Family Assessment for Nursing

Family Assessment

Description of Family / Genogram

Profile of Family

The 'T' family has been chosen for the completion of this assignment. Mr. T is the 95-year-old patriarch. His wife and mother of their two children is Mrs. T, 92 years of age. Their children are Wilma and Leon; ages 60 and 62 respectively. Theirs is a nuclear family. Both husband and wife are quick to affirm their lives are full of joy and fulfillment at having a family and raising two healthy kids.

Diagnosis of the Family

Developmental Stages and Tasks

I made the acquaintance of Mrs. T approximately four years ago when we worked side-by-side as customer service representatives; and remained work colleagues for the ensuing three years. Today we are fast friends although I have returned to school to pursue a degree in nursing. I enlisted her aid in a nursing theory project recently; her response was enthusiastic. The assignment was to be done as partial credit for a class in community health. Students were required to interview a family in their homes to better understand the unique and dynamic parameters of this environment - referred to as a 'community setting'.

In the spirit of full disclosure I prepared Mrs. T in advance about the types of questions that would be asked including queries about individual family members' health definitions; current health-related issues and coping strategies to address them. Her response was heartening; ensuring me the family was available to assist any evening that was best for my schedule. Before parting I thanked her profusely in advance for her cooperation; and advised her that the family could be guaranteed their exchanges would remain private - the point of the exercise was to allow me an opportunity to develop therapeutic communication expertise. To further ensure confidentiality - only the participants' initials would appear in any report and not their entire names. Any information that was forthcoming from the interviews would only be seen by the professor; and only for the purpose of assessing my abilities to interact effectively in a home setting. Before departing I advised her to prepare her family for the upcoming interview. When next we spoke it was to set up a date and time to meet.

With final arrangements in place I showed up at their doorstep promptly on time; dressed casually but professionally and conspicuously sporting my student I.D. Introductions were made all around with warm handshakes and excited smiles. We sat and I explained I was attending school at GBC in the field of practical nursing and then shared assignment expectations; reiterating in particular the extreme measures of confidentiality to be taken on their behalf. Before proceeding, I confirmed the consent of each family member of their voluntarily participation; the adults were additionally required to sign an agreement to that end - a class prerequisite to submitting any part of the assignment. Thus began my first experience in community nursing.

As would be instinctually expected of the community nurse; I was highly respectful of the household and its members upon each visit. I focused on my non-verbal communication techniques that called for non-judgmental expressions and gestures. All facial expressions, body posture, eye contact and voice modulation were designed to put the interviewee at ease; and more likely to be honest and forthcoming. I did not have to feign interest and I smiled and listened attentively to each family member. I leaned forward during verbal exchanges to develop a sense of intimacy and kept eye contact to reassure the speaker that I was 'mentally present' and highly interested in their responses; thereby setting an engaging tone that superimposed itself over the length of the assignment. I found that this authentic interest prompted family members to be more open and willing to share private thoughts and concerns.

One instance that challenged my communication skills occurred almost immediately at the opening of our first session when the daughter seemed unable to grasp the need of 'interviewing' at this length. To drive home the idea I returned to the text that explained to nursing students effective communication relies on message delivery, interpretation and feedback that allows for proper interpretation. The daughter peppered me with questions; and tried to draw a correlation to her own life experiences. I reiterated that an interview is a verbal exchange that opens up the doors of communication - but in this context it was a tad different and more intricate. I explained to her that one of the most important aspects of an interview is honesty and used some simple questions as examples such as querying her about her favorite activities. To cement the concept I used television viewing as a second example and pretended again to be the interviewee and interviewer - showing that one answer could be that she enjoyed a show about tree houses. At this point Wilma revealed that she comprehended the need of the interview at this time and was clear on what was expected of her.

Correlation with HP2020 Objectives and LHIs

Universal health care requisites

The requisites of universal self-care are common to everyone along the continuum of phases despite an individual's age, health and/or developmental status. These health care prerequisites universal to all people include Food, Elimination, Activity and rest, Solitude and social interactions, Hazards to human life, functioning and overall well-being. These factors are used to assess all families as part of the overall community health process. Let us consider each briefly and separately.

