Family Assessment and Nursing Process

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According to Stanhope & Lancaster (2001), a family nursing assessment is considered to be the cornerstone for family nursing interventions and is used in a systematic fashion for the identification of the family's developmental stages and risk factors. There are many tools available that provide guidelines for how to best get to know a family and to determine their strengths and weaknesses. One such tool is the Friedman Family Assessment tool which provides a guideline for nurses to interview a family. Theory is also a necessary tool when assessing a family because it is theory that most powerfully explains clinical situations and provides guidelines when working with families (Friedman, Bowden, and Jones, 2003).

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The theory that will be applied to family assessment in this paper is the structural-functional theory. The structural-functional theory recognizes the interaction between family members within their internal and external environment (Friedman et al., 2003). Once a comprehensive family assessment is complete and health issues are identified, the nursing process is implemented in order to render care that is imperative for assisting each family member to achieve an optimum level of wellness (Gilliss & Davis, 1993).

In compliance with HIPPA regulations of strict confidentiality, the fictitious name of Listo will be used to identify the family that is assessed in this report. The Friedman Family assessment model will be followed as a guideline to discuss the family's identifying data, the structure-function of the family members, and how the family handles stress, coping and adaptation. Lastly, key assessment data will be used in the nursing process in order to assess, diagnose, plan, intervene, and evaluate a family member's diagnosis.

The Listo family is an extended family that is composed of a marital dyad, their two adult sons, the maternal grandmother and the son's girlfriend who is in her second trimester of pregnancy. The husband and wife have been married for 30 years and their sons are ages 23 and 26years old. The husband identifies his ethnicity as Italian. His primary language is English and he was born and raised in California. His parents migrated to the United States from Italy in the early 1940's. Because they migrated at such a young age, his patents have acculturated to the American way of life, but still feel strongly about their cultural heritage (McCallion, Janicki, & Grant-Griffin, 1997). The wife identifies her ethnicity as Caucasian. She was also born and raised in California. Both husband and wife grew-up in the Catholic faith and attended church primarily on holidays. In their mid-thirties, they accepted Christ as their personal savior and became born again Christians; first the husband and then a few months later the wife.

The husband owns a painting business for residential properties and the wife sales residential real estate and works for a local real estate company. They are considered a lower-middle class family. The major distinguishing characteristics of the lower-middle class family are respectability, achievement, hard work and honesty (Friedman et al., 2003). Neither husband nor wife has a college degree. Both are hard-working and are proud that they have provided financially for their sons who have both received a college education. Previously, the 25 year old son and his girlfriend were living together and were a dual income household.

They both moved in with his parents when the girlfriend had to quit her job because of complication she suffered during the first few months of her pregnancy. They plan to marry once they are financially stable. The son is currently working as a physical fitness coach for a college football team and contributes financially to the family. In June of this year, the 22 year old son graduated with a Bachelor's degree and moved back home. He is currently looking for employment and hopes to move out within the year. The grandmother is 76 years old and has lived with the family for the past year due to the progression of her COPD.

FAMILY STRUCTURE

According to Friedman, Bowden and Jones (2003), the concept of analyzing the structure of a family refers to how the family is organized, how the components are arranged and how they relate to each other. The four main structures of the family are roles, values, communication processes and power and decision-making. The role theory is the structure that is the focus of the Listo family.

Family roles play a critical part in the organization of the family and because of this the family nurse must understand role relationships in order to be able to promote healthy role behaviors and identify role problems (Friedman et al., 2003). According to the role theory, a family member will play many roles in a family. There are both formal and informal roles within the family structure. Formal family roles include the more obvious roles such as mother-wife, father-husband, and father-son. The less obvious roles are that of encourager, harmonizer, initiator, scapegoat, compromiser, etc. Informal roles are more likely to be based on personality than age or sex (Kievit, 1968).

