A family nursing assessment was done on the Lois G. family during three nursing visits over a period of one month. The family lives at 1234 Main St. and their home phone number is 314-987-6543. This is a lower- middle class (Friedman, Bowden & Jones E.G., 2003), African American, Baptist, single-parent, career, divorced family that is child-oriented and not geographically mobile. Lois is 45 and has three children, Carmen, a 16 year old girl, Emille and Camille, twin 9 year old girls. The mother is the sole custodial parent of the oldest child.
Carmen has minimal contact with her father, Wayne, whom her mother divorced when she was 2 years old. The twins’ father, Sherman, has joint custody and shares full parental responsibilities for their care. Lois does not have a relationship with either Wayne or Sherman. The twins live with their father 3 to 4 days a week and then spend equal time with their mother. The family is in Duvall’s 5th life cycle stage.
The potential task and transitions for this family are changes in roles and status; career changes; loss of parent in family of origin and changes in physical health (Friedman, et al., 2003). In addition to these developmental tasks, the family is currently facing the tasks of balancing freedom with responsibility and problems with parent-teenager communication. The family nursing diagnosis for this family is “Parental Role Conflict” and “Deficient Health Care Knowledge” which is related to the family’s current health care concerns.
Lois has a master’s in education and mathematic. She is a high school math teacher and values education and good grades. Carmen is social, active, but quite. Carmen does assisted with the care and supervision of the twins, but now is involved in more school and social activities that take up most of her free time. She has a mild interest in establishing a relationship with her father and states he is attending sports activities and making same efforts to be a part of her life. She is an A student and participates in high school sports and church activities. Camille and Emille are both very outgoing and enjoy being around their older sister and being the center of attention. Camille and Emille like living with both of their parents, but say it would be nice if they could just stay at one home and still have both parents there. Emille does very well in school, and although Camille is working at grade level, she has been struggling in some subjects. The family is very active in their church and attends services every Sunday and bible study on Wednesdays with her sister and her family. In Lois’ family of origin, there are five children and she is the middle child. She has an older sister, an older brother and two younger brothers.
Her grandparents on both side of her family are from Mississippi, but later moved to St. Louis to raise their families in better living and working conditions. Her parents are from St. Louis. Lois’ mother, Catherine, died of colon cancer when Lois was 28. Lois’ father, JC, is in the late stages of Alzheimer’s disease but is able to stay in his home because his second wife, Ms. Verdell, provides him 24 hour care. This illness has been very difficult for the family but they have a lot of faith in God and this has assisted them in dealing with his slow decline. Lois states she is very thankful that her father has the support of his wife, because she doesn’t feel she and her sister would be able to provide him the type of care he receives from her. Lois states she has a very good relationship with all of her immediate and extended family members. She is very close to her sister and sees her and her sisters’ family at least on a weekly basis, if not more often.
Her three brothers, who are unmarried, live out of town but come to St. Louis to visit frequently. She is also close to her extended family on both her mother and fathers side of the family and will travel to Mississippi several times a year to visit them. Lois states that she is not aware of any health issue with her siblings although she thinks her oldest brother may have high blood pressure. She had aunts on both sides to die from cancer (unknown type) and two uncles to die from heart disease. The nuclear family has no special needs, is not experiencing any major illnesses, nor is there an immediate family member with disabilities. Lois is experiencing a lot of stress contemplating a hysterectomy this summer due to uterine fibroids and menorrhagia. Carmen has been experiencing irregular menses, but now is on birth control pills (BCP) to regulate her cycle. She however, doesn’t want to take the BCP’s. The twins have mild to moderate eczema, which is being treated with a prescription topical steroid, but this is inconsistent because when the twins are with their father he doesn’t always apply the daily ointment as ordered. There is no history of surgeries, chronic or prolonged illnesses, asthma or allergies in the family. Lois states she needs more information on treatment options for her fibroids; treatment options for Carmen’s’ irregular menses and a better way to make sure the twins are using their medication for their eczema when they’re at their father’s home.
