Family Nursing Diagnoses
Community Nursing
The community health nurse has a primary role to assess the relationship of variables in the community with how they relate to patients and health. Cultural, religious, ethnic, and personal upbringings are variables that are considered to gain a basic understanding of the community framework. The purpose of this paper is to discuss three nursing diagnoses related to AL and his family living in a suburban community in Staten Island, New York. Interventions and outcomes will be expected for each diagnosis and will be integrated into the care plan and educational program specially designed for the chosen family.
Family Assessment
AL is a 65 year old man with an Italian ethnic background. He is a smoker who has been recently diagnosed with Type II Diabetes Mellitus, mild obesity, and a history of coronary artery disease with one stent last year. His physician stated he is borderline diabetic that could be managed through diet and lifestyle modifications, and could not advance if he is compliant with suggested regimens. He lives in a two-family residence with his wife, and his father who lives in the side apartment downstairs. He has two adult children who live within close range and visit several times a week.
Jean Watson’s Theory of Human Caring
When caring for a special population group within a community, the nurse must integrate clinical thought to assimilate specifically designed interventions for patients. Nurses must be conscious of their responses and actions that may inadvertently affect the patient’s response. Jean Watson’s Theory of Human Caring uses a contemporary, holistic framework designed by using multiple disciplines to care for individuals and those within a community. Experienced nursing professionals are familiar with Watson’s theory viewing all persons into the dimension of mind, body, and soul. Nurses assess the surrounding environment for disharmony, which may lead to illness and disease that could be prevented through change that leads to holistic healing (Falk Rafael, 2000).
Family Nursing Diagnoses
The community health nurse is responsible for making accurate nursing diagnoses with interventions and treatment options specially designed for patients and the community. There are three nursing diagnoses that are related to AL and his immediate family: Knowledge deficit, imbalanced nutrition, and activity intolerance. NANDA (North American Nursing Diagnosis Association) is a professional nursing organization that uses standardized nursing language to create specific diagnoses related to patients used to design an accurate and effective plan of care. These diagnoses are not to be confused with medical diagnoses, but are used to support physicians by using strategic interventions with measureable goals that will result with positive patient outcomes (NANDA International, 2013).
Knowledge deficit related to lack of understanding to care for a newly diagnosed diabetic condition as evidenced by non-therapeutic blood glucose levels and asking questions regarding self-management with diet and lifestyle modifications. This is the first diagnosis of AL related to health seeking behaviors that raises increased awareness that this family needs extensive education on several factors to promote health and manage existing disease. Education must be given to assist the patient and his family for healthier nutrition, increased daily exercise, effective blood glucose management techniques, and monitoring glucose levels regularly. One Healthy People 2020 leading health indicator that is related to this diagnosis is under the topic of clinical preventative services. According to Healthy People 2020 this indicator is categorized within the “Adult diabetic population with an a1c value greater than 9 percent” with a goal to improve number of persons by 10 percent ("2020 LHI Topics," 2013). Interventions are directed toward educating patient and family on nutrition: simple versus complex carbohydrates, sugars and sugar substitute, and list of suggested foods that are diabetic friendly. The community health nurse must first assess the individual needs of the patient, readiness to learn, and identify barriers to effective learning. Education is given on proper use of the blood glucose monitoring machine, frequency of testing, normal blood glucose parameters, signs and symptoms of high and low blood sugar, emergency measures, and keeping an accurate log book.
Imbalanced nutrition: More than bodily requirements related to excess caloric intake with low activity expenditure as evidenced by sedentary lifestyle, unhealthy eating habits, and excess body weight more than 20 pounds. This is the second nursing diagnosis given to AL and his family and relates to all family members. Goals will be reasonable and measureable and the patient will develop a daily exercise regimen, verbalize support groups that will assist with attaining goals, and create a daily food plan based on suggested nutritional information provided by resources given. One Healthy People 2020 leading health indicator related to this diagnosis is topic of nutrition, physical activity, and obesity. This indicator is categorized under the topic to “Reduce the proportion of adults who are obese”, having a target of a 10 percent overall improvement to reduce persons who are obese ("2020 LHI Topics," 2013). Interventions include providing education to the patient on health conditions directly related to obesity, monitoring caloric and fat intake, organize a daily meal plan, increased water intake, provide suggestions to develop an individualized personal exercise and wellness regimen, and offer additional resources such as brochures for local weight loss support groups and nutritional information.
Activity intolerance is the third nursing diagnosis created for AL that is related to sedentary lifestyle as evidenced by fatigue when walking at fast pace, up staircase, or after prolonged periods of time. Goals will include having increased tolerance to activity that will improve by five minutes weekly and by patient stating he is not fatigued after walking up stairs, prolonged periods of time, vital signs within baseline parameters, and able to walk at a fast pace for a sustained period of time over three minutes before complaining of fatigue. According to Healthy People 2020, this is also under the topic of nutrition, physical activity, and obesity but is categorized under the topic of “Adults who meet current Federal physical activity guidelines for aerobic physical activity and muscle-strengthening activity” ("2020 LHI Topics," 2013). Nursing interventions will include a detailed assessment of mobility, nutritional status, risk for injury, monitor vital signs during activity, fatigue, nutritional needs, and provide emotional support to make the patient feel more confident for success with goals.
Legal and Ethical Considerations The community health nurse is subject to many legal or ethical considerations they may encounter when caring for patients in the public setting. These include breach of confidentiality, risk for injury, informed consent, conflict with personal beliefs, and ensuring accurate documentation of patient records. Confidentiality is important to safeguard in every health care setting and it is our legal, professional right as nurses to protect patient privacy. When visiting patient homes, nurses must be aware of any physical or environmental hazards that may cause physical harm in the home. Informed consent must be obtained prior to start of care and before procedures begin. Ethical dilemmas such as interpersonal conflict with personal beliefs pose a difficult situation for both the nurse and patient. The nurse must respect the patient’s wishes, regardless if they agree with their personal health care decisions. Accurate documentation of patient records in the community health setting are just as important as the inpatient setting and must include communication with physicians, assessment, patient complaints, health hazards in the home or living conditions, readiness to learn, education provided, or any other pertinent information. According to Dimond (2005), “Failure, therefore, to maintain reasonable standards of record keeping could be evidence of professional misconduct and subject to professional conduct proceedings” (p. 460). Nurses working in public health settings may be recommended to have personal malpractice insurance if not covered by employers.
Advocacy and Education Patient advocacy is one of the many roles of community and public health nurses. The nurse prioritizes necessary services after carefully collecting, monitoring, and analyzing patient data and then organizes the most effective interventions for the plan of care. This process is implemented along with the patient’s input to encourage independence in decision-making and encourage disease self-management. Moreover, education is given to patients to encourage and promote healthy lifestyle modifications and behavior (Stanhope & Lancaster, 2012). Advocating for patient AL and his family includes providing education to strengthen knowledge on healthy lifestyle behaviors through diet, nutrition, exercise, and smoking cessation. This is not limited to advocating through local, state, or Federal executives to gain easier access to health care services within the community and encouraging patients to receive annual immunizations. It is important that the patient and family are aware of health risks that may be affected by family structure and roles. For example AL is a smoker who occasionally smokes in his home, regardless if his family disapproves. He states he is the man of the house and the sole bread winner and should be allowed to smoke whenever he wants in his own home. Second-hand smoke is harmful to his family, putting them at risk for respiratory ailments and other health risks. Nurses who work with a diverse group of patients may sometimes encounter bias on beliefs that are not similar to their own personal beliefs, morals, or values. The patient AL refuses to quit smoking at this time regardless of the immediate health risks it poses on him or his family. It was indisputable that he did not want further resources or pamphlets on smoking cessation or stress management. This had an impact on the outcomes of interventions used to promote better health not only for AL, but for setting an example for his other family members. There was a personal bias I had that conflicted with his family values through his behavior and viewpoint on health and the importance of health within the family because I have different beliefs on the subject. Treating the patient holistically includes balancing all aspects of life together as one to promote health, well-being, prevent disease, and enhance quality of life.
