Guidelines for Family Nursing Practice

Sequence of Activities in The Family Nursing Practice:

1. Establishes a working relationship with the client a. initiates contact b. communicates interest in the familys welfare c. expresses/shows willingness to help with expressed need (s) d. maintains a two-way communication with the family 2. Conducts an initial assessment to determine the presence of any health problems. TOOL: Initial Data Base for Family Nursing Practice

3. Categorizes Health Problems into: Health Threats Health Deficits Foreseeable Crisis Situations or Stress Points TOOL: Typology of Nursing Problems in Family Nursing Practice: First Level Assessment

4. Determine the nature and extent of the familys performance of the health tasks on each of the health problems categorized in activity no.3; Define family nursing problems based on: Typology of Nursing Problems in Family Nursing Practice: Second Level Assessment

5. Determine priorities among the list of health problems Considers the nature of the problem presented Evaluates the modifiability of the problem Evaluates the preventive potential of the problem Evaluates the familys perception/evaluation of each problem in terms of seriousness and urgency of attention needed. TOOL: Scale for Ranking Health Problems according to Priorities 6. Ranks health problems according to priorities.

7. Decides on what problems to tackle in the order of immediacy/urgency, based on priorities set.

8. Defines nursing objectives in realistic measurable terms jointly with the family. SMART

9. Plans approaches, strategies of action (interventions), criteria and standards for evaluation.

10. Implements the plan of care.

11. Evaluates the effectivity of implemented aspects of the plan.

12. Re-defines nursing problems and re-formulates objectives according to evaluation findings.

Initial Data Base for Family Nursing Practice

A. Family Structure & Characteristics 1. Members of the household & relationships to the head of the family 2. Demographic Data: age, sex, civil status, position in the family 3. Place of Residence of each member whether living with the family or elsewhere 4. Type of family structure: matriarchal, patriarchal, nuclear or extended 5. Dominant family members in terms of decision making in matters of health care 6. General relationship presence of any obvious readily observable conflict between members; characteristic communication patterns among members

B. Socio-Economic & Cultural Factors 1. Income and Expenses Occupation, place of work and income of each working member Adequacy to meet basic necessities (food, clothing and shelter) Who makes decisions about the money and how is it spent? 2. Educational attainment of each member 3. Ethnic Background and Religious Affiliation 4. Significant Others role they play in the familys life 5. Relationship of the family to larger community familys participation in the community activities

C. Environmental Factors 1. Housing Adequacy of living space Sleeping arrangement Adequacy of the furniture Presence of insects and rodents Presence of accident hazards Food storage and cooking facilities Water supply source, ownership, potability Toilet Facility type, ownership, sanitary condition Garbage/Refuse Disposal type, sanitary condition Drainage System type, sanitary condition 2. Kind of neighborhood: congested, slum, etc. 3. Social & Health facilities available 4. Communication & Transportation Facilities Available

D. Health Assessment of each member 1. Medical & Nursing history indicating past significant illnesses, beliefs & practices conducive to illness.

2. Nutritional Assessment (specially vulnerable or at risk members) Anthropometric data: weight, height, mid upper arm circumference Dietary history indicating quality & quantity of food intake per day Eating/Feeding Habits/Practices

3. Current health status indicating presence of illness states (diagnosed or undiagnosed by medical practitioner)

E. Value placed on prevention of disease 1. Immunization Status of Children 2. Use of other preventive services

Typology of Nursing Problems in Family Nursing Practice

I. Presence of Health Threats, Health Deficits & Foreseeable Crisis A. Health Threats conditions conducive to disease, accident or failure to realize ones health potential, Ex. 1. Health history of specific disease/condition (like family history of diabetes) 2. Threat of cross infection from a communicable disease case 3. Family size beyond what family resources can adequately provide 4. Accident hazards ex. broken stairs, fire & fall hazards, pointed/ sharp objects, poisons & medicines improperly kept

5. Nutritional Inadequate food intake both in quantity & in quality Excessive intake of certain nutrients Faulty eating habits

