Case Study essay paper

Case Study

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The Nursing Process in Practice
Formulating a Family Care Plan Case Study
Mr. R., an 80-year-old retired pipe fitter, lives with his wife; he has had diabetes for 15 years. Although his diabetes has been moderately controlled with diet and daily insulin, some complications have occurred. He experiences arteriosclerotic cardiovascular disease and peripheral neuropathy, and he recently spent 2 months in the hospital due to circulatory problems in his left leg. The progressive deterioration of circulation resulted in an amputation below the knee. Although fitting him with a prosthesis would be possible, he has refused this and is wheelchair bound. Mr. R. currently depends on someone else to help with transfers. He is cranky, irritable, and demanding to almost everyone. He recently has stopped following his diabetes regimen because he claims, “It just doesn’t matter anymore.” Case Study
Mr. R.’s wife, Doris, is a 74-year-old woman who has been a homemaker most of her life. She has always been the “watchdog” for Mr. R.’s health. Mostly through her changes in food preparation and her lifestyle adjustments, Mr. R.’s diabetes has been managed. She schedules his physician appointments, buys his medical supplies, and administers his insulin. He is now refusing to accept her help, and she is anxious and angry about his behavior. They frequently have arguments, after which Mrs. R. retreats to her room. Case StudyMr. and Mrs. R. have three children and four grandchildren who live in the same city. The eldest daughter, Patricia, calls or stops by about once a week. The other children, Tom and Ellen, are busy with their families and see their parents mostly on holidays; they have very little communication with Patricia or their parents. When the children do come to visit, Doris tries to put on a happy expression and pretend that everything is going well to avoid worrying them. She is also embarrassed about Mr. R.’s behavior and does not want anyone from outside the family to see what is happening.
On her initial home visit to this family, the community health nurse notes that Mr. R. appears somewhat drowsy and unkempt. Mrs. R. looks anxious and tired, her skin color is slightly ashen, and she has circles under her eyes. When the nurse asks them what they hope to get out of the nursing visits, Mrs. R. says, “Actually, you don’t need to keep visiting. In a few weeks we’ll be back to normal and doing fine.”
Based on a thorough assessment of the family, the community health nurse may begin to develop a mutually acceptable plan of care with the family.
Assessment
In the initial interview, the community health nurse completes a genogram and an eco-map with the family (see Figures 13-3 and 13-4). After the second family interview, the nurse also completes a family map that describes the members’ interactions with each other (see Figure 13-2). A family guide to help structure a family assessment is presented in Box 13-7. Case Study
Completing the genogram helps break the ice to get the family to talk about their situation. The genogram provides a safe and thought-provoking way for Mrs. R. to supply appropriate information about the situation. During this process, the nurse obtains information about other family members, their general levels of functioning, and the possibility of acting as resources. She identifies family members’ patterns of closeness and distance.
