Famiy Nursing Process

Family Nursing Process

Family

Objectives 1. Explain the importance of family nursing in the

community setting.

2. Describe family demographics.

3. Define family, family nursing, family health, and healthy/non-healthy/resilient families.

4. Analyze changes in family function and structure.

5. Compare and contrast the four family social science theoretical frameworks.

6. Explain the various steps of the family nursing process.

Objectives (continued) 7. Summarize the importance of the assessment to the

intervention outcomes.

8. Compare and contrast the four ways to view family nursing.

9. Explain one assessment model and approach in detail.

10. Describe the various barriers to family nursing.

11. Share the implications for family policy.

12. Explore issues of families in the future.

Family

Family: refers to two or more individuals who depend on one another for emotional, physical, and/or financial support; members of the family are self-defined

Family Nursing consists of nurses and families working

together to ensure the success of the family and its members in adapting to responses to health and illness

Family HealthFamily Health: a dynamic changing relative

state of well-being that includes the biological, psychological, sociological, cultural, and spiritual factors of the family system

Families are neither all good nor all bad; therefore nurses need to view family behavior on a continuum of need for intervention when the family comes in contact with the health care system

All families have both strengths and difficultiesAll families have seeds of resilience

Four Approaches to Family Nursing

Family as the context, or structure: has a traditional focus that places the individual first and the family second

Family as the client: family is first, and individuals are second

Family as a system: focus is on the family as client, and the family is viewed as an interacting system in which the whole is more than the sum of its parts; simultaneously focuses on individual members and the family as a whole

Family as a component of society: family is seen as one of many institutions in society, along with health, education, religious, or financial institutions

Theoretical Frameworks for Family Nursing

Structure-Function Theory: families are examined in terms of their relationship with other major social structures (institutions)

Systems Theory: encourages nurses to view clients as participating members of a family

Developmental Theory: looks at the family system over time through different phases that can be predicted with known family transitions based on norms

Interactional Theory: views families as units of interacting personalities and examines the symbolic communications by which family members relate to one another

Case Study Marty Belfair, a 55-year-old accountant, is the

father of three children and has been married to his wife, Joanne, for the past 25 years. Mr. Belfair’s children are Joshua, age 20, Mary, age 17, and Kyle, age 14. Mr. Belfair’s mother, Delia, has lived in the Belfair household since her husband, Martin, passed away 4 years ago from lung cancer. A few months ago, Mr. Belfair was diagnosed with bladder cancer. After surgery and chemotherapy, the cancer still has not receded. The family physician estimates Mr. Belfair has only 5 months to live.

Case Study Alex Von Bremen is the hospice nurse

working with the Belfair family. Mr.Von Bremen explains to the Belfairs that his goal is to work with the whole family in coping with Mr. Belfair’s illness. Mr. Von Bremen asks each family member, “How do you feel Mr. Belfair’s illness will affect the way in which the members of your family function and interact with one another?”

Case Study Joanne Belfair responds, “Right now we do not

talk about Marty being sick. It is the elephant in the room. I am afraid that if Marty does not get better, the whole family will fall apart and never see each other.”

Delia Belfair shared, “I do not know where I will live. We don’t talk about it. I don’t know if I’m welcome to stay if Marty’s not here.”

Mr. Belfair encourages his family, “I know my illness is hard to accept now, but we have been through tough times in the past and the family stayed together then. Remember when I lost my job? We all made sacrifices for the family and were a stronger family as a result.”

Which family nursing approach did Mr. Von Bremen use? A. Family as the context

B. Family as the client

C. Family as a system

D. Family as a component of society

C. The focus is on the family as a client, and the family is viewed as an interactional system in which the whole is more than the sum of its parts. Because Mr. Von Bremen asked about family interactions and functioning, he is approaching the family as a system.

A. Family as a context: The family has a traditional focus that places the individual first and the family second.

B. Family as the client: The family is primary and individuals are secondary.

D. Family as a component of society: The family is seen as one of many institutions in society, along with health, education, and religious and financial institutions.

Using the outcome-present-state testing model (OPT), how can Mr. Von Bremen assist this family with the intervention and decision-making step?