6. Stress provoking factor Strained marital relationship Strained parent-sibling relationship Interpersonal conflicts between family members

7. Poor environmental sanitation Inadequate personal belongings/utensils Lack of food storage facilities Polluted water supply Unsanitary waste disposal Improper drainage system

8. Unsanitary food handling & preparation 9. Personal habits/practices Frequent drinking of alcohol Excessive smoking. Walking barefoot Poor personal hygiene Self medication 10. Inherent personal characteristics (like short temper) 11. Health history which precipitate/induce the occurrence of a health deficit ex. previous history of difficult labor

12. Inappropriate role assumption ex. Child assuming mothers role

13. Lack of immunization / inadequate immunization status of children

14. Family disunity Self-oriented behavior of members Unresolved conflicts of members Intolerable disagreements

B. Health Deficit instances of failure in health maintenance 1. Illness states, regardless whether it is diagnosed or undiagnosed by medical practitioner

2. Failure to thrive/develop according to normal rate

3. Disability arising from illness, whether transient/temporary Ex. Aphasia or temporary paralysis from a CVA, blindness from measles, lameness from polio, leg amputation secondary to diabetes

C. Stress Points / Foreseeable Crisis Situations anticipates periods of unusual demand on the individual or family in terms of adjustments/family resources Ex. 1. Marriage 2. Pregnancy, Labor, Puerperium 3. Parenthood 4. Additional member (newborn, lodger) 5. Abortion 6. Entrance at School 7. Adolescence 8. Loss of Job 9. Death of a member 10. Resettlement in a new community 11. Illegitimacy

II. Inability to recognize the presence of a problem due to: 1. Ignorance of facts 2. Fear of consequences of diagnosis of problem Social stigma, loss of respect of peer/significant others Economic - cost Physical / Psychological 3. Attitude / Philosophy in life

III. Inability to make decisions with respect to taking appropriate health action due to: 1. Failure to comprehend the nature, magnitude / scope of the problem 2. Low Salience of the problem 3. Feeling of confusion and/or resignation brought about by failure to breakdown problems into manageable units of attack 4. Lack of knowledge / insight as to the alternative courses of action open to them 5. Inability to decide which action to take from among a list of alternatives 6. Conflicting opinions among family members / significant others regarding action to take

7. Ignorance of community resources for care 8. Fear of consequences of action

Social Economic Physical / Psychological

9. Negative attitude towards the problem by negative attitude is meant one that interfere with rational decision making 10. Inaccessibility of appropriate resources of care
Physical location Cost 11. Lack of trust / confidence in the health personnel / agency 12. Misconceptions or erroneous information about proposed course (s) of action

The view of metro Manila from the northwest.

IV. Inability to provide adequate nursing care to the sick disabled, dependent or vulnerable/ at risk member of the family due to:

1. Ignorance of facts about the disease/ health condition (nature, severity, complications, prognosis and management); child development & child care

2. Ignorance of the nature & extent of nursing care needed

3. Lack of the necessary facilities (equipment & supplies) for care

4. Lack of knowledge & skill in carrying out the necessary treatment/ procedure/ care

5. Inadequate family resources for care

Responsible member Financial Physical resources isolation room

6. Negative attitude towards the sick, disabled, dependent, vulnerable / at risk member

7. Attitude / philosophy in life

8. Members preoccupation with own concerns / interests

V. Inability to provide a home environment which is conducive to health maintenance and personal development due to: 1. Inadequate family resources Family Physical (lack of space to construct facility) 2. Failure to see benefits (specifically long term ones) of investment in home environment improvement 3. Ignorance of importance of hygiene and sanitation 4. Ignorance of preventive measures 5. Lack of skill in carrying out measures to improve home environment 6. Ineffective communication patterns 7. Attitude / philosophy in life