Lois has lived in the St. Louis area all of her life and now she and her family live in Hazelwood MO, a middle-class, culturally diverse suburban area in St. Louis County, MO. Her home is easily assessable to highways, schools, hospitals, shopping and entertainment. She is able to easily get to her sisters’ and fathers’ homes and to church. She doesn’t have a lot of interaction with her neighbors; her community is centered more on where her family and church are located and not necessarily on where she lives. Lois lives in a nicely decorated, well maintained, three bedroom ranch home, with a fenced yard on a low traffic street. Lois and Carmen have their own bedrooms and the twins share a bedroom with twin beds. She has a finished basement that the children utilize for their recreational activities. There are several TV’s and computers in the home and each person has access to these for both leisure and school work. The family room is just off the kitchen and this is the center of family interaction. The family’s communication is didactic and usually occurs around the kitchen table at meal times.
The twins review their day at school and Carmen relates what her upcoming activities are. Lois reviews their progress in school, or addresses issues specific to each child. She does have one-on-one with each child, although not every day, it is several times a week. Lois states communication with Carmen has become more difficulty over the last 6 months. Lois and Carmen have always been very close, but as the twins have required more of Lois’ attention and Carmen has gained more independence, she feels this is changing. Although Lois states that she has always been able to talk with Carmen, she now feels there are more disagreements and some lack of communication. Lois feels Carmen doesn’t show her the expected amount of respect when she is told to do something or reminded to do chores and her tone is not acceptable to Lois. Carmen talks freely with her mother to negotiate her wants and needs or to express her feelings, but gets angry when she feels her mother is unreasonable in her expectations. She states she wishes her mother would listen more and not raise her voice and then get angry at her when she does the same. Lois states there are areas that she makes the sole decision, like home rules and behavior expectations; some areas that are negotiable, like social activities and the use of BCP’s for irregular menses; and then there are areas that Carmen makes her own decisions, like clothes and hair styles.
I explained to Lois this is a normal pattern for adolescent development and that some research has shown that when the child is young they are more likely to have value agreement with the parent, but it seems relatively uncharacteristic of families with middle and late adolescents (Edgar-Smith, 2010). Currently Carmen does not want to take BCP’s because she said it makes her feel “funny”. She isn’t able to give a broader description of the feeling and hasn’t voiced any specific physical complaint or symptom, but just states she wants to stop taking the BCP’s. Lois and Carmen had a discussion around this issue and agreed that Carmen would take the BCP’s for 6 months and then follow up with her doctor to see if continuing or stopping the BPC’s would be the best option for her. Lois is able to communicate openly with both Camille and Emille and they are responsive to the rules and expectations that Lois has laid out for the household and individually. Carmen will talk to the twins, but it’s usually to give correction or instruction, not to inquire. Lois states the twins share their own style of communication which is verbal and non-verbal when interacting with each other.
With others, Camille will usually start the communication and then Emille will join in. Lois prepares all the meals and is very aware of the importance of a balanced meal plan. She makes breakfast and lunches for everyone in the morning and then cooks dinner every night. She usually cooks the meals while the girls are doing homework, watching TV or playing games. She said she needs more help at meal times. I asked her if she could assign task for each child to do so everyone would have a part in meal preparation and she said she would start a routine that involves all the children in this. Carmen is capable of independent meal preparation (but does not initiate this), so she will be the one to set up the food preparation and organize items for the twins. Lois will give specific instructions on what she wants everyone to do, so she won’t have the entire responsibility of meal preparation for every meal every day. Lois, as the mother and only parent in the home, is the sole power source for decision making in the family and has reward and coercive power over the children, although she will confer with the twin’s father due to the legal agreement of joint custody. Carmen, as the oldest child, has inferred power over the twins. The twins, as the two youngest children, are on an equal power base. When asked about the closeness in the family structure, Lois feels she is closest to Carmen and Camille.