Educational Needs Upon extensive review of AL and his family, there are several educational needs that will be reviewed. Topics for discussion include incorporating daily exercise, diabetic friendly diet, nutritional content of foods, blood glucose monitoring, stress reduction, and smoking cessation. Exercise and active lifestyle is one major factor the family is lacking and is interrelated to reducing stress, eating healthy diet, and reducing smoking to eventually quitting. Brochures and pamphlets on nutritional information of healthy foods for a diabetic diet, recipes, and smoking cessation will be included with the education plan.
Family Nursing Diagnosis Family member | Relationship in family | Age | Education/Job | stressors | Mr. L | Father | 65 | Truck Driver | Long driving hours at work | Mrs. L | Mother | 64 | Homemaker | None identified | AL | Son (does not live in home) | 34 | Union worker | Occasional alcohol problem | LL | Daughter (does not live in home) | 37 | Speech Therapist | New baby | DL | Father (lives in side apartment) | 85 | Retired business owner | Ageing and self-care |
Family member | Developmental stage | Coping Mechanisms | Religion | Mr. L | Integrity vs. Despair | Talk with wife, smoking | Roman Catholic | Mrs. L | Integrity vs. Despair | Praying, reading, church | Roman Catholic | AL | Intimacy Vs Isolation | Alcohol binging, smoking, music | Roman Catholic | LL | Intimacy Vs Isolation | Occasional exercise, reading, meditation, music | Roman Catholic | DL | Integrity vs. Despair | Watching TV, music | Roman Catholic |
Family History:
Mr. A.L. is a patient who has been residing in Staten Island, New York for almost 30 years. Originally from Brooklyn, he comes from an Italian-American family and is second generation from Naples, Italy. The neighborhood is a solid, middle-class suburban area of New York City. AL has been working at a local truck driving company for the past 25 years and plans to retire within the next three years. His past medical history only consists of one cardiac stent last year, smoking < 1 pack per day, mild obesity, and newly diagnosed Type II Diabetes. Mrs. L is a 64 year old homemaker with a history of hypertension. The couple has two children, AL and LL who do not live at the residence, live within close proximity, and visit several times a week. The home is a two-family residence with a side apartment rented to AL’s father who is an 85 year old who uses a cane to ambulate. AL was recently diagnosed with Type II Diabetes Mellitus by his physician, who suggests treating non-pharmacologically first by incorporating a healthy diet and lifestyle modifications.
3 Nursing Diagnoses:
1. Knowledge deficit related to lack of understanding to care for a newly diagnosed diabetic condition as evidenced by non-therapeutic blood glucose levels and asking questions regarding self-management with diet and lifestyle modifications.
2. Imbalanced nutrition: More than bodily requirements related to excess caloric intake with low activity expenditure as evidenced by sedentary lifestyle, unhealthy eating habits, and excess body weight more than 20 pounds.
3. Activity intolerance related to sedentary lifestyle as evidenced by fatigue when walking at fast pace, up staircase, or after prolonged periods of time.
References
2020 LHI Topics. (2013). Retrieved from http://www.healthypeople.gov/2020/LHI/2020indicators.aspx
Dimond, B. (2005). Exploring the principles of good record keeping in nursing. British Journal of Nursing, 14(8), 460-464.
Falk Rafael, A. R. (2000). Watson’s philosophy, science, and theory of human caring as a conceptual framework for guiding community health nursing practice. Advances in Nursing Science, 23(2), 34-49.
NANDA International. (2013). http://www.nanda.org/
Stanhope, M., & Lancaster, J. (2012). Public health nursing: Population-centered health care in the community (8th ed.). Maryland Heights, MO: Mosby Elsevier.
