Family Nursing Diagnosis
Susan Kenney, RN
NUR/405
June 9, 2014
Beth Edwards, MSN, FNP-BC

Family assessment, roles and structure The family I have been working with consists of three sisters who live in a house owned by the eldest of the three, C.H. C.H. is a 64 year old Caucasian female who was born with cerebral palsy and mental retardation. She has never been able to walk, and her mentation never progressed past the age of an approximately 4 year old child. She lived at home with her parents and two sisters and one brother until the age of 11 when she was institutionalized in a facility notorious for the mistreatment and neglect of its residents. The facility has long since closed, and in 1991, C.H. was placed with our organization, Community Vision Inc. (CVI). Her parents were both deceased by that time, and her sister D.H.C. assumed legal guardianship, with sister N.W. helping with her needs. CVI is a non-profit organization that assists disabled individuals to live as independently as possible, and enables them to purchase and live in their own homes if possible. We provide caregivers and in collaboration with social services and interdisciplinary personnel facilitate the supported individual to live to their maximum potential. Each person has their own individual service plan with health, safety, and vocational goals, and staffing is provided as required to meet the individual’s needs.
Assessment of C.H. and her living situation
The home the sisters live in is an older small three bedroom with nice yards in front and back in Gresham, Oregon. When CVI placed C.H. in the home, she was cared for 24/7 by our staff, since she cannot be left alone. In 2004, sister D.H.C. moved in with her, followed soon after by N.W. The sisters work outside the home, so our caregiver staff is still primarily in charge of her home and care. C.H. is wheelchair bound and is totally dependent on caregivers for all of her needs. She is verbal but expressively aphasic, and it is difficult to understand what she says until you become used to her speech patterns. She understands what others say to her and responds to simple statements and questions. She suffers from dysphagia, and there is a protocol for aspiration precautions in place. Her food must be pureed, and her drinks need to be nectar thick. All food and liquids are tracked on a daily log. She has mild hypercholesterolemia which is controlled by a specially formulated diet, and once daily Lovastatin. She is approximately 15-20 lbs. over her ideal weight, but with her age, medications (Depakote causes weight gain), and mobility limitations, her physician does not consider her weight an issue for concern, and she is weighed once a month on her Hoyer lift scale. Her health is otherwise very good, and she is rarely sick. There are orders for thrice weekly ROM exercises to stretch her leg muscles to avoid atrophy and improve her lower extremity flexibility. Her legs are stiff and she has significant bilateral foot drop. She has compression stockings ordered to wear at all times when she is out of bed, and no lower extremity varices or edema is apparent. She complains when ROM activities are being performed that it hurts her legs. She takes Depakote for seizure prevention (she has no reported history of seizure) and depression, and phenobarbital as a sedative at bedtime. Other than those, she takes only dietary supplements and cetirizine for mild sinus problems. Her skin is clean dry and intact, and has no evidence of breakdown anywhere on her body. Her affect is calm and pleasant, and she likes being around people and animals, especially babies and cats. She likes to watch cartoons and cooking shows on T.V., and loves to eat. She doesn’t have the capability of judging when she is full, so she will continue to eat until she makes herself sick if allowed to. Her diet has been carefully formulated into a very specific menu by a dietician her brother hired, because he said she was “getting fat”, however, C.H. refuses to eat according to a set menu every day, so it is used primarily as a dietary guideline for her nutrition. She has no significant chronic health problems, and usually just goes with the flow of whatever is going on around her.