Food: The community nurse must determine the extent to which each member of the family is nourished and hydrated. Who is responsible for food preparation? Does the family eat together? In the case of the T. family there are no obvious signs of alcohol and/or substance abuse of any kind by any member. However, meal time atmospheres are somewhat chaotic so a thorough assessment of each family member's meal intake was difficult. In general, when siblings are enlisted to oversee the eating habits of their younger counterparts; the latter are often fed such unhealthy foods as soda, snacks and candy.

Elimination: This is a fact of life that many are reticent to discuss openly; therein lies the need for trust. In the case of the T. family there are inadequate resources for proper hygiene despite all bathrooms being functional in the home. The real problem is a shortage of bathrooms that cramps everyone's morning routine as they prepare for the day. The T. family does employ a nanny; and one of her responsibilities is to attend to the physical hygiene needs of the S. children. The home appears clean and neat however.

Surprisingly, the family has quite a menagerie that includes a rat and pig. The T. family tends to the elimination needs of their pets and attempts to ensure there is no risk of contamination of their food supply. But the truth is that the possibility exists the pets occasionally have access to human foodstuffs. Disposal and cleanup of pet wastes is proper.

Activity and rest: In this example the father is employed full time in the Navy and the mother is a stay-at-home fashion designer. Their inability to receive the proper amount of rest is not uncommon in families with children. One problem is that the children enter the parents' bedroom at night; preventing them from receiving restorative sleep. However, the parents do not use sleep aids - which tend to become a crutch to the sleeping process long-term.

Solitude and social interaction: The example for use in this section is a step-family. The step children do not get along and incompatibility reigns. Additionally, the children are rude to their step-parent and inclined to disregard instructions. The parental units have tried to repair the rift by creating multiple opportunities for family activities including such things as sailing, shopping and home repair. A nanny is responsible for mean preparation and the family takes meals together. The children attend public schools and take part in a wide variety of activities in the arts, sports, leadership and more. The parents exude mutual respect, affection, sexual attraction and love for each other. Finally, each has personal transportation that ensures they are able to meet their own obligations.

Hazards to human life, human functioning and human well-being: There are relatively few safety hazards evident in this household. However, they reside in an older home that requires a challenging amount of cleaning and repair. As the parents and nanny are busy; the children are not always supervised appropriately the chance exists for accidents. They have also been the cause of a number of unsafe impish acts such as setting off fire alarms, using a forklift in a shopping center, climbing on unsafe objects and more. The parents are not always able to ward off these behaviors successfully.

Family Concepts

Defining the Health of a Family

Next, I requested that family members work as a team to develop a definition of 'health' and then explain its personal meaning. After a few moments of conversation the mother offered the following eloquent description. "Health is the absence of incurable issues - such as physical, mental and emotional problems." Queried individually, each member agreed with this explanation. Seeking further clarification, I asked Mrs. T to explain what they meant by 'incurable issues'. Her replay was "some physical ailments can be treated and cured such as ear infections that doctors treat with antibiotics. In other cases, such as HIV / AIDS - the sufferer is never able to overcome the disease and can only find a way to extend their life with the aid of medicine." She also stated that they believe cancer is not curable (personal communication, September 24, 2013); a misconception to be sure. It was interesting to note that the family also believed that health was the pursuit of behaviors that ensured maintenance through exercise and healthy eating. This insight was heartening; and I followed up the idea by asking the family to decide if they were healthy according to their own definition. Both parents responded with an immediate and resounding 'No'; after which they elaborated. Mr. T claimed he suffered from diabetes for the past half-decade; but this has not deterred him from continuing to make poor food choices. Mrs. T is a long time insulin-dependent diabetic and also fails to exercise; habits she has picked up since have children. Conversely, both children stated they were not very healthy either and suffered from similar diseases.

Health Issues from the Family's Past

I next asked the family to describe a previous health incident - only if they felt at ease sharing the information. Silence filled the air for a moment and then the daughter remarked that her mother had suffered a miscarriage. Mrs. T provided further information on the subject; explaining she had experienced 3 miscarriages in a row - one was a set of twins -- and hence she was now suffering from Adenocarcinoma ovaries and uterus. Sadness crossed the faces of the whole family; and a somber silence ensured. After a respectful amount of time had passed I asked how the family had handled this series of devastating events. Mr. T replied that it was incomparable as a thing of pain for both adults and Mrs. T interjected that only "through the grace of God and family and church support were they able to get through the experience" (personal communication, September 13, 2013).