Box 13-7 Family Assessment Guide
I Identifying Data Case Study
Name: ___________________________________________________________________________________________________
Address: __________________________________________________________________________________________________
Phone number(s):_____________________________________________________________________________________________
Household members (relationship, gender, age, occupation, education):____________________________________________________
Financial data (sources of income, financial assistance, medical care; expenditures):___________________________________________
Ethnicity: __________________________________________________________________________________________________
Religion: __________________________________________________________________________________________________
Identified client(s):______________________________________________________________________________________________
Source of referral and reason: Case Study ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
II Genogram
Include household members, extended family, and significant others
Age or date of birth, occupation, geographical location, illnesses, health problems, major events
Triangles and characteristics of relationships
III Individual Health Needs (for each household family member)
Identified health problems or concerns: ________________________________________________________________________________
Medical diagnoses: _____________________________________________________________________________________________
Recent surgery or hospitalizations: _________________________________________________________________________________
Medications and immunizations: _________________________________________________________________________________
Physical assessment data: ______________________________________________________________________________________
Emotional and cognitive functioning: _______________________________________________________________________________
Coping: _____________________________________________________________________________________________________
Sources of medical and dental care: ____________________________________________________________________________
Health screening practices: ____________________________________________________________________________________
IV Interpersonal Needs
Identified subsystems and dyads:________________________________________________________________________________
Prenatal care needed: _________________________________________________________________________________________
Parent–child interactions:_______________________________________________________________________________________
Spousal relationships:_________________________________________________________________________________________
Sibling relationships:_________________________________________________________________________________________
Concerns about older members:___________________________________________________________________________________
Caring for other dependent members:________________________________________________________________________________
Significant others:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
V Family Needs
A. Developmental
Children and ages:____________________________________________________________________________________________
Responsibilities for other members: _____________________________________________________________________________
Recent additions or loss of members:_____________________________________________________________________________
Other major normative transitions occurring now:____________________________________________________________________
Transitions that are out of sequence or delayed:_____________________________________________________________________
Tasks that need to be accomplished:_______________________________________________________________________________
Daily health-promotion practices for nutrition, sleep, leisure, child care, hygiene, socialization, transmission of norms and values: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Family planning used:_______________________________________________________________________________________
B. Loss or Illness
Nonnormative events or illnesses:______________________________________________________________________________
Reactions and perceptions of ability to cope:________________________________________________________________________
Coping behaviors used by individuals and family unit:_________________________________________________________________
Meaning to the family:_________________________________________________________________________________________
Adjustments family has made:________________________________________________________________________________
Roles and tasks being assumed by members:_________________________________________________________________________
Any one individual bearing most of responsibility:_____________________________________________________________________
Family idea of alternative coping behaviors available:____________________________________________________________________
Level of anxiety now and usually:_________________________________________________________________________________
C. Resources Case Study and Support
General level of resources and economic exchange with community:_________________________________________________________
External sources of instrumental support (money, home aides, transportation, medicines, etc.):____________________________________
Internal sources of instrumental support (available from family members):___________________________________________________
External sources of affective support (emotional and social support, help with problem solving):_____________________________________
Internal sources of affective support (who in family is most helpful to whom?): _________________________________________________
Family more open or closed to outside?______________________________________________________________________________
Family willing to use external sources of support?_______________________________________________________________________
D. Environment
Type of dwelling:________________________________________________________________________________________________
Number of rooms, bathrooms, stairs; refrigeration, cooking:_______________________________________________________________
Water and sewage:______________________________________________________________________________________________
Sleeping arrangements:_____________________________________________________________________________________________
Types of jobs held by members:_______________________________________________________________________________________
Exposure to hazardous conditions at job:___________________________________________________________________________
Level of safety in the neighborhood:____________________________________________________________________________________
Level of safety in household:________________________________________________________________________________________
Attitudes toward involvement in community:___________________________________________________________________________
Compliance with rules and laws of society:____________________________________________________________________
How are values similar to and different from those of the immediate social environment?_____________________________________
E. Internal Dynamics
Roles of family members clearly defined?______________________________________________________________________
Where do authority and decision making rest?_____________________________________________________________________
Subsystems and members:__________________________________________________________________________________
Hierarchies, coalitions, and boundaries:________________________________________________________________________
Typical patterns of interaction:_______________________________________________________________________________
Communication, including verbal and nonverbal:__________________________________________________________________
Expression of affection, anger, anxiety, support, etc.:________________________________________________________________
Problem-solving style:________________________________________________________________________________________
Degree of cohesiveness and loyalty to family members:___________________________________________________________________________________________________________________________________________________________________________
Conflict management:________________________________________________________________________________________
__________________________________________________________________________________________________________
VI Analysis
Identification of family style:__________________________________________________________________________________
Identification of family strengths:_____________________________________________________________________________
Identification of family functioning:____________________________________________________________________________
What are needs identified by family? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
What are needs identified by community/public health nurse?______________________________________________________________________________________________________________________________________________________________