The role of the nurse is to offer guidance to the family, provide information, and assist in the planning process. Mr. Von Bremen already has begun to encourage the family to address their communication problems. Mr. Von Bremen can act as a facilitator for the family discussions, provide information on resources in the community, and help the family plan how they will cope with Mr. Belfair’s declining health.

The definition of a family is which of the following?

A. Two or more people who are bonded together by legal blood relationships

B. A group of people with whom a person closely identifies

C. Two or more people who depend on each other for emotional, physical, and/or economic support

D. Two or more people who are related through adoption, guardianship, or marriage

Which of the following is not a barrier to practicing family nursing?

A. The traditional charting system in health care has been oriented to the individual.

B. A lack of comprehensive family assessment tools exists.

C. The nursing diagnostic systems are disease- and individual-focused.

D. Insurance carriers recognize the family as a unit, as well as the individual client.

Pre-encounter data collected before a family interview includes which of the following?

A. Referral source

B. Family

C. Previous records

D. A and C

E. A, B, and C

FAMILY HEALTH NURSING

that level of CHN practice directed to the FAMILY as the unit of care with HEALTH as the goal and NURSING as the medium, channel or provider of care

Family Case Load - the no. and kind of families a nurse

handles at any given time - variable for cases are added or

dropped based on the need for nursing care and supervision

Universal Characteristics of Families

1. Every family is a small social system

2. Every family has its own cultural values and rules “ Family matters must always stay within the family operating rule: “Do not tell anyone about our problems”. Power distribution and roles

3. Every family has structure: Shapes and sizes (nuclear and extended, traditional and non-traditional)

4. Every family has certain basic functions

5. Every family moves through stages in its life cycle

The Family as a Social SystemThe attributes of open systems that explain how families

function:

1. Families are interdependent = Each member’s actions affect the other members

2. Families maintain boundaries = ego-boundaries + generation boundaries + family-community boundaries

The Family as a Social SystemCont…

1. Families exchange energy with their environment:

Input-output relationship: Families never stay the same they shift and change in response to internal and external forces;

2. Families are adaptive:

Equilibrium-seeking systems; roles; new members added, members leave by death or divorce; roles and relationships changed with age. External influences include, school, work, peers, neighbours, religion and government. CHN play an influential role in family- equilibrium seeking.

Families are goal-oriented = They exist for a purpose

In order to fulfill this purpose a family must perform basic functions such as providing love, security, identity, a sense of belonging, assistance with preparation of adult roles in society, and maintenance of order and control.

Family culture:

1. Family members share certain values that affect family behaviour

2. Certain roles are prescribed and defined for family members

3. A family’s culture determines its distribution and use of power

The Role of the CHN in Promoting the Health of the Family

1. Providing affection

2. Providing security

3. Instilling identity

4. Promoting affiliation

5. Providing socialisation

6. Establishing controls

(Duvall & Miller, 1985)

Assessment of Families

Learning Objectives:

1. Describe characteristics of a healthy family

2. Identify five family health practice guidelines

3. Describe twelve major assessment categories for families

4. List the five basic principles the CHN should follow when assessing family health

Signs of a Healthy Family

How would the CHN determine the health status of a family?

Parachin (1997) identified 6 signs of a healthyfamily:1. Maintaining a spiritual foundation2. Making the family a top priority3. Asking and giving respect4. Communicating and listening5. Valuing service to others6. Expecting and offering acceptance

Characteristics of a Healthy Family

Olson (1991) and Friedman (1998):

1. Facilitative process of interaction among family members

2. Enhance individual member development

3. Role relationships are structured effectively

4. Actively attempt to cope with problems

5. Healthy home environment and lifestyle

6. Regular links with the broader community

Family Health Practice Guidelines

Family Nursing = Nursing practice where the family is the unit of service (Friedman 1998)

1. Work with the family collectively

2. Start where the family is: Present not ideal level of functioning

Family Health Practice GuidelinesConti….