The family continued to open about the miscarriages and how they had affected the family. Mrs. T related that her mother came to stay with the family for a while to help tend to the upkeep of the house and child. Too, the family could not help but question the will of God to allow for such devastation. The extended family and church worked hard to keep them uplifted; and Mrs. T actually sought grief counseling to deal with the pain. She stated that "nothing could replace the love she and her husband held for both children (such a poignant thought) but when our youngest was born I put my grief aside to revel in the joy of the birth; I had a reason to smile again." She sagely added that "life is full of disappointments and people must learn to work through the pain to find joy again." Then the family reemphasized the importance of prayer and faith in their lives as a coping strategy; and family affection and support also helped. Again, Mrs. T noted that grief counselors helped her get through this dark period and the family 'came out on the other side' whole and happy.

The Current Health Issues of the Family

The T. family iterated their current health concerns included diabetes - both parents and children have diabetes steadily for the past decade; unhealthy eating is a second problem - their salt intake is much too high. Too, hypertension is a long-standing problem and Mrs. T admits she tends to over season foods with salt when she cooks. Mr. T has had a long standing problem with diabetes; at this point I stopped the interview to take his blood sugar pressure. His random blood sugar was at 245.

Yet another problem plaguing the members of the family is their decided lack of exercise. Both parents admit they rarely engage in any physical fitness activities and as a result they often feel sluggish. Too, it has led to weight gain in both adults and obesity in the daughter. Also, the father's work schedule has led to insomnia issues and he claims he rarely gets enough sleep. The children jumped in at this point mentioning that weight was a family issue. I then asked then to collaboratively identify what they would prioritize as a health issue and they unanimously that diabetes was at the top of the list (personal communication, September 24, 2013).

There is no denying that the entirety of the T. family's health issues are all pressing; according to my assessment diabetes is the most damaging and, therefore, takes priority. After all, each adult has been a decade long diabetic; each claiming they do so to help deal with the stress in their life. Additionally, Mr. T has a family history of hypertension; and it is my hypothesis that there is a direct correlation to this condition and his excessive intske of unhealthy or sweetened food. It was easy to show the family this connection using the sugar stats I had collected on the father. I also showed them some of the clinical proof that diabetes causes a variety of health problems including heart and vascular issues, circulatory problems, organ damage and much more. As I iterated these problems I became more convinced than ever that diabetes truly was the greatest risk factor to the T. family's health as a whole. As if to confirm my assessment; Mrs. T chimed in that of late she has been having trouble catching her breath and was suffering from excessive fatigue - all of which she attributed to her sugar levels.

Adults are inclined to ignore the fact that their eating habits adversely affects the mental health of their children who themselves may suffer from anxiety over worrying about the health of their parents - as today's kids are much more health savvy than in previous generations. Realizing this, only underscored my decision to address diabete as the first issue to tackle. Even a brief visual assessment led me to recognize that both adults appeared much older than their age would belie; and both were overweight as well with the majority of their excess fat settled in their abdomens. The son was not overweight, however, and also showed no other obvious signs of unhealthiness and the daughter was obese. Ultimately, my assessment and that of the family's were identical - we all believed that diabetes was the most urgent health issue that needed to be addressed.

Gordon's Functional Patterns

Formulation

Thus began the process of creating a step-by-step process for helping the adults address the issue of diabetes. Both parents eagerly stated they would like to quit desserts and sweetened foods within a two-month time frame; which would take them into the New Year as healthy eaters. I introduced the SMART goal criteria at this point and assisted them in its use as they created this first aim which read "By January 1, 2014 our intent is to have completely withdrawn from the intake of desserts. We will meet this goal by reducing the number of sweetened foods we eat one per week for 15 weeks. At the end of this time period we will have completed reducing our daily intake of sweetened food."

The parents then turned to the children to help them create a health goal and set up the framework to meet it. For the daughter the goal was to "reach a point where she has completed fifteen hours of exercise using the video game called Just Dance 2. They agreed to do this for half an hour each day - over a thirty day period."

This stage of the assessment required that I draw on verbal therapeutic communication skills - specifically "Questioning" (Fortinash & Holiday Worret, 2008) such as when I asked Mr. T if he understood that the genogram confirmed a history of diabetes in the family and "in light of this and other heart issues; how does this frame your own approach to your health outcomes"? Mr. T seemed visibly uncomfortable with the question; breaking eye contact with me. It was apparent that the directness of my question made him reflect on the state of his health - and realize it was essential for him to modify his behavior. At this point, though, I was a little upset with myself because I think perhaps I had gone a bit too far and was too personal and my questions may have been too invasive.