Carmen is closest to her mother and Camille. Emille is closest to Camille and her father. Camille is closest to her mother and Emille. Lois doesn’t feel there is a lack of bonding with any of the children. The family exhibits the traditional middle class African-American values of strong family bonds; support from kin and friendships; flexibility in family roles; and strong religious commitment and participation. She has the middle class values of honesty, hard work, progress, achievement and respectability (Friedman, et al., 2003). Individualism and equality are valued, but she stresses respect for God, family and elders; good grades and academic achievement above all else. Health care for the children is important to her. She utilizes her health care insurance to makes sure they have all the needed physicals, immunizations, eye and dental care recommended by their pediatrician. She has delayed her own routine health and dental care and screenings to meet work or family commitments. I explained to Lois that in a recent study a questionnaire was given at both men and women to evaluate family burdens; domestic responsibilities; the appraisal of work and family; and values involved in work-family balance.
The results of this study show that, in the present economic and cultural context, assuming family burdens and domestic responsibilities increases the positive appraisal of work and family (Cantera, Cubells, Martinez & Blanch, 2009). Lois sees her family as very healthy since there are no illnesses or major health crises; but also sees how delaying her health care could directly affect the health status of the family. The children are active in sports, but Lois feels she has been neglecting herself by not getting the exercise she has been used to even though her weight remains consistent and within normal limits. The family’s diet consists of all food groups and is appropriate for each child’s growth needs. All the children are within their normal body mean index (BMI). Meal times are structured and usually occur at home, although she will have one or two nights a month after church where the family eats out. I educated Lois regarding several studies that have investigated the effects of diet on the growth of fibroids. According to the National Institute of Health (NIH), recent findings from a study of more than 22,000 African American women showed that women who consumed milk, cheese, ice cream, or other dairy products at least once a day were less likely to develop fibroids than were women who consumed dairy less frequently (National Institute of Health, 2013).
Lois states one thing she makes sure she does is get enough rest; she sleeps about 7 hours each night. If she feels she needs more rest, she goes to bed earlier. She doesn’t drink alcohol, smoke tobacco, use illicit or recreational drugs, nor do any of the children engage in any of these practices. The main stressor the family is experiencing is the parent-adolescent relationship which Lois is aware is a normal developmental task that the family will progress through. Another area of stress Lois expressed is lack of knowledge related to treatments for uterine fibroids. She was given educational material from the NIH website factsheet on uterine fibroids and current studies and treatment options. Also Lois wanted information on current treatment options for teenagers with irregular menses.
Lois was given information from the PebMed website on a study to determine the effectiveness and acceptability of progestogens alone or in combination with oestrogens in the regulation of irregular menstrual bleeding. The study results state there is no consensus about which regimens are most effective and further research is needed (Hickey, M., Higham J.M., Fraser I. 2012). I encouraged her to follow up with Carmen’s doctor after the 6 month course of BCP’s and then discuss her options. Lois was also given information on treatment options for eczema (Weston, 2011). I encouraged her to have the twin’s father apply the medication to them daily and if he wasn’t able to adhere to the treatment schedule, she could have the twins apply their own ointment. The family handles stressors well; overall family adaptation is appropriate; and the family is meeting all the expected developmental task of this stage. See attachment for genogram.
Cantera, L., Cubells, M., Martínez, L., & Blanch, J. (2009). Work,
family, and gender: Elements for a theory of work-family balance. The Spanish Journal Of Psychology, 12(2), 641-647. Edgar-Smith, S. E. (2010). Family relational values in the parent-adolescent relationship. Counseling & Values, 54(2), 187-200 Friedman, M. M., Bowden, V.R., & Jones, E. G. (2003). Family nursing: Research, theory, and practice. (5th ed.). Upper Saddle River, NJ: Prentice Hall. Hickey, M., Higham J.M., Fraser I. (2012). Progestogens with or without oestrogen for irregular uterine bleeding associated with anovulation. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD001895. DOI: 10.1002/14651858.CD001895.pub3. National Institute of Health. U.S. Department of Health and Human Services, National Institutes of Health. (2013). Uterine fibroids. Retrieved from United States Government website: http://report.nih.gov/nihfactsheets/ViewFactSheet.aspx?csid=50&key=UWeston, W.L., (2011). Epidemiology, clinical manifestations, and diagnosis of atopic dermatitis (eczema). http://www.uptodate.com/home/index.html.
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