Within the Listo family, the husband-wife dyadic relationship is complimentary exhibited by a contrasting relationship (Friedman et al., 2003). As the formal role of wife, Mrs. Listo is the leading dominant personality and makes most of the decisions in the family including decisions about the children and the household finances. She is also the main source of income for the family. As the formal role of husband, Mr. Listo is more of a follower, a position he appears to be content with. According to Friedman, Borden, and Jones (2003), there is a strong element of dependency between the husband and wife in a complimentary relationship. This is true for the Listo family; they have a close bond and seem to be comfortable with their husband-wife give and take relationship.

Assessment of the Listo family revealed numerous informal family roles. The grandmother takes on the informal role of recognition seeker. As explained by Friedman, Bowden, Jones (2003), the recognition seeker goes to great lengths to draw attention to self. When questioning the grandmother about other members of the family, she continued to turn every conversation back to a subject that involved her as the center figure. The two Listo boys have the informal role of caretaker. During the interview the grandmother continued to ask the boys to get her purse, find her glasses, and bring her some tea. When the boys were out of the room, the grandmother complained about how lazy the boys are and that they don't understand her condition and what she's going through with her COPD.

The husband has the informal role of follower. He goes along with the wishes of the family and if there is a dispute over how or what to do, he just listens and only participates in the conversation if he is directly asked a question. The wife has the informal role of Initiator-Contributor. She motivates the children with ideas and ways to accomplish goals and solve problems. According to Kantor and Lehr (1975), the Initiator-Contributor causes movement in the family and is characterized by the initiation of action. The girlfriend has the informal role as the encourager. She gives compliments freely and often. She appears to be genuinely interested in listening to others and she rarely draws attention to herself.

"The greater the perceived clarity of role expectation the higher the quality of role enactment" (Friedman et al., 2003, p. 324). When evaluating the quality of each role, it was determined that the family members clearly understand their roles and are content with the expectation that is attached to each role. The exception was the 23 year old son, who exhibited role conflict with his duties as caregiver for the grandmother. After having the freedom of college life, it has been difficult for the 23 year old to be living back at home and having specific expectations put upon him. According to Friedman, Bowden, and Jones (2003), the youngest son is experiencing intersender role conflict, which happens when there are conflicting expectations regarding the enactment of a role.

FAMILY HEALTH FUNCTION

According to the Structure-Function theory, a function is an outcome or consequence of the structure. Function is described as being what the family does. Friedman, Bowden, and Jones (2003) describe 5 specific functions: affective, socialization, reproductive, economic and health care. The focus of the Listo family assessment is the function of health care. The Friedman Assessment Model was used as a guide. According to Friedman, Bowden, and Jones (2003), health practices and health care services are extremely varied from family to family. Families are diverse in the way they conceptualize health and illness and when to seek health care.

The Listo family prides themselves on how healthy they have been. Until recently, the family had what they described as "catastrophic" medical insurance. The mother and father are both independent contractors and do not have insurance through their place of employment. Their insurance policy carried a $1,500 deductible. This high deductible deterred the family from visiting the doctor for regular check-ups. The Listo family falls under the umbrella of "underinsured" which has prevented them from receiving comprehensive health care. With the wife's real estate doing so well over the past couple of years, the Listos now have an insurance plan that covers standard check-ups and dental care as well.

The 25 year old son receives health coverage from his employer and the girlfriend has private insurance. With so many years without health care access, the Listo family has not participated in health management. According to Friedman, Bowden, and Jones (2003), the family needs to be in direct partnership with health care providers. Clients also need to be the ultimate decision makers and managers of the health issues that affect their lives. Health education is needed so that the Listo family can feel empowered to direct their own health care (Friedman, et al., 2003).

The 2 sons exercise regularly and eat a well-balanced diet that includes fruits, vegetables and grains and are in good health. The girlfriend takes charge of her health and the health of unborn child by keeping all of her scheduled appointment, asking important questions, and following the guidelines agreed upon between her and her physician. The husband is overweight and has hypertension and hyperlipidemia. The hypertension and hyperlipidemia are controlled with medication. The husband is not consistent with getting his check-ups and having his blood The wife is slightly overweight which she attributes to a bad diet and lack of exercise. Generally, the Listo family is in good health. In the case where the family is healthy, health promotion is the goal of family nursing (Friedman, et al., 2003 p. 436). One goal for the Listo family is health promotion.

