Formulating a Family Care Plan (PLEASE READ THE FALLOWING GIVEN INFORMATION AND complete the file .)
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.”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.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.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.
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.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.The eco-map presents a picture to both the nurse and Mr. and Mrs. R. of a family that is not well connected to outside resources. Little energy is coming in or going out of the immediate family system, with the exception of intervention by the health care system, which the family wants to discontinue. When the community health nurse later completes a family map, she becomes aware of Mrs. R.’s tendency to act as a parent and Mr. R.’s tendency to act as a child. This blurring of boundaries has set up a behavior pattern in which Mr. R. gives away responsibility for his own health. At the same time, however, the rigidity of these boundaries keeps the children out of these interactions. After assessing the family, the nurse tries to guide her practice with some questions. She asks herself about the family’s needs, strengths, functioning, and style. She examines the family’s priorities and the resources they are using or are potentially able to use. She looks at her own skills and abilities and attempts to define her responsibility to the family system. These questions help her begin to analyze the family data. This analysis leads to several determinations.