Assessment of D.H.C., C.H.’s sister and legal guardian
Sister D.H.C. is a 54 year old Caucasian female who appears somewhat younger than her actual age, and has no apparent disability or defect. She has a history of obesity, high blood pressure, smoking, and alcoholism. She has lost 50 lbs. and kept it off “for the most part” over a period of 3 years. She is a recovering alcoholic, and has been a member of A.A. for many years and is very involved in the group and its activities. Although she still smokes, due to the alteration of some of her high risk behavior, her physician no longer finds it necessary for her to take BP medications. She struggles with her weight with some success, which she attributes to her lifetime membership with Weight Watchers, and states she is “about 15 lbs. away” from her personal goal weight. She admits to “binging on junk food” and “comforting” herself with food in times of distress. She is terrified of being “fat again”, but states she feels “out of control at times” when it comes to eating, and has gained 15 lbs. in the past 8 months. She does not look overweight to me. She is an educated person and continues to pursue the ways and means to improve herself and her family’s circumstances. She works as a secretary, and hopes to return to college at some point to further her career. She has been divorced for ten years, doesn’t date and states she has “no life”. She is not a morose or negative personality, and strives to remain philosophical about what the future holds for her. She feels overwhelmed at the responsibility of caring for her sisters, especially since her sister N.W. has begun to have health problems as well. She wants to quit smoking and spend some time at the gym to get herself to a better state of health, but feels she has little time to focus on her own needs. She does use electronic cigarettes to reduce the health risk of her smoking, but admits she is still smoking about three packs per week, down from a pack a day.
Assessment of N.W., youngest sister, and occasional caregiver to C.H.
Sister N.W. is a 52 year old Caucasian female who appears somewhat older than her years. She is at least 50 lbs. overweight, smokes at least a pack a day, and has been diagnosed with COPD and more recently sleep apnea. Her respiratory problems are attributed to her heavy smoking, and she recently had an occurrence of acalculia believed to be brought about in her case by lack of oxygen to the brain, possibly as a result of persistent respiratory interruption while sleeping. She suffers from shortness of breath upon exertion, and has a history of gastrointestinal problems as a result of overeating and very poor dietary habits. She is a sedentary person and although she keeps busy with her work, the physical activity required for her job is minimal. From my initial assessment, I concluded that most of N.W’s health issues could be managed by lifestyle alterations, and she is aware of this fact. She is a very pleasant, good natured woman, and despite her health issues, works a lot of overtime hours at her job, which she enjoys. When I began my clinical study with this family, she had just had an MRI of the brain the day before due to symptoms of acalculia, which her Dr. believed could possibly have been caused by a stroke or TIA, or other damage to the brain resulting from oxygen deprivation. The MRI came back normal, and the physician ordered speech and occupational therapy, and a sleep study to determine the extent of her sleep apnea. She tends to be very private about her personal health issues, and even her sister was not aware of her symptoms until she called from the diagnostic center for a ride home. The two sisters live in the same house, but only see each other twice a week on average, and are frustrated with each other at times due to the responsibilities of caring for their disabled sister, and issues surrounding the upkeep of the house and the shopping, cooking and cleaning. D.H.C. feels that the bulk of the work falls on her, and she and N.W. have very different values when it comes to housework. D.H.C. is a stickler for order and cleanliness, and N.W. is much more laid-back in her attitude toward all things domestic. The friction results in lack of communication, and the problems are not being dealt with in a constructive manner. Although no tendencies toward neglect or abuse are in any way evident, as informal caregivers, they feel exhausted at times, and as they are faced with the realities of caring for their disabled sister for life, their stamina is dwindling, and they admit to feeling resentful at times.