The one member of the Listo household that is chronically ill is the Grandmother. She admits that her COPD was caused by 40 years of smoking 1-2 packs of "Camel" no filter cigarettes a day. Each year in the United States, hundreds of thousands die prematurely due to living unhealthy lifestyles (Friedman, et al., 2003). As the caretakers for the grandmother, the Listo family is at risk for role strain. The grandmother's condition is progressive and as time goes on she will become more dependent on the family members for care. Orem's self-care model is applicable to this family. According to Orem's self-care theory, nursing care is required when an adult is no longer able to care for themselves. It also states that nursing care may need to be directed toward the caretakers (Friedman et al., 2003).

FAMILY STRESS, COPING, AND ADAPTATION

The Listo family is resilient and they have recovered, adjusted, and adapted to stressful situations in their family. This is why The Resiliency Model of Family Stress, Adjustment, and Adaptions Model best describes the way the Listo family deals with stressors. According to this theoretical framework, there are four basic assumptions about the family: First, it's a natural part of life to encounter hardship and changes. Second, families develop strength and capabilities that cause them to grow and develop as a family unit.

Third, the strengths and capabilities gained during a stressful event provide protection for the family and allow the family to adapt to the new situation. Fourth, families benefit from the contribution they make to the network of relationships and community during times of family stress (McCubbin & McCubbin, 1991). The stressors that have caused the Listo family to gain strength and capabilities and to grow as a family are many. Some current stressors are caring for a chronically ill family member, unmarried son's girlfriend is pregnant, son and girlfriend moving in with the family, financial insecurity due to self-employment, and youngest son is unemployed.

SOCIAL AND SPIRITUAL COPING STRATEGIES. According to Friedman, Bowden and Jones (2003), there are two types of coping strategies; internal and external. Internal family coping strategies are when the family becomes reliant on their own resources such as pulling together and creating more structure and organization in the home, whereas with external coping strategies the family relies on community, extended family, neighbors and friends. Most often, the Listo family uses an internal family coping strategy. They have restructured their lives so that each member can contribute to the care of the grandmother since she moved into the family home.

They have also pulled together and reorganized their home to accommodate the son's girlfriend. When business is slow for the parents, the eldest son contributes financially to assist with finances. The husband and wife also use external family coping through spiritual strategies such as having faith in God and prayer (Friedman et al., 2003). The Christian faith is where the husband and wife draw comfort and peace in times of stress. Their faith in God is strong. They believe that the Lord will guide them during a crisis and will not allow them fall. "Numerous studies have shown the clear linkage between spiritual well-being and an individual's or a family's enhanced ability to cope with stress and illness" (Friedman et al., 2003, p. 486). The Listo parents believe that their enhanced ability to cope with stress and illness comes from their personal relationship with Christ.

DYSFUNCTIONAL COPING STRATEGIES. According to Friedman, Bowden, and Jones (2003),

Dysfunctional families most often unconsciously choose to use coping strategies that have been passed down through the generations. These defensive coping strategies usually do not relieve stress nor eliminate the stressor. The Listo family's dysfunctional coping strategy is authoritarianism. This happens when the family members submit to a dominant, ruling figure. The husband and sons are very submission to the authority of the wife-mother. They sons are adults in their twenties, but they constantly call their mother prior to making any relevant decisions in life. The husband also defers to his wife for any family decision. The dominant figure, Mrs. Listo, is also dependent on her subordinates because it satisfies her need for power and control (Friedman et al., 2003). The family adores their mother and the husband also speaks very kindly of her. She is domineering, but very loving and often lavishes the family with gifts.

INTERVIEW NOTES BASED ON THE FRIEDMAN FAMILY ASSESSMENT MODEL

IDENTIFYING DATA

1. Family Name: Confidential (Listo is the fictitious family name)

2. Address and Phone: Confidential

3. Family Composition: see Family Genogram (Figure 1)

4. Type of Family Form: Extended Family

Father - Painter, Mother - Real Estate Agent, two unmarried adult sons

Grandmother, Son's girlfriend

5. Cultural (Ethnic) Background: Caucasian American and Italian (English Speaking)

6. Religious Identification: (Born-again Christian)

7. Social Class Status: Lower-middle class, family works hard to pay the bills.

Income sources: Painting business - father, Real estate business - mother,

Sports Trainer - son, grandmother - social security

Father and mother have high school education

Two sons - first generation to receive a college degree

8. Social class mobility: stationary at this time. Limited income and live paycheck to paycheck. The parents are supporting the grandmother, 2 sons, and son's girlfriend.

DEVELOPMENTAL STAGE AND HISTORY OF FAMILY

9. Family's developmental stage_: Stage VI: Families launching young adults_

10. Extent Family is Fulfilling Developmental Tasks: parents were empty nesters until 1 month ago when the eldest son moved back home with his girlfriend who is 5 months pregnant, the youngest son just graduated college and moved back home, and the grandmother moved in less than a year ago. The parents are adjusting to having children back in the home.

11. Nuclear Family History: both father and mother come from traditional nuclear families.

12. History of Family of Origin of Both Parents: Both husband and wife come from nuclear families in which the father was the provider and the mother was a homemaker.

ENVIRONMENTAL DATA

13. Characteristics of Home: home is a little crowded with all the members currently living there. The youngest son shares a room with his grandmother. The home has 3 bedrooms and 2 baths with a medium size kitchen with attached family room. The home is clean and well organized.

14. Characteristics of Neighborhood and Larger Community: The neighborhood has similar single family homes that were all built around the same year. The lawns are well maintained and the streets are clean. The neighbors participate in a neighborhood watch group to keep the area safe. Children can be seen riding the bikes and skateboards on the block. The city is in the Foothills, not far from Los Angeles and the home is in walking distance to the market and other shopping.

15. Family's Geographical Mobility: The family lived in a more affluent area when the boys were growing up. At that time, the husband had steady work as he was partnered with a contractor who built estate homes. Approximately 10 years ago the partnership broke up and the husband found it difficult to market himself. The house went into foreclosure and the family borrowed money from family to help them purchase the home they're in now. The family is stationary in their current geographical setting.

16. Family's Association and Transaction with Community: The mother and father are involved in the local church. They attend regularly and volunteer to help with special events. They know some of their neighbors, but they don't get together with them socially. The younger son volunteers at the YMCA working with youth. There are 4 vehicles in the family, so the family is not dependent on public transporation.

FAMILY STRUCTURE

17. Communication Patterns: According to Mrs. Listo, a majority of the conversation between the father and the sons revolve around sports and is void of any discussion of an intimate matter. The father tends to be quiet until the subject of baseball comes up and then he sits up straight and gets enthusiastic about the conversation. Mrs. Listo often interrupted the conversation of other family members to make an announcement about subjects she feels are relevant. The grandmother doesn't seem to have an audience when she's trying to communicate to family members. She continues to converse even when it's obvious no one is really listening to her. Mr. Listo appeared to get annoyed with the grandmothers complaints, but he didn't verbally communicate his feelings. There were some obvious gender differences in communication.

18. Power Structure: The mother is dominant and the father is passive. This marital relationship would be considered complementary. When asking each member of the family who the dominant figure was, each stated that it was the mother. The mother also said that she was the dominant figure in the house. No one in the family seems to be discontent with where the power lies.

19. Role Structure: The formal roles are father-husband, mother-wife, son-brother, grandmother, and girlfriend. Informal roles: follower- father, initiator/contributor - mother, family caretaker - mother /sons, encourager - girlfriend, grandmother- recognition seeker

20. Family Values: Respect, honesty, hard-working, college education, Christianity, giving to help others (volunteering), helpful commitment and trust.