In the 'Working' phase of this assignment I incorporated the therapeutic verbal technique known as 'Assisting in goal setting' in the following way. I told them that I realized the SMART goal technique could be challenging to utilize but I would be there "to guide them in formulating their aims and objectives - and interject with suggestions that would aid in their success" (Fortinash&HolodayWorret, 2008). It seemed this bit of verbal encouragement resulted in greater willingness on behalf of the family to attempt to learn and manipulate the SMART goal system.

Implementation

One of the purposes of community health in which the trained professional meets with families in their own environments is to encourage them to step in and take over the responsibility for their own health choices - while making educated decisions. Here I felt it was important to share information of the negative effects of unhealthy eating on health and provide them with examples of how other people have managed to successfully kick the habit. There were a wealth of ideas to help address the expected cravings that accompany unhealthy or highly-sweetened cessations. The hope is that these suggestions would improve their resiliency throughout the process. Additionally, I aided the family by helping to develop a teaching plan that outlines behaviors to foster or avoid in the march towards reaching their goal of ending unhealthy or dessert intake.

Health Plan

Family Care

What now follows is the health care plan for the T. family. This 'plan of care' includes a nursing diagnosis, self-care deficits, client and nursing interventions, and evaluation criteria aligned to the goals.

Altered Family Processes is one nursing diagnosis applied in this family's case. It occurs as a result of a family member's inability to 'adjust or perform'; thereby causing family dysfunction and a general interruption or prevention of development. There are a number of challenges facing this new family unit including such things as their diet, habits and routines. Communication - or the lack thereof - seems to be at the heart of the matter. Rules are unspecified; parents' expectations send mixed messages. There is also an obvious deficit in self-care regarding solitude and social interactions. Hence, the following nursing interventions are recommended. First, the nurse should individually assess family members for their perceptions of the problem which are then collectively labeled as 'family problems'.

It is incumbent upon the health care provider to explore each family member's feelings - such as anger, fear or anxiety - and then demonstrate how they can be broken into manageable components; after which the family can utilize a variety of resources to develop coping strategies that address the problems. The interventions would then be evaluated as such: has the family developed improved means of communication; have they identified problem solving resources; have they learned to verbalize the mutual concerns.

'Disturbed Sleep Pattern' is a second diagnosis for this family. According to NANDA it is defined as a disruption of the rest and sleep patterns of the individual (Gulanick and Myers, 2003). The nurse will note that the family has recently taken up residence in a new home and the family dynamics themselves have changed. Therefore, it is not surprising that there has been difficulty in adjusting to a new location and the sleep patterns of 'strangers'. This troubled sleep has manifested itself in the form of verbal complaints, excessive yawning, irritability, and occasionally dozing off. Hence, the self-care deficit for this family is in the area of activity and rest; and the following nursing interventions can be used/applied: assess each family member's perception of the reasons for the sleep problems and also gather ideas for how to address it successfully according to that individual. Remedies could include such things as changes to the sleep environment or the creation of a household sleep schedule that further meets the needs of each person. The nursing intervention will not be successful if there is not complete buy-in from the family members; and ultimately each person is able to get an optimal amount of sleep. The success will be evident in a more rested appearance, less irritability and more positive dispositions.

A third diagnosis regarding this family is the 'Impaired Home Maintenance' problem best defined as the individual's inability to maintain growth-promoting safety - independently - in one's home environment. Each member of the family has already experienced the adverse effects of a disrupted eating life style; but it has been further exacerbated by less than optimal home living conditions. The home is in need of repair; and self-care deficit falls under 'Hazards to life, human functioning, and human well-being'. The most apropos nursing intervention is to begin with a full home assessment for problems followed by interviews of individual family members regarding their personal feelings about the deficits. Here the nurse should determine each individual's understanding of hygiene and safety; and offer a list of appropriate community resources. The goal is measured by home maintenance and family member's ongoing freedom from injury.

Returning to the T. family; my research uncovered the 'William Osler Health Centre "Kick It" program' - a free resource for persons trying to manage diabetes or any other health problem. It is available to people in the peel area; preregistering occurs by phone. I believe this will increase the T. family's chances of success. I directed them to the website designed by the Mayo Foundation for Medical Education and Research as well. It offers another diet management plan that includes the following steps:

Write down every time you think about in-taking something sweet - and then reiterate why you are trying to quit in list form. Carry this list with you and refer to it when you have the urge to indulge.

