High-Risk Family Assessment and Health Promotion
Mary Ann Bennett
University of Phoenix
NUR/542
Melinda Church
August 6, 2012

High-Risk Family Assessment and Health Promotion Assessing health needs is a fundamental nursing skill. Unfortunately, many nurses only associate the assessment process to the individual patient they are caring for and fail to assess and address the needs of the entire family. Performing a family assessment is vital, especially when working with high risk individuals and groups. High risk families can be defined as those families with a higher than expected risk for developing a particular disease or injury in association to their lifestyle, environment, habits, or socio-economic conditions. Post active-duty war veterans are a group that is at high risk for developing Post Traumatic Stress Disorder (PTSD), which can lead to physical, psychological, and social problems. These problems not only affect the veteran but also strongly alter the health and lifestyle of the entire family. The objective of this paper is to present the health profile and behaviors of PTSD veterans, describe assessment models and theories that are applicable to the patient and family, and identify Healthy People 2020 objectives that relate to this high risk group. In addition, the paper will present nurse intervention strategies based on health promotion and prevention as well as the role of advanced practice nurses as case managers.
Health Profile According to the Mayo Clinic (2012), PTSD “is a mental health condition that is triggered by a terrifying event” (p. 1). After experiencing severe trauma or a life-threatening event, many deployed war veterans develop symptoms of post-traumatic stress. Many feel as though their lives or the lives of others are in imminent danger in which they have no control. These feelings develop into symptoms that include recurring nightmares or flashbacks, loss of interest, anger, irritability, sleeplessness, and depression. To compound the issue, often the affected veteran will turn to high-risk behaviors in an attempt to find resolution or relief including smoking, social isolation, abuse of alcohol and drugs, and the display of violent or aggressive behavior. Frequently, depression or other mental health issues arise. In a domino effect, the high risk behavior frequently leads to unemployment, habitual drug or alcohol use, poor or absent parenting, fractured family units, unsafe sex, participation in dangerous sports or driving, and in some instances, suicide. Last, stress along with the indulgence of smoking and the consumption of alcohol and drugs can also lead to chronic health issues including hypertension, stroke, cardiovascular disease, diabetes, pulmonary disease, and digestive disorders.
Assessment and Theory Application Effective treatment of PTSD can only take place if the disorder is recognized. Symptoms of PTSD are commonly divided into three defining sections: (1) reliving the traumatic event, (2) detachment and avoidance, and (3) exaggerated responses (NCBI, 2010). When a patient relives the traumatic event, it occurs in a manner in which it interferes with the normal process of daily life. This can include recurring flashbacks or dreams and distressing memories, which manifest negative physical reactions. Detachment and avoidance is demonstrated through loss of interest in current living situation, avoidance of people or places that may bring memories of the event, loss of memory of the event, and assuming an attitude of hopelessness and despair. Exaggerated responses can include inability to sleep, startled responses, spontaneous anger outburst, and overindulgence in drugs, alcohol, smoking, and negative sexual behavior. The clinical interview is the most common method used by family nurses for assessing individuals for PTSD. The most important factor the family nurse must understand is that when a patient and his or her family present to a medical facility seeking help, they often are weary in asking for help and need a trusting environment in order to be open with their past experiences and current issues. According to Briere and Scott (2007), the nurse must show empathy, avoid body language or judgments that show disgust, show sensitivity when forming questions must be aware of avoiding behavior, and remember speaking of traumatic events may evoke undesirable reactions. The family nurse will most commonly perform a clinical interview first with the veteran as he or she seeks professional help. However, a family assessment/interview should be conducted to obtain the family member’s perspective and needs. These interviews should be followed by a joint interview allowing each party to say and hear the other side’s perspective and to agree jointly to development of a plan and intervention. Some clinician may use more structured assessment tools to conduct interviews that are more geared toward assessing stress and traumatic responses. These can include the Clinician-Administered PTSD Scale (CAPS), the Brief Interview for Post-traumatic Disorder (BIPD), Acute Stress Disorder Interview (ASDI), or the Impact of Event Scale (IES). When performing a family assessment involving PTSD, Hill’s Family Stress Theory (1949) can be used as the theoretical framework. Hill’s work focused on war-time separation and reunion and the family stressors that ensue. While using family stress theory, the nurse’s assessment should focus on the actual stressors, the family’s perception of the stressor, resources available, coping mechanisms, and how the crisis has disrupted the family unit (Friedman, Bowden, & Jones, 2003).
Healthy People 2020 The Healthy People initiative was developed in 1990 as a national movement to decrease disparities among communities by endorsing health promotion and prevention. Every 10 years, new objectives are established striving to identify serious health issues within the nation, and attempts to bring public awareness on the measures individuals can take to prevent the development or advancement of a disease or condition. Healthy People 2020, as its predecessors focus on health maintenance, promotion, and prevention. Therefore, every person nationwide can benefit from this movement. When addressing patients and families coping with PTSD, many objectives from Healthy People 2020 are pertinent including access to quality health care services, substance abuse, and tobacco use. However, the objective most prominent when dealing with the diagnosis of PTSD is the objective to improve “mental health through prevention and by ensuring access to appropriate, quality mental health services” (Healthy People, 2012, p. 1). Taking a pro-active stance to promote mental wellness is the goal of this initiative. Currently, little is done during deployment to assist military men and women to deal with the atrocities they may encounter while at war. Upon discharge, few military personnel seek mental health assistance because of the stigma of appearing weak or unstable. The Veterans Administration system proceeds in a reactive mode overburdened with postwar injuries and care. The emphasis must be changed to be pro-active in assessing soldiers’ needs earlier and getting the supportive care they need earlier rather than when a soldier is in crisis. In addition, family nurses, physicians, and community outreach programs need to intervene earlier to prevent the stress from devouring the veteran and his or her family.
Nurse Intervention Strategies Once a comprehensive client and family assessment is performed, the family nurse can develop nursing diagnoses in order to develop a plan of care. Nursing diagnoses are descriptive phrases used to identify a health conditions, potential risk, or health altering life processes (NANDA International, 2011). Common nursing diagnoses for PTSD include the risk for suicide, anxiety, and ineffective coping. Establishing client-centered goals, setting priorities, and choosing interventions, are important elements to patient planning. The planning and intervention must be according to the urgency of each problem. Family nursing intervention strategies can involve lifestyle modification guidelines including modeling, self-confrontation, operant conditioning, cognitive reframing, and stimulus control (Friedman, Bowden, & Jones, 2003). Veterans with PTSD and their families can benefit from lifestyle modifications. Initially, the family nurse can use self-confrontation in a way to determine each family member’s values, beliefs, and behaviors in reference to the fellow members in the family. When looking at these guidelines, the nurse can use modeling to demonstrate positive health behaviors versus those behaviors, which have a negative outcome. The nurse can utilize operative conditioning in an attempt to understand the family’s desires and goals and to help establish common goals between the veteran and his or her family members. Initially the goals should be realistic, short-term, and result in positive reinforcement. For example, setting the goal to decrease the amount of cigarettes smoked on a daily basis. Exercising cognitive reframing helps the veteran and his or her family understand how to resolve past issues in order to move on to address the issues that are currently destroying the family. Cognitive reframing can be used in conjunction with support groups (Friedman, Bowden, & Jones, 2003). Last, stimulus control is an intervention that helps the family focus on circumstances that provoke unacceptable behavior (Friedman, Bowden, & Jones, 2003). Provoking issues can include abuse of alcohol and drugs, movies depicting war conflict, or news programming. The nurse should focus on activities that generate a positive attitude such as going on a hike, interacting with animals, or going on a quiet family outing.