3. Adapt nursing intervention to the family’s stage of development

4. Recognise and validate the variation in family structures

Remember that what is normal for one family may not be for the other family

Families are constantly changing

5. Emphasize family strengths

Family Health Assessment The twelve assessment categories for data collection:1. Family demographics: composition, socio-economic

status, ages, education, occupation, ethnicity and religion

2. Physical environment: geography, climate, housing, space, social and political, food availability and dietary habits

3. Psychological and spiritual environment: affectional relationships, mutual respect, support

4. Family structure and roles: family organisation, division of labor, allocation and use of authority and power

5. Family functions: providing for family members’ needs

6. Family values and beliefs: raising children, making and spending money

Family Health Assessment (continued)

7. Family communication patterns: Frequency and quality of communication

8. Family decision-making patterns: How are decisions made in the family? By whom are they made? How are they implemented?

9. Family problem-solving patterns: Flexibility of family’s approach to problem-solving, nature of solutions

Family Health Assessment (continued)

7. Family coping patterns: How does the family handle conflict and life changes, nature and quality of family support systems

8. Family health behaviour: Health history, current physical health of members, use of health resources, health beliefs

9. Family social and cultural patterns: family discipline, limit-setting practices, promotion of members’ creativity

Guidelines for Family Health Assessment

1. Focus on the family as a total unit. Family health > sum of individual members

2. Ask goal-directed questions

3. Collect data over time: Allow adequate time

4. Combine quantitative and qualitative data

5. Exercise professional judgment: Involve family with assessment

Nursing Process Applied to Families as Clients

Working with families where they live: The Home visit purpose: Assist the clients to achieve as high a level of wellness as possible

HEALTH TASKS OF THE FAMILY( Freeman, 1981)

1. recognizing interruptions of health or development

2. seeking health care

3. managing health and non-health crises

4. providing nursing care to the sick, disabled and dependent member of the family

5. maintaining a home environment conducive to good health and personal development

6. maintaining a reciprocal relationship with the community and health institutions

Family Nursing Problem

Arises when the family cannot effectively perform its health tasks

Nurse’s Roles in Family Health Nursing

1. HEALTH MONITOR

2. PROVIDER OF CARE TO A SICK

FAMILY MEMBER

3. COORDINATOR OF FAMILY

SERVICES

4. FACILITATOR

5. TEACHER

6. COUNSELOR

INITIAL DATA BASE FOR FAMILY NURSING PRACTICE

Family structure, Characteristics, and Dynamics

1. Members of the household and relationship to the head of the family

2. Demographic data – age, sex, civil status, position in the family

3. Place of residence of each member – whether living with the family or elsewhere

4. Type of family structure – e.g. matriarchal or patriarchal, nuclear or extended

5. Dominant family members in terms of decision-making, especially in matters of health care

6. General family relationship/dynamics – presence of any readily observable conflict between members; characteristics communication patterns among members

Socio-economic and Cultural Characteristics

1. Income and Expenses

Occupation, place of work and income of each working members

Adequacy to meet basic necessities

Who makes decisions about money and how it is spent

2. Educational attainment of each other

3. Ethnic background and religious affiliation

4. Significant Others – role(s) they play in family’s life

5. Relationship of the family to larger community – Nature and extent of participation of the family in community activities

Home and Environment

1. Housing Adequacy of living peace Sleeping arrangement Presence of breeding or resting sites of

vectors of diseases Presence of accidents hazards Food storage and cooking facilities Water supply – source, ownership, portability Toilet facility – type, ownership, sanitary

condition Drainage system – type, sanitary condition

2. Kind of neighborhood, e.g. congested, slum, etc.

3. Social and health facilities available

4. Communication and transportation facilities

available

Health Status of each Family Member

1. Medical and nursing history indicating current or past significant illnesses or beliefs and practices conducive to health illness

2. Nutritional assessment Anthropometric data: Measures of nutritional

status of children, weight, height, mid-upper arm circumference: Risk assessment measures of obesity: body mass index, waist circumference, waist hip ratio

Dietary history specifying quality and quantity of food/nutrient intake per day

Eating/ feeding habits/ practices

3. Developmental assessments of infants, toddlers, and preschoolers – e.g., Metro Manila

4. Risk factor assessment indicating presence of major and contributing modifiable risk factors for specific lifestyles, cigarette smoking, elevated blood lipids, obesity, diabetes mellitus, inadequate fiber intake, stress, alcohol drinking and other substance abuse

5. Physical assessment indicating presence of illness state/s

6. Results of laboratory/ diagnostic and other screening procedures supportive of assessment findings

Values, Habits, Practices on Health Promotion, Maintenance and Disease

Prevention.

