Family Nursing Assessment and Intervention.

Family Health Promotion

By Nataliya Haliyash, MD, PhD, BSN Ternopil State Medical University Institute of Nursing

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 Nursing practice requires the ability to use nursing knowledge and reason through details to make skilled judgments while not losing sight of the whole client picture and desired outcomes of care.
Nurses determine through which lens the family health problem will be best addressed: from a family-as-context perspective, family-as-client perspective, or family-as-community perspective.

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Lecture Objectives
Identify family assessment tools Be able to select sensitive family assessment and measurement tools Applying nursing and clinical reasoning Compare the essential elements of main Family nursing assessment models Discuss the role of the nurse in supporting families Incorporate health promotion into families lifestyle
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FAMILY ASSESSMENT
is the process of collecting data about the family structure, and the relationships and interactions among individual members.
It is a continuous process. Its aim is to generate Nursing diagnoses with goals and interventions for care created in collaboration with the child and caregivers.

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Assessment Instruments
A genogram is a format for drawing a family tree that records information about family members and their relationships over a period of time, usually three generations.
An ecomap is a visual representation of a family in relation to the community. It demonstrates the nature and quality of family relationships and what kinds of resources or energies are going in and out of the family.
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Genogram

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Ecomap

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 The genogram and ecomap are essential components of family assessment. They should be used concurrently with all family assessment approaches.

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Nursing reasoning
Each step of working with families requires a thoughtful deliberate clinical reasoning process.
Nurses decide: what data to collect and how, when, and where that data is collected; the relevance of each new piece of information; how it fits into the emerging family story. Each item of new information must be judged in terms of accuracy, clarity, and relevance.
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 Family nursing process. Source: Ross (2001).

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In-depth Family Assessment

Calgary Family Assessment Model (Wright & Leahey, 1994):
Gather information about family structure, development and functioning.

Friedman Family Assessment Model (Friedman, 1998):

consists of six broad categories of interview questions.

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COMPARISON OF ASSESSMENT APPROACHES DEVELOPED BY FAMILY NURSES

Name of Model
Friedman Family Assessment Model

Name of Model
Calgary Family Assessment and Intervention Model (CFAM/CFIM)

Purpose
Concrete global family assessment interview guide that looks primarily at families in the larger community in which they are embedded.

Purpose
Conceptual model and multidimensional approach to families that looks at the fit among family functioning, affective, and behavioral aspects
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COMPARISON OF ASSESSMENT APPROACHES DEVELOPED BY FAMILY NURSES (CONT)

Theoretical Underpinnings
Developmental Structural-functional Family stresscoping Environmental

Theoretical Underpinnings
Systems:

Cybernetics Communication Change theory

Level of Data Collected Level of Data Collected Qualitative: Nominal Qualitative: Nominal
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COMPARISON OF ASSESSMENT APPROACHES DEVELOPED BY FAMILY NURSES (CONT)

Unit of Analysis
Family as client Family as component of society Strength Comprehensive list of areas to assess family Weakness Large quantities of data that may not relate to the problem No quantitative data

Unit of Analysis
Family as system Strength

Multiple theoretical approach

Weakness Not concrete enough to be useful as a guideline unless you study this model and approach in detail

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Family Nursing Diagnosis

Once the data have been clustered, a family nursing diagnosis is determined for each set of data.
Nursing diagnoses create the links between collecting information and care planning (Gordon, 1994). The North American Nurses Diagnosis Association (NANDA; 2003) is the most global nursing classication system.
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NANDA NURSING DIAGNOSES RELEVANT TO FAMILY NURSING

Risk for impaired parent/infant/child attachment Caregiver role strain Risk for caregiver role strain Parental role conflict Compromised family coping Disabled family coping Readiness for enhanced family coping Dysfunctional family processes: alcoholism Readiness for enhanced family processes Interrupted family processes Readiness for enhanced parenting

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NANDA NURSING DIAGNOSES RELEVANT TO FAMILY NURSING cont.

