 1.) the statement of the unhealthful response Ex.) Inability to recognize presence of a possible complication of pregnancy A Self-Regulated Learning Module 32 These are some of the possible unhealthful responses: ⮚ Inability to make decisions for taking appropriate health action ⮚ Inability to provide desired care to the sick/disabled individual ⮚ Inability to maintain environment conducive to health promotion maintenance and personnel development ⮚ Inability to utilize community for health care 2.) the statement of factors which are maintaining the undesirable response/non-performance of family health tasks Ex.) due to inadequate knowledge; due to inadequate resources; These are some of the possible factors that maintain the undesirable response/non-performance of family health tasks: ⮚ inadequate knowledge or skill in carrying out the necessary intervention or treatment ⮚ Philosophy in life which hinders utilization of the community ⮚ Lack of support from the community Thus, the whole statement of an example of family nursing problem looks like this: ⮚ Inability to recognize presence of a possible complication of pregnancy due to inadequate knowledge Below are few examples of FAMILY NURSING DIAGNOSIS (a set of family nursing problems in each health problem): Ex #1: Health Problem: Possible Complication of Pregnancy as a Foreseeable Crisis Situation Family Nursing Problem: Inability to recognize presence of a possible complication of pregnancy due to inadequate knowledge Ex. #2) Health Problem: Cough as Health deficit Family Nursing Problems: ⮚ Inability to recognize the presence of cough as a health problem due to: a.) inadequate knowledge b.) inadequate family resources specifically finances ⮚ Failure to utilize the community resources for health care due to: a.) inadequate knowledge; b.) inadequate time resources. Ex.) #3 Health Problem: Covid-19 Pandemic as a Health Deficit Family Nursing Problems: ⮚ Inability of the family to provide desirable care to the family member who is infected with Covid-19 due to inadequate knowledge on the management of the disease. A Self-Regulated Learning Module 33 ⮚ Failure to utilize the community resources for health care due to: a.) inadequate knowledge on the use of isolation facility; b.) inadequate time resources. **Note: In examples 2 and 3, there are two family nursing problems identified in just one health problem. This is possible as long as you have data that support your statement. DEGREE OF GENERALITY AND SPECIFICITY The categorization of problems in the typology constitutes several levels according to the degree of generality or specificity. After each main category of problems, several more specific problems are identified reflecting contributory problems to or explanations for the existence of the main problem. The more specific the problem definition, the more useful is the nursing diagnosis in determining nursing intervention. To illustrate in a family with a prenatal patient who is at the same time the breadwinner of the family and who is not receiving any care/supervision, the family nursing problem may be stated as: (General) INABILITY TO UTILIZE COMMUNITY RESOURCES FOR HEALTH CARE DUE TO LACK OF ADEQUATE FAMILY RESOURCES, SPECIFICALLY: (Specific) a.) financial resources b.) manpower resources c.) time CHAPTER 6: DEVELOPING THE CARE PLAN Developing the care plan is the next step in the family health nursing process after assessment. This chapter focuses on the steps that guide you in making the Family Nursing Care Plan (FNCP). LEARNING OBJECTIVES: After completing this chapter, you will be able to: 1. Apply the steps of developing family nursing care plan 2. Identify the criteria of priority setting of family problems 3. Develop SMART goals and objectives to help a family achieve optimal health 4. Set criteria for evaluation of care THE FAMILY NURSING CARE PLAN (FNCP) Family nursing care plan is the blueprint of the care that the nurse designs to systematically minimize or eliminate the identified health and family nursing problems through explicitly formulated outcomes of care ( goals and objectives) and deliberately chosen of interventions, resources and evaluation criteria, standards, methods and tools. QUALITIES OF A NURSING CARE PLAN: It should be based on clear, explicit definition of the problems. A good family nursing care plan is based on a comprehensive analysis of the problem situation. A good plan is realistic. A Self-Regulated Learning Module 34 The nursing care plan is prepared jointly with the family. The nurse involves the family in determining health needs and problems, in establishing priorities, in selecting appropriate courses of action, implementing them and evaluating outcomes. The nursing care plan is most useful in written form. THE IMPORTANCE OF DEVELOPING FAMILY NURSING CARE PLAN 1. They individualize care to clients. 2. The FNCP helps in setting priorities by providing information about the client as well as the nature of his problems. 3. The FNCP promotes systematic communication among those involved in the health care effort. 