Examples include:

1. Immunization status of family members

2. Healthy lifestyle practices. Specify.

3. Adequacy of: rest and sleep exercise use of protective measures- e.g. adequate

footwear in parasite-infested areas; relaxation and other stress management

activities

4. Use of promotive-preventive health services

A TYPOLOGY OF NURSING PROBLEMS IN FAMILY

NURSING PRACTICE

FIRST-LEVEL ASSESSMENT

I. Presence of Wellness Condition:

1. 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.

2. Wellness potential is a nursing judgment on wellness state or condition based on client’s performance, current competencies or clinical data but no explicit expression of client desire.

3. Readiness for enhanced wellness state is a nursing judgment on wellness state or condition based on client’s current competencies or performance, clinical data explicit expression of desire to achieve a higher level of state or function in specific area on health promotion and maintenance.

Samples of the following:

1. Potential for Enhanced Capability: Healthy lifestyle – e.g. nutrition/diet, exercise/

activity Health Maintenance Parenting Breastfeeding Spiritual Well-being – process of a client’s

unfolding of mystery through harmonious interconnectedness that comes from inner strength/sacred source/GOD (NANDA 2001)

Others,

Samples of the following:2. Readiness for Enhanced Capability for:

Healthy Lifestyle Health Maintenance Parenting Breastfeeding Spiritual Well-being Others,

Health Threats

Are conditions that are conducive to disease, accident or failure top realize one’s health potential.

Health ThreatsExamples of these are the following:

1. Family history of hereditary condition, e.g. diabetes

2. Threat of cross infection from a communicable disease case

3. Family size beyond what family resources can adequately provide

4. Accidental hazards Broken stairs Sharp objects, poison, and medicines

improperly kept Fire hazards

Health Threats

5. Faulty nutritional habits or feeding practices.

Inadequate food intake both in quality & quantity

Excessive intake of certain nutrients Faulty eating habits Ineffective breastfeeding Faulty feeding practices

Health Threats6. Stress-provoking factors –

Strained marital relationship

Strained parent-sibling relationship

Interpersonal conflicts between family members

Care-giving burden

Health Threats

Inadequate living space

Lack of food storage facilities

Polluted water supply

Presence of breeding sites of vectors of disease

Improper garbage

Unsanitary waste disposal

Improper drainage system

Poor ventilation Noise pollution Air pollution

7. Poor home condition-

Health Threats8. Unsanitary food handling and preparation9. Unhealthful lifestyles and personal habits-

Alcohol drinking Cigarette smoking Inadequate footwear Eating raw meat Poor personal hygiene Self-medication Sexual promiscuity Engaging in dangerous sports Inadequate rest Lack of inadequate exercise Lack of relaxation activities Non-use of self protection measures

Health Threats10. Inherent personal characteristics – e.g. poor

impulse control

11. Health history which induce the occurrence of a health deficit, e.g. previous history of difficult labor

12. Inappropriate role assumption – e.g. child assuming mother's role, father not assuming his role

13. Lack of immunization/ inadequate immunization status specially of children

Health Threats

14. Family disunity – Self-oriented behavior of member(s) Unresolved conflicts of member(s) Intolerable disagreement Other

15. Other

Health Deficits

Are instances of failure in health maintenance.

Health Deficit Samples include:

1. Illness states, regardless of whether it is diagnosed or by medical practitioner

2. Failure to thrive/ develop according to normal rate

3. Disability – whether congenital or arising from illness; temporary

stress Points/ Foreseeable Crisis Situations

Are anticipated periods of unusual demand of the individual or family in terms of family resources.