Role of Advanced Practice Nurses as Case Manager Whereas most nurses encounter veterans and their families at the bedside in an acute care setting, using advanced practice nurses in the case management role is essential for all high-risk populations. Although the immediate health care needs of the PTSD veteran are paramount, the healing of the family is a vital part of the recovery process. As a case manager, the nurse can address the entire family’s immediate health needs but also can be an advocate in arranging post-acute care by providing support and resources. The physical and psychological issues of the veteran will always affect his or her loved ones. Often the initial symptoms of PSTD spill over creating health disorders in the veteran and in their family members. The advance practice nurse is put in a position of trust to observe, assess, and work cohesively with the family to develop appropriate plans of action during hospitalization and upon discharge of all members involved. While the most urgent issues must be addressed immediately, the family nurse must also transition into the case management role to promote health and prevent avoidable disease and injuries in the future.
Research on Topic With the wars in the Middle East, more emphasis has been placed on PTSD. In a Journal of Psychosocial Nursing article written by Ann Marie Naback (2008), research has confirmed that the delay or lack of access to adequate health care potentially complicates the early diagnosis and treatment of PTSD. The article continues on further to state that research has “indicated those individuals affected by health disparities, there is a greater burden of illness and disability, higher morbidity and mortality rates, and increased behavioral risk factors” (p. 43). The article provides statistics from the National Security Archives (2006), which list PTSD as the second largest category of illnesses for which veterans from the Iraq and Afghanistan conflicts seek treatment. According to Naback (2008), “PTSD is highly associated with comorbidity of other psychiatric diagnoses such as major depression, anxiety, and alcohol and drug abuse or dependence” (p. 48). In addition, victims of PTSD have an increase risk of obesity, cardiovascular disease, and cancer related to high-risk behaviors such as smoking that is common with persons with this disorder. The research has indicated a need for education, policy changes, early detection, and further research in diagnosing and treating PTSD.
Conclusion
While PTSD will remain a high-risk health issue, only through education and early detection will the family nurse be instrumental in alleviating some of the devastating effects that occur to our veterans and his or her family members. Accurate nurse assessments, planning, interventions, and support is the key for the health promotion and health prevention of this disorder.

References
Briere, J. & Scott, C. (2007). Principles of Trauma Therapy: A Guide to Symptoms, Evaluation, and Treatment. Thousand Oaks, CA: Sage.
Friedman, M. M., Bowden, V. R., & Jones, E. G. (2003). Family nursing: Research, theory, & practice (5th ed.). Upper Saddle River, NJ: Prentice Hall.
Healthy People. (2012). Healthy People 2020. Retrieved from http://wwwhealthypeople.gov
Mayo Clinic. (2012, March). Post-traumatic Stress Disorder (PTSD). Retrieved from hhtp://www.mayoclinic.com/health/posttraumaticstressdisorder/DS00246/DSECTION
NANDA International. (2011). NANDA nursing diagnoses: Definitions and classifications, 2009–2011. Philadelphia, PA: NANDA International.
National Security Archive. (2006, October). VA takes nine months to locate data on disability claims by veterans of Iraq and Afghanistan wars. Retrieved from the George Washington University Web site: http://www.gwu.edu/%7Ensarchiv/news/20061010/index.htm
Nayback, A. (2008). Health disparities in military veterans with PTSD: Influential sociocultural factors. Journal of Psychosocial Nursing & Mental Health Services, 46(6), 42-53. doi:10.3928/02793695-20080601-08
National Center for Biotechnology Information (NCBI), National Library of Medicine at the National Institutes of Health. (2010). Post-traumatic stress disorder. Retrieved from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001923/.