4. Continuity of care is facilitated through the use of family nursing care plans. Gaps and duplications in the services provided are minimized, if not totally eliminated. 5. FNCP facilitates the coordination of care by making known to other members of the health team what the nurse is doing. STEPS IN DEVELOPING A FAMILY NURSING CARE PLAN (FNCP): a. Priority setting b. Setting goals/objectives c. Specifying intervention plan d. Developing the evaluation plan a. Priority setting ⮚ Priority setting is the process of establishing a preferential sequence for addressing nursing diagnoses and interventions. The nurse and client begin planning by deciding which family problem requires attention first, which second, and so on. ⮚ It is not necessary to resolve all high-priority problems before addressing others. The nurse may partially address a high-priority problem and then deal with a problem of lesser priority. Furthermore, because the client may have several problems, the nurse often deals with more than one problem at a time ⮚ The nurse must consider the following criteria when assigning priorities: Criteria for setting priorities: 1. Nature of the problem: ▪ Categorized the problem if it is: ▪ health deficit, ▪ health threats, ▪ foreseeable crisis situations or ▪ wellness state 2. Modifiability of the problem ▪ refers to the probability of success in enhancing the wellness states, improving the condition, minimizing, A Self-Regulated Learning Module 35 alleviating or totally eradicating the problem through interventions 3. Salience ▪ Families perception about the seriousness of the problem ex.) Failure on the part of the family to perceive the existence of the problem Family may realize the existence of the problem but is too busy at the moment with other concerns Sometimes the family perceives the existence of the problem but does not see it as serious enough to warrant attention 4. Preventive potential ▪ whether future problem can be prevented, eradicated or controlled if the current problem is addressed. The table below presented the score and weight for each criteria of priority setting: This score and weight would be your basis for computation and identifying the most and least prioritized problems. SCALE FOR RANKING HEALTH PROBLEMS CRITERIA SCORE WEIGHT NATURE OF THE PROBLEM: 1 Wellness State 3 Health deficit 3 Health threat 2 Foreseeable crisis 1 MODIFIABILITY: 2 Easy modifiable 2 Partially modifiable 1 Not modifiable 0 PREVENTIVE POTENTIAL: 1 High 3 Moderate 2 Low 1 SALIENCE: 1 Perceives the existence of the problem that needs 2 immediate attention Perceives the existence of the problem but not needing 1 immediate attention Failure to perceive the problem needing change 0 SCORING: 1.) Decide on a score for each of the criteria. 2.) Divide the score by the highest possible score and multiply by the weight: (score/highest score) x weight. 3.) Sum up the scores for all the criteria. A Self-Regulated Learning Module 36 ***The highest score is 5. The highest the score of a given problem, the more likely it is taken as the most priority to address. The problem who has the lowest the score becomes the least priority. ( Bailon and Maglaya devised this tool to objectivize priority setting) The table below shows how to use the scale for ranking health problems: IMPROPER HYGIENE PROBLEM: IMPROPER HYGIENE CRITERIA COMPUTATION ACTUAL JUSTIFICATION SCORE Nature of the (2/3) x 1= 0.6 The problem is a health threat in Problem which the family can possibly acquire diseases which could be transmitted by unwashed hands and contact with dirt, which could alter and hinder their performance of the activities of daily living. Modifiability of (2/2) x 2= 2 It is easily modifiable in which the the Problem student nurse can teach and instruct the family to perform hygienic practices such as handwashing before consumption of meals and bathing at least once a day and the family has adequate water and soap for addressing hygiene issues. Preventive (3/3) x 1= 1 It is highly preventable by the Potential implementation of preventive measures which are easy to perform, thereby minimizing the occurrence of the disease and spread of infection. Salience (2/2) x 1 = 1 The family recognized the problem and felt the needs to address immediately the issue on hygiene measures Total score 4.6 b. Defining/setting goals/objectives GOAL is a general statement of the condition or state to be brought about by specific courses of action. The cardinal principle in goal setting states that goals must be set jointly with the family. This ensures the family’s commitment to the plan of care. Ex.) Goal of Care: After nursing interventions, the family will be able to identify healthy practices and be able to practice them habitually. OBJECTIVE is a more specific statement of the desired results or outcomes of care. It specifies the criteria by which the degree of effectiveness of care are to be measured. Goals tell where the family is going; objectives are the milestones to reach the destination. A Self-Regulated Learning Module 37

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