Case Study

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The Nursing Process in Practice

Formulating a Family Care Plan

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 Study

Mr. 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.Case Study

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.

AssessmentCase Study

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

Name: ___________________________________________________________________________________________________

Address: __________________________________________________________________________________________________

Phone number(s):_____________________________________________________________________________________________

Household members (relationship, gender, age, occupation, education):____________________________________________________

Financial data (sources of income, financial assistance, medical care; expenditures):___________________________________________Case Study

Ethnicity: __________________________________________________________________________________________________

Religion: __________________________________________________________________________________________________

Identified client(s):______________________________________________________________________________________________

Source of referral and reason: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

II GenogramCase Study

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 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 DynamicsCase Study

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?