If the keystone issue does not fall under one of these accepted NANDA nursing diagnoses, nurses are encouraged to write the family nursing diagnosis in a NANDA format.
Nurses should forward the most common, unlisted family nursing diagnoses to the North American Nursing Diagnosis Association to be considered for inclusion in the diagnosis list.
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NURSING DIAGNOSES
Other diagnostic classification systems that can be used with families include:
the Omaha System for use in the community (Martin & Scheet, 1992),

the Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric Association, 2000),
the International Classification of Disease (ICD-9; American Medical Association, 2004).
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SELECTED FAMILY-CENTERED DIAGNOSES FROM DSM-IV-TR

V61.9 Relational problem related to a mental disorder or general medical condition
V61.20 Parent-child relational problem V61.10 Partner relational problem V61.8 Sibling relational problem V71.02 Child or adolescent antisocial behavior V62.82 Bereavement V62.3 Academic problem
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 After the keystone family diagnosis has been identied and veried with the family, the next step is determining the present state, the outcome, and the testing evaluation criteria that will be used to determine if the outcomes have been achieved.

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OUTCOME STATEMENTS
The nurse works with the family to determine realistic outcomes.
Outcome statements should: be adjusted for each aspect of the present state; need to be based on the ability of the family to successfully adapt to the health issue, rely on the given strengths of the family and the patterns of family response in similar situations, consider the trajectory of the family health care problem, should be stated positively and in measurable terms. The type of outcomes possible depends on the frame of the problem for the family.
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EXAMPLES OF OUTCOME STATEMENTS

Identify realistic perception of role.
Acknowledge problems contributing to inability to carry out usual role in the family. Describe a decrease in the difficulties of managing medications for family member. Express feelings and perceptions regarding impacts of illness, disability, or hospitalization on parental role. Verbalize internal resources to help deal with the family situation.
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 From experience and information known about the family, the nurse predicts what tests or assessment processes will be used to analyze the course of events or the pattern of change expected to occur.
Testing is the process of juxtaposing the family present state with projected family outcomes in order to determine what progress the family has made toward achieving the outcome.
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Nursing interventions
While making decisions about interventions, it is important for nurses to recognize that the family has the right to make its own health decisions. The role of the nurse is:
to offer guidance to the family, to provide information, and to assist in the planning process.
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Nursing interventions (cont.)

The nurse may assist the family by
(1) providing direct care, (2) removing barriers to needed services, (3) and improving the capacity of the family to act on its own behalf and assume responsibility.

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BARRIERS THAT MAY INTERFERE WITH ACCOMPLISHING FAMILY CLIENT OUTCOMES

Family apathy Family indecision about the outcome or actions Nurse-imposed ideas Negative labeling Overlooking family strengths Neglecting cultural or gender implications Family perception of hopelessness Fear of failure Limited access to resources and support Limited finances Fear and distrust of health care system

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Family Health Promotion

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Family Health Promotion

Fostering the health of the family as a unit and encouraging families to value and incorporate health promotion into their lifestyle are essential components of family nursing practice.
Health promotion is learned within families, and patterns of health behaviors are formed and passed on to the next generation. The role of the family nurse is to help families attain, maintain, and regain the highest level of family health possible. Family health promotion should become a regular part of taking a family history and a routine aspect of nursing care.
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Definition
Family health promotion is dened as achieving maximum family wellbeing throughout the family life course and includes the biological, emotional, physical, and spiritual realms for family members and the family unit
(Bomar, 2004; Loveland-Cherry & Bomar, 2004).

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Models of Family Health

Building on Smiths (1983) models of health, Loveland-Cherry (1986) suggests that there are four views of family health:
The clinical model. The role-performance model. The adaptive model.

The eudaimonistic model.

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SUMMARY
The selection of appropriate and sensitive assessment tools is important, as the information collected serves as the foundation for the development of client-specific plans. Each step of working with families, whether applied to the individual within the family as context or to the family as client, requires a thoughtful, deliberate clinical reasoning process. Family nursing is more than simple medical care for the individual with the health issue. When the nurse meets with the family, it is important to investigate how all the members of the family are affected by the issue.
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SUMMARY (cont.)
Promoting and protecting the health of the family unit is in the formative stages; therefore, health professionals have challenging opportunities to develop and test interventions in family health promotion.
Advanced practice nurses in primary care are in the best position to foster family health given the fact that a major aspect of primary care is health promotion.
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Q&A?

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