Samples of these include

Marriage Menopause Pregnancy Loss of job Parenthood Hospitalization of a Additional member

family member

Abortion Death of a manner Entrance at school Resettlement in a Adolescence

new community

Divorce Illegitimacy

Second Level Assessment Focus on determining family’s capacity to perform

the health tasks Statements on family health nursing problem:

a. Inability to recognize the presence of the condition or problem

b. Inability to make decisions with respect to taking appropriate health action

c. Inability to provide adequate nursing care to the sick, disabled , dependent or vulnerable member of the family

d. Inability to provide a home environment conducive to health maintenance or personal development

e. Failure to utilize community resources for health care

Scale for Ranking Health conditions and Problems according to priorities

Criteria:

a. Nature of the condition or problem presented

( wellness state, health deficit, health threat, forseeable crisis)

b. Modifiability of the condition or problem

( easily, partially, not modifiable)

c. Preventive Potential (high, moderate , low)

d. Salience ( needs immediate attention, not immediate, not perceived as a problem)

COMMUNITY HEALTH CARE PROCESS

Assessment Purpose : To identify the health needs of the people

Planning of nursing actionsPurpose : To act on the determined needs of the

community people Implementation Purpose : To achieve the optimum level of health of

the community people Evaluation

Purpose : To determine the effectiveness of health care programs

NURSING PROCEDURES CLINIC VISIT- process of checking the client’s health condition in

a medical clinic HOME VISIT- a professional face to face contact made by the

nurse with a patient or the family to provide necessary health care activities and to further attain the objectives of the agency

BAG TECHNIQUE-a tool making of the public health bag through

which the nurse during the home visit can perform nursing procedures with ease and deftness saving time and effort with the end in view of rendering effective nursing care

THERMOMETER TECHNIQUE

-to assess the client’s health condition through body temperature reading

NURSING CARE IN THE HOME

- giving to the individual patient the nursing care required by his/her specific illness or trauma to help him/her reach a level of functioning at which he/she can maintain himself/herself or die peacefully in dignity

ISOLATION TECHNIQUE IN THE HOME

-done by :

1. separating the articles used by a client with communicable disease to prevent the spread of infection:

2. frequent washing and airing of beddings and other articles and disinfections of room

3. wearing a protective gown , to be used only within the room of the sick member

4. discarding properly all nasal and throat discharges of any member sick with communicable disease

5. burning all soiled articles if could be or contaminated articles be boiled first in water 30 minutes before laundering

INTRAVENOUS THERAPY insertion of a needle or catheter into a

vein to provide medication and fluids based on physician’s written prescription

- can be done only by nurses accredited by ANSAP

Critical Analysis Questions

1. The majority of the emerging conceptualizations of the family tend to define the family as a unit consisting of mother, father, and young children. True or false?

2. Two or more individuals who depend on one another for emotional, physical, and/or financial support constitute a family. True or false?

3. The nurse who views the family as client and as an interacting system in which the whole is more than the sum of the parts is approaching the family using the family as context perspective. True or false?

4. Proper application of interactional theory to family nursing is reflected when the nurse in community health recalls that each family is unique in its composition and complexity of age-role expectations and positions. True or false?

5. List at least eight trends in family life course events that have implications for nurses in community health working with families.

6. Discuss the application of structural-functional theory, systems theory, developmental theory, and interactional theory as frameworks useful for family nursing.

WeblinksChildstats.gov - America's Children in Brief 2006 – IntroductionChild Welfare Information GatewayChildren's Defense Fund: Children in the States :: CDFhttp://cdf.convio.net/site/DocServer/Greenbook_2005.pdf?docID=1741CYFERnet - Children, Youth and Families Education and Research NetworkDOL WHD: The Family and Medical Leave Act of 1993

A Grandparents' Guide for Family Nurturing & Safety

How to Impact Public Policy for Families, NCR 443

The National Parenting Center The Urban Institute | National Survey of

America's Families Search Results - THOMAS (Library of C

ongress) Positive Parenting - Main Menu Stepfamily Network Home Page

EHS: Wong on Web Welcome to ZERO TO THREE's Web S

ite Archived: Commissioned Papers: Teach

ing Parenting and Basic Skills to Parents - What We Know

Healthy Teen Network -- Welcome to Healthy Teen Network

ScienceDaily: Study: Most kids making bad health choices

N C H S - Healthy People 2010 - Focus Areas at a Glance

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The moral of the story…

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