FAMILY FUNCTIONS

21. Affective Function: The husband wife relationship is close and the mother and eldest son seem close. The relationship between the youngest son and mother seems to be strained due to the 23 year old wanting his independence. See Family Attachment diagram

22. Socialization Function: The father and mother have been married for 30 years and have raised their 2 sons. The mother stayed home with her sons until they were both in elementary school. The mother is a homemaker/real estate agent. Attending church was mandatory when the children were growing up. Once they reached the age of 18, the parents didn't require that their sons attend church. The boys are now adults, but are currently living at home. They show respect for both parents and authority and appear to be well-adjusted. The father and mother are excited about the upcoming birth of their first grandchild.

Health Care Function: The father has controlled hypertension and hyperlipidemia. The wife is slightly overweight, but has no medical condition. She admits to eating too much sugar and fried foods. The two sons are healthy. The pregnant girlfriend had difficulty in her first trimester, but she is doing well now. The grandmother is in poor health. She has COPD that is progressing to the point where she is on constant oxygen. The family has not been consistent with regular check-up until recently when they upgraded their medical insurance coverage.

FAMILY STRESS, COPING, AND ADAPTATION

24. Family Stressors, Strengths, and Perceptions: stressors: financial struggles, sons that don't practice the Christian faith, eldest son is unmarried and expecting his first child, youngest son doesn't have employment and will be moving out of the home as soon as he does, grandmother has COPD.

Strengths: Mother and Father have a strong faith, the children are respectful, the eldest son helps financially, they have paid down their debt and are building credit, the family is managing their health

25. Family Coping Strategies: There number one source of peace and comfort comes from their relationship with God and their faith - external source of coping. The family members help each other out financially and emotionally- Internal source of coping.

26. Family Adaptation: The family is resilient. They take one day at a time and face the challenges as they come. They readjust their lives when stressors come along and they seek God's plan to help them learn and grow through the stress of circumstances. Overall, the family adapts to the stressors that come their way and become closer as a unit as a result.

NURSING DIAGNOSIS

RELATED TO

MANIFESTED BY

KEY ASSESSMENT DATA & RATIONALE FOR RANKING

(1) Ineffective self Health management (father)

Lack of health care access. For the past 25 years, the family has had inadequate insurance and does not qualify for state assistance. They have avoided doctor visits as much as possible due a high deductible and out of pocket expense

Uncontrolled

hypertension & hyperlipidemia, obesity, sedentary life-style, poor diet, inconsistent medication adherence, infrequent check-ups

This is ranked first because the father's lack of maintenance could lead to Cardiovascular disease and Myocardial Infarction. Although the grandmother's disease (COPD) is incurable and progressive, it is the father who has the capability to change the outcome of his condition with health maintenance. If the father's condition deteriorates, he will not be able to run his business and the family will suffer financial strain.

(2) Risk for caregiver role strain

Caring for the grandmother who has a progressive disease (COPD)

Physical exhaustion, frustration, emotional fatigue, isolation

The mother works full time and runs the household. She is exhausted by the end of the day, but still needs to make time to care for her mother. There are multiple doctor appointments every week than she or her son the grandmother to. Most days the mother has nothing left over for herself and is too tired to socialize or go out. The youngest son is frustrated that he is expected to help care for the grandmother. He is looking for work so he can move out and get away from the situation

(3) Dysfunctional Family Communication

Wife and husband,

Husband and sons,

Grandmother and family

Husband does not voice his opinion to his wife.

Husband and sons only communicate about impersonal information. No one listens to the grandmother and the grandmother only discusses negative issues and complaints.

The husband is submissive to the wife. He doesn't voice his opinion or challenge decisions that he disagrees with. He avoids any kind of confrontation. The Father and the son's keep the conversation on the surface. They don't talk about feelings or ideas. The grandmother has gotten into the habit of complaining and possibly doesn't know how to show care or concern for others. She is overwhelmed by her condition.

(4) Ineffective family coping

The youngest son's frustration over his caregiver role

The youngest son's outbursts and his threats to move out as soon as possible.

The youngest son is 23 years and has just moved home after having the freedom of living in a dorm at a university. Because he is the one member of the family that is not currently employed, he has the responsibility of caring for the grandmother during the day and taking her to all of her doctor appointments. His way of coping is closing himself in his room and threatening to leave the house forever.