VI. Failure to utilize community resources for health care due to:
1. Ignorance or lack of awareness of community resources for health care. 2. Failure to perceive the benefits of health care / services 3. Lack of trust / confidence in the agency / personnel 4. Previous unpleasant experience with health worker 5. Fear of consequences of action (preventive, diagnostic, therapeutic, rehabilitative) Physical / Psychological Financial Social (ex. loss of esteem of peer / significant others)

6. Unavailability of required care / service 7. Inaccessibility of required care / service Cost Physical location

8. Lack of inadequate family resources Manpower Financial (cost of medicine prescribed)

9. Feeling of alienation to / lack of support from the community (ex. mental illness)

10. Attitude / philosophy in life

SCALE FOR RANKING FAMILY HEALTH PROBLEMS ACCORDING TO PRIORITIES Criteria 1. Nature of the problem presented Scale: Health Threat. Health Deficit. Foreseeable Crisis Weight

1 2 3 1

2. Modifiability of the Problem Scale: Easily modifiable... Partially modifiable Not modifiable

2 2 1 0

Criteria 3. Prevention Potential Scale: High.. Moderate. Low.. 4. Salience Scale: A serious problem, immediate attention. 2 A problem but not needing immediate attention. 1 Not a felt need / problem.. 0

Weight

1 3 2 1

Scoring 1. Decide on a score for each of the criteria. 2. Divide the score by the highest possible score and multiply by the weight. Score ----------------Highest Score

X Weight

3. Sum up the scores for all the criteria. The highest score is 5, equivalent to the total weight. 4. The higher the score (near 5 and above) of a given problem, the more likely it is taken as a PRIORITY. 5. With the available scores, the nurse then RANKS health problems accordingly.

Examples of computation 1. Intestinal infestation/parasitism (PRIORITY) Criteria 1. Nature of the problem Health Deficit 2. Modifiability of the problem Partially modifiable 3. Preventive Potential Moderate 4. Salience A serious problem, immediate attention Total 3/3 x 1 1

x2 2/3 x 1

2/3

2/2 x 1

1 3 2/3

2. Inadequate nutrition Criteria 1. Nature of the problem Health Threat 2. Modifiability of the problem Partially modifiable 3. Preventive Potential Low 4. Salience A serious problem, immediate attention Total 2/3 x 1 x2 1/3 x 1 2/3 1

1/3

2/2 x 1

1 3

3. Poor environmental sanitation Criteria 1. Nature of the problem Health Threat 2. Modifiability of the problem Partially modifiable 3. Preventive Potential Low 4. Salience A problem but not needing immediate attention. Total

2/3 x 1 x2 1/3 x 1

2/3 1

1/3

x1

Criteria in Different Priorities

1. Nature of the Problem Presented Categorized whether a Health Threat, Health Deficit or Foreseeable Crisis 2. Modifiability of the Problem Refers to the probability of success in minimizing alleviating or totally eradicating the problem through health intervention Factors: Current knowledge, technology and interventions to manage the problem Resources of the family (physical, financial, manpower) Resources of the nurse (knowledge, skills, time) Resources of the community (facilities & community organization)

3. Preventive Potential Refers to the nature and magnitude of the future problem that can be minimized or totally prevented if intervention is done in the problem. Factors: Gravity and severity of the problem Duration of the problem Current management Expose of any high risk group

4. Salience Refers to the family perception & evaluation of the problem in terms seriousness & urgency of attention needed. To determine the score for Salience, the nurse evaluates the familys perception of a problem. As a general rule, the familys concerns and felt needs require priority attention

- Is the set of actions the nurse decides to implement to be able to resolve identified family health and nursing problems.

1. focuses on actions (designed to solve or alleviate existing problems).The PLAN is a Blueprint for action. 2. product of deliberate systematic process 3. relates to future 4. revolves around identified health & nursing problems 5. means to an end, not an end in itself 6. continuous process

1. Clear definition of problem 2. Consistent with the goals & philosophy of the health agency 3. Realistic 4. It is drawn with the family nurse works with the family not for the family 5. Be kept in written form

Provides individualized care Helps in setting priorities Promotes systematic communication Continuity of care Facilitate coordination of care