CFAM/CFIM Nursing Diagnoses and Interventions for Elderly Patient

Patient History and Background

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.

Diagnosis 1: Critical Health Issues

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.

Short-Term Goal 1: Fracture Healing

The patient has recently suffered a fracture. Facilitating her healing is the first short-term goal.

Interventions:

• The patient needs to continue taking co-codamol 8/500, two tablets every six hours, to manage her pain as recommended by her doctor.
• Paracetamol is to be discontinued.
• The patient needs to visit an orthopaedic surgeon.
• She is further recommended to enhance her intake of supplements through her diet.

Short-Term Goal 2: Controlling Hypertension to Reduce Fall Risk

Another short-term goal is to ensure that her hypertension, which is contributing to her falls, remains controlled.

Interventions:

• Her history of falls is related to unassisted mobilization; therefore, she is to be provided with a Zimmer frame.
• Her falls are caused in part by postural hypotension associated with her diuretic. Continued intake of bendroflumethiazide (bendrofluazide) 5 mg is recommended.
• Her osteoarthritis increases her risk of falls and contributes to pain. Paracetamol is to be discontinued as she is already taking co-codamol 8/500.
• Her osteoporosis raises the risk of fracture in the event of a fall. She is recommended to continue alendronate 10 mg daily, taken in the morning before her first meal.

Long-Term Goal 1: Restoring Mobility and Maintaining Medical Management

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:

• Paracetamol may be resumed once her injury has healed and her doctor advises discontinuation of co-codamol 8/500.
• Given her long history of hypertension and a cardiac arrest seven years ago, continued use of bendroflumethiazide (bendrofluazide) 5 mg is recommended in the long term. No alternative diuretic is advised given her current medication profile.
• Alendronate 10 mg daily is to be continued to prevent fractures, taken each morning before her first meal.
• Use of dairy products, vitamins, and other nutritional supplements is also recommended to support bone strength.

Long-Term Goal 2: Building Physical Resilience

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.

• A community doctor is recommended to conduct weekly residence-based check-ups, reducing the burden on her family.
• Monthly visits to an orthopaedic surgeon are recommended, given her history of osteoporosis and osteoarthritis, to keep her pain well controlled.
• Participation in community welfare programs designed for elderly patients is encouraged.

Diagnosis 2: Difficulty in Daily Routine

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.

Short-Term Goal 1: Improving Quality of Daily Life

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:

• A carer from social services is recommended to assist her during the day. The aim is not to undermine her autonomy but to provide practical support that allows her to function effectively.
• Due to her diuretic intake, she experiences frequent urination — her last fall occurred during a trip to the bathroom. Since the diuretic cannot be reduced or stopped, continued use of pads is recommended, as she has previously found them acceptable and comfortable.
• Her family is advised to maintain an ample supply of pads. If a carer is engaged, this responsibility can be shared.
• Her family is encouraged to maintain close communication with the carer to monitor her living conditions.

Short-Term Goal 2: Making Her Routine Independent of Family Availability

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:

• As many skipped meals arise because she does not enjoy the available food, it is recommended that a food delivery service be arranged. Frozen meals may be used to ensure a consistent supply of preferred options.
• In the absence of family or a carer, all important contact numbers — family members, nearby stores, and hospitals — should be readily accessible. A mobile device with speed-dial functionality is suggested.
• Social services should be engaged to support her exercise routine.
• Home delivery services from nearby grocery stores can be used for any additional needs.

Long-Term Goal 1: Supporting Independent Living

The long-term goal is to enable the patient to function independently, with access to all necessary resources and consistent care.

Interventions:

• Beyond the short-term carer recommendation, it is suggested that a social worker specializing in elderly care be assigned on a longer-term basis to oversee her wellbeing.
• Participation in community programs for elderly citizens is encouraged to maintain social contact and prevent depression or anxiety.
• Given that the patient was a teacher, providing her with reading materials would help her cultivate a positive outlook on her living circumstances.
• It is suggested that her daughter and son-in-law commit to spending time with her on weekends — even an hour together would be beneficial.

Long-Term Goal 2: Creating a Conducive Home Environment

In addition to increasing social contact, the patient's home environment needs to be adapted to support safe movement and communication.

Interventions:

• Her family is recommended to install wooden handrails in her bedroom, bathroom, and the passage to the kitchen to support safe movement.
• Long-term use of a Zimmer frame is recommended.
• Visits to a Falls Clinic are recommended to rebuild her confidence in mobilizing independently.
• A residence-based visit from an occupational therapist is also recommended.

Conclusion and Supporting Diagrams

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.

The genomap identifies key health conditions across generations of the patient's family. The patient's sister (aged 70) shares diagnoses of osteoporosis and osteoarthritis. Her son-in-law (aged 45) has hypertension, and her niece (aged 48) has diabetes. These familial health patterns are relevant to understanding both the patient's medical profile and the health literacy of her immediate caregiving family.

The eco-map illustrates the patient's connections to healthcare services, her daughter and son-in-law, and extended family and relatives. Together, these diagrams support a holistic, family-centered understanding of her situation and reinforce the rationale for the multi-dimensional interventions described in this care plan.

References

About Ecomaps. Retrieved from

Wright, L. M., & Leahey, M. (2005). Nurses and families: A guide to family assessment and intervention (4th ed.). Philadelphia: F. A. Davis.

Wright, L. M., Watson, W. L., & Bell, J. M. (1990). The family nursing unit: A unique integration of research, education and clinical practice. In J. M. Bell, W. L. Watson, & L. M. Wright (Eds.), The cutting edge of family nursing (pp. 95–112). Calgary, Alberta: Family Nursing Unit Publications.