(5) Risk for complicated grieving

Potential loss of significant person (grandmother)

Inability of the family members to discuss the course of the grandmothers COPD. The youngest son verbalizes anger over caring for his grandmother.

The family does not discuss the end result of grandmother's COPD. When there is a decline in the grandmother's functioning or an exacerbation of her condition, the family refers to it as just a temporary set-back. The youngest son refuses to be social with the grandmother because he resents that he is needed to care for her. It is likely that he will have some guilt feeling and more difficulty with grieving after her death.

FAMILY NURSING PROCESS

The word "process" refers to a deliberate and conscious act of moving from one point to another toward goal fulfillment (Friedman et al., 2003, p. 174). The nursing process moves systematically from assessment, diagnosis, planning, implementation, and evaluation and is said to be interrelated and continuously cyclical of thought and action (Friedman et al., 2003). After a trusting relationship was established, the first step in the Listo family assessment was gathering information in a systematic fashion using the Friedman Family Assessment Model. The information was then classified, and analyzed to interpret their meaning. The following document outlines the nursing process as it relates to the Listo family.

MAIN DIAGNOSIS

PLANNING (GOALS)

INTERVENTION (IMPLEMENTATION)

RATIONALE FOR INTERVENTION

EVALUATION

Ineffective self Health Management (father)

Short-term goal:

The father will discuss his fear and inhibition to implementing a health regimen prior to the end of the nurses' visit with the family.

(1) Assess the client's feelings, values, and his reasons for not adhering to the prescribed plan of care

(2) Assess the father's family patterns, economic issues, and cultural patterns that may be influencing compliance with a given medical regimen.

(Ackley, J. G., Ladwig, G. B., 2011).

Change theory is applicable to the Listo family: According to this theory, the nurse works with families to facilitate change. These changes can include structure as well as health behaviors.

(Friedman et al., 2003).

(1) Evidence Based Practice: assessment of an individual's preferences for participation in health care decision making encourages involvement in decision making at the preferred level.

(Ackley, B.J., & Ladwig, G.B., 2011)

(2) Evidence Based Practice:

Adherence to a treatment regimen is significantly influences by the family's culture, spiritual beliefs and family norms (Ackley, B.J., & Ladwig, G.B., 2011)

Short-term goal achieved: the father discussed his reluctance to manage his health. He admits that his own family was proud of how healthy they were without involving health care professionals. Another reason he explained for his lack of involvement in his own care is his fear that a regular check-up would reveal something serious. He verbalized his understanding that it is better to discover an illness early for prevention. He expressed a desire to be more involved in his own care.

Long-term goal:

The father will visit his health care provider within the next 30 days in order to decide on a therapeutic regimen that is congruent with health goals and lifestyle.

(1) Help the client to choose a healthy lifestyle that will address his condition and to encourage appropriate diagnostic screening tests

(2) Review how to contact health providers that are listed under his insurance plan and how to address issues and concerns regarding self-management.

King's Theory of Goal Attainment is applicable to the father in this family. In King's model, the nurses' goal is to help the client maintain their health so they can adequately function in their role. (Friedman, et al., 2003).

(1) Healthy lifestyle measures, such as exercising routinely, maintaining a healthy weight, eliminating smoking and limiting alcohol intake can help to reduce the risk of chronic illnesses.

(Ackley, B.J., & Ladwig, G.B., 2011)

(2) Evidence Based Practice: people with chronic illnesses need to know how to obtain interventions that are needed to address issues and concerns regarding self-management.

(Ackley, B.J., & Ladwig, G.B., 2011)

Recommend: Revisit the family in 30 days to follow up on the fathers visit to his health-care provider. Evaluate the father adherence to his therapeutic regimen and his lifestyle goals.

Conclusion

The Friedman Family Assessment Model served as a guide to complete a comprehensive assessment of the Listo family. Nursing theories, including the structure-function theory, helped to analyze the data collected. A systematic approach through use of the nursing process was implemented in order to devise a nursing care plan for the identified needs of the Listo family. This exercise required the author to spend a substantial amount of time getting to know a family and learning the intricate details of how to interview and observe a family for the purposes of health-care analysis.

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