Rely on a support system -- sweetened cessation is one of the most difficult challenges; and everyone can use some help.

Keep the number of a 'Diabetic's Help Line' on your speed dial for those times when a craving feels impossible to resist.

Stay hydrated - that helps to flush unnecessary sugar out of your system.

Stay away from places and things that trigger your desire to indulge. Visit places where there is very little exposure to desserts and make friends with people who don't indulge in sweeteners or are trying to quit as well.

Keep your stress under control - stress is one of the most common triggers for diabetes. Get organized and stay that way - don't let worries fester - address them - in the end you will be glad you did.

Reward yourself with treats that replace sugar intake such as going to a movie. Put the money you would have spent on a donuts in a jar and watch it add up.

Communication skills

Throughout the working phase of this class requirement the therapeutic communication technique - providing feedback - was employed. It was especially useful supporting the T. family in the development of their SMART goal. I used such phrases as "why not tell me what it is you are attempting to verbalize and then I can translate that into the SMART criteria." This feedback technique allowed me to assess their thoughts and emotions while guiding them through what is an unquestionably complicated process for the novice. When we reached the termination phase I relied on the 'Reinforcing healthy behaviors' technique - stating that the family had made great strides for improved health. I was sincere when I told them that "they were inspiring in the way they had worked together to meet their goals." Upon later reflection I was proud and humbled to think that I had played a part in empowering this family to transition their lives towards healthier actions; and my positive reinforcement had led to the incorporation of better behaviors.

Assessment

The T. family was paid a visit dutifully and it was heartwarming to see that their plan was in action as planned. They were about to achieve their first milestone. Mr. T and Mrs. T had lowered their sugar intake to one indulgence a week. Their previous ratio was 3 in a week. So for now, both of them stated that they had lowered their sugar intake with no intense desire seen. Furthermore, Mr. T and Mrs. T have now registered with Diabetic's helpline and will attend an information seminars when held in their area.

The children were optimistic with the results and were hoping to become much more managed in their diet as well. Mr. T concluded that he was able to sleep better when he didn't indulge. He looked a lot healthier owing to proper sleep. Mrs. T made a mental note of using less salt in her food. She was given a shopping list from Heart and Stroke Foundation free of cost.

Relationship

The assignment was almost completed as the relationship with T. family became more cordial and friendly. The trust level was high and partnership was quite two way. There weren't any issues which materialized, but one issue was quite bothersome.

The family was feeling more and more confident now as they would pry about my personal life once in a while. This means 'boundary violations occur in case nurse exceeds the defined client-patient relationship and steps into the personal relationship with a patient' (Fortinash & Holoday Worret, 2008, p 75, par. 9).

The fact that Mrs. T and I became close friends became a hurdle in our assignment and the lines between friendship and professionalism became cloudy. We had entered unchartered territory. The friendship was all the more in conjunction with the assignment at hand. Her family allowed me to hear about her miscarriages and other delicate information.

Our meetings were much easier as their residence was close by. Only professional language was employed and attention to all members of the household was given. Thus, their undivided attention and trust was gained. Their individual and collective goals came to limelight. Quite a many therapeutic techniques were employed for instance:

Stress positive behavior

Feedback

Questions

Giving information

The techniques were useful in clearing confusion regarding information, collect delicate information and reflect a bit, whilst providing feedback and genuine pointers for their aims and empower the family on the whole. The family was all the more appreciative of the efforts made and they couldn't be more thankful to be assessed on their healthy behaviors.

Working with a family was easier than working in hospital settings. There are some reasons for that. The primary reason for this change of environment was the health promotion. In the pre-graduate era, there wasn't sufficient time to sit through with a patient hours at length. Other patients require assistance too and the surroundings become distracting. Spending quality time with one patient is a tad bit difficult. In the community settings, there is massive potential to employ various therapeutic techniques present in textbooks. In case of hospital settings, meeting with all family members wasn't possible due to lack of time. It was hard to assess their situation and work out their common dilemmas. With a community setting, the family is connected to one another. The clients in hospital settings are often admitted and discharged as quickly as possible during the pre-graduation era. The results were impossible to see and long-term goals were nonexistent. In a community setting, the family has a location, address, telephone number and thus can be evaluated for SMART goals progression.