This paper presents a family-centered nursing care plan for a 78-year-old female patient using the Calgary Family Assessment Model (CFAM) and Calgary Family Intervention Model (CFIM). The patient presents with multiple co-morbidities including hypertension, osteoarthritis, osteoporosis, urinary stress incontinence, and a history of falls. Four nursing diagnoses are identified: critical health issues, difficulty in daily routine, strained family relationships, and fear of mobilization. For each diagnosis, short-term and long-term goals are established alongside targeted interventions. The plan integrates medical, social, and psychological support strategies while accounting for the patient's family dynamics and living conditions.
The patient is a 78-year-old woman. Her diagnosis is performed by keeping family problems in consideration, in accordance with the Calgary Family Assessment Model (CFAM) and Calgary Family Intervention Model (CFIM) (Wright & Leahey, 2005; Wright, Watson & Bell, 1990). Further explanation is provided with the help of a genomap and eco-map (About Ecomaps, 2012). She has been admitted to an elderly care ward following a history of falls.
The patient lives in a flat with her daughter and son-in-law. She is mainly housebound but is taken out most weeks by her family. She is content with these arrangements and has refused further social support, reporting that she is happy with her own company. Her family handles her shopping, washing, and similar tasks.
She has a history of hypertension and appears to have a good understanding of her condition. This has been well controlled on bendroflumethiazide (bendrofluazide) 5 mg in the morning. She is normotensive on admission and her blood pressure appears to have been stable over a long period of time.
Since her daughter and son-in-law are employed, the patient relies on frozen meals for lunch, which she heats in a microwave oven. There is no carer to assist her. These frozen meals are her chosen lunchtime food, and a dietician was involved in selecting an appropriate range. However, her family faces difficulty in arranging meals of her preference due to their busy schedules.
She suffers from osteoarthritis in her hips and takes paracetamol 1 g four times a day. She mobilizes without any assistance, which has been identified as a contributing cause of her falls. She has a wound on her shin from a fall, which became infected and is slow to heal.
She has a history of urinary stress incontinence, which was fully assessed a few months prior. She follows a routine to minimize incontinence and does wear pads, though her supply is running low. The patient takes alendronate 10 mg daily to prevent fractures due to mild osteoporosis. This medication is proving effective and no change is planned. She takes it 30 minutes before food in the mornings while sitting upright.
During her 10-day hospital stay, she was found to have postural hypotension as a result of her diuretic, which is believed to be the cause of her fall. Her physicians determined from her medical history that her blood pressure becomes raised if she stops her diuretic, so she will continue on bendroflumethiazide when she goes home. She has been started on co-codamol 8/500, two tablets every six hours, to manage her pain more effectively, and her paracetamol has been stopped.
The patient is keen to go home. The multidisciplinary team (MDT) wished to keep her in a little longer, but she felt well enough and the doctors agreed to discharge her ten days post-admission. Apart from the wound management and the change in analgesia, no other changes to her care are planned.
The patient has complained about a lack of care from her family. She does not share a particularly close relationship with her daughter. According to earlier interviews, her daughter is married, and together with her husband they constitute the patient's only immediate family. Both are employed. Given the patient's multiple health issues, they find it difficult to manage her care, and this strain has begun to affect their own relationship. The daughter is not willing to transfer her mother to an elderly care home but is concerned about her marriage and career.
The patient has critical health issues. She is currently suffering from hypertension, osteoarthritis, a history of urinary stress incontinence, mild osteoporosis, and a history of falls.
The patient has recently suffered a fracture. Facilitating her healing is the first short-term goal.
Interventions:
Another short-term goal is to ensure that her hypertension, which is contributing to her falls, remains controlled.
Interventions:
The long-term goal is to restore the patient's mobility and ensure she receives necessary medical care. For managing her ongoing conditions — osteoporosis, osteoarthritis, hypertension, and urinary stress incontinence — she is recommended to maintain her existing medication regimen with the following adjustments:
The patient has been managing these health issues for approximately ten years. She needs to build physical resilience. She has been reported to skip meals and medications on occasion and has also been advised to undertake mild exercise, which she has reportedly been reluctant to do.
The patient lives alone for most of the day while her daughter and son-in-law are at work. Her history of falls has been attributed not only to health factors but also to non-conducive living conditions. She requires support for daily functioning and for mobilization.
The first goal is to improve her quality of daily life. Living alone during the day results in skipped meals, poor maintenance of living conditions, missed medications, and mild but recurring episodes of low mood. She is dissatisfied with the meals chosen by her family, and her family sometimes fails to provide necessities such as clean clothing and a well-maintained living environment.
Interventions:
Since most of her current difficulties stem from her family's busy schedule, interventions are needed to make her daily routine less dependent on their direct involvement.
Interventions:
The long-term goal is to enable the patient to function independently, with access to all necessary resources and consistent care.
Interventions:
In addition to increasing social contact, the patient's home environment needs to be adapted to support safe movement and communication.
Interventions:
The patient's immediate family consists only of her daughter and son-in-law. Both are employed and struggle to meet her needs consistently. The patient has experienced recurring illness and multiple hospitalizations over recent years. Her son-in-law has lived independently for much of his life and finds it difficult to connect with her. Her daughter is unwilling to place her in a care home but is also under strain in her marriage and career. The interventions below are designed to reduce the caregiving burden on the daughter and son-in-law while ensuring the patient's needs are met.
The first goal is to reduce the direct caregiving responsibilities of the daughter and son-in-law.
Interventions:
"Reducing family caregiver burden and conflict"
"Restoring patient confidence and mobility"
The genomap and eco-map diagrams included with this care plan illustrate the patient's family health history and her network of social and healthcare relationships. These tools, integral to the CFAM/CFIM approach, contextualize the interventions recommended throughout this plan.
You’re 39% through this paper. Sign up to read the remaining 2 sections.
Sign Up Now — Instant Access Already a member? Log inAlways verify citation format against your institution’s current style guide requirements.