#1 Nursing diagnosis
The first nursing diagnosis for the family is; Nutrition, Altered: Imbalance more than body requirement related to tendency for poor dietary habits. Healthy People 2020 Leading Health Indicator related to this nursing diagnosis is Nutrition, Physical Activity, and Obesity (Healthy People 2020: LHI, 2014). The nursing intervention most appropriate according to Healthy People 2020 objectives includes providing education about following the dietary suggestions outlined by the healthful eating food pyramid, and limiting empty calorie foods that add sugar, salt, bad fats, and calories to the diet, but very little nutrition or eating satisfaction. To increase physical activity, the Mt. Scott Community Center approximately one mile from the family home offers activities and exercise programs, including a swimming pool for water aerobics, yoga and Zumba classes, and an indoor walking track. There are swimming programs for disabled individuals, as well as for those with no physical impairment, for people in all stages of physical condition. To learn how to follow proper dietary guidelines and to prepare healthful meals for the whole family, the sisters could participate in Cooking Matters, a course taught through the Oregon Food Bank Nutrition Education Program at Reynolds Middle School in a partnership with the Metropolitan Family Service (MFS) SUN Program. Classes are open to men and women, and are available in English and Spanish, with Spanish interpretation offered for this class (Anderson, 2014, para. 3-7). Since all of C.H.s food is to be entered into a daily log, and D.H.C.s Weight Watchers program calls for food tracking, N.W. will also keep a food journal, and the sisters will weigh in once a week to monitor their progress, and
#2 Nursing diagnosis The second nursing diagnosis for this family would be Ineffective health maintenance related to smoking behavior. The nursing intervention most appropriate according to Healthy People 2020 objectives would be to “draw attention to both individual and societal determinants that affect the public’s health and contribute to health disparities from infancy through old age, thereby highlighting strategic opportunities to promote health and improve quality of life for all Americans” (Healthy People 2020: LHI, 2014). Smoking and tobacco use is one of the United States deadliest and most costly public health challenges The interventions include education about the progression of chronic illness brought on by continued tobacco use, and the incidence of tobacco related morbidity and mortality. Another nursing intervention will be to also provide information on the Oregon Tobacco Quit Line, refer them to, and make introductions with the Tobacco Prevention and Education Program Staff. According to the “Oregon Health Authority: Public Health” (2014), “The Quit Line is open 24 hours a day, seven days a week, and is a telephone and web-based counseling service to help Oregonians quit using tobacco and nicotine products” (Oregon tobacco quit line). This service is sponsored by The Oregon Health Authority, and the participants in the program are given written information and website access to American Cancer Society and American Lung Association approved local programs such as those offered by The Oregon Research Institute. Many who call are eligible for nicotine patches or gum to get them started on their quit. The websites and phone lines available for those attempting to quit tobacco products provide access to helpful hints and suggestions to get them over the rough spots, and they can talk one-to-one to a smoking cessation counselor at any time who know what they are going through and can ease the transition to non-smoking, and encourage a more healthful way of living. To evaluate the progress the sisters have made, the nurse will check with them weekly at first, and then monthly. Also a measurable outcome for N.W. would be improvement in her COPD status, and improved gas exchange reducing her risk for further damage due to lack of oxygen as evidenced by ease of breathing upon exertion, improvement in restful sleeping, and no further deterioration of brain function.#3 Nursing diagnosis The third nursing diagnosis is readiness for enhanced family coping, related to the family members willingness to learn and adapt to more healthful lifestyle choices, and expressed desire by family members to make contact with others outside the family who are familiar with their circumstances and might help them to adjust, and encourage them to seek more positive supports for family coping skills (Ackley & Ladwig, 2014, p. 291). Healthy People 2020 objectives include addressing “Mental health disorders as a leading health indicator due to the serious impact on physical health and are associated with the prevalence, progression, and outcome of some of today’s most pressing chronic diseases, including diabetes, heart disease, and cancer” (Healthy People 2020: LHI, 2014). Nursing interventions are to discuss the options for enhanced coping, and assess the level of readiness, ability and willingness of the family to learn effective coping methods, and discuss goals for outcomes desired by the family. I will provide information on care for the caregivers programs, and counseling available to them through The Aging and People with Disabilities and Family Caregivers Programs sponsored by The Department of Human Services (Oregon.gov: Aging and people with disabilities, 2012), and within our own organization through our counseling, support and Caregiver Respite programs ("Community Vision Incorporated", 2014). They will be provided a list of support groups and meeting times to network with other families living in similar circumstances, to alleviate their feelings of isolation, and to share experiences and to get new ideas and information about activities and resources others in similar circumstances have used successfully. To evaluate the outcome of this intervention the nurse will accompany the family to the first support group meeting and assess their level of comfort and assimilation, and personally refer the family to our Family Partnership Program ("Community Vision Incorporated", 2014), and facilitate their entry into that program. The nurse will do progress checks through the CVI caregiver and facilitator staff, and directly from the family members with quarterly visits after the initial implementation period for both objective and subjective signs of improvement in family coping capabilities.Legal implications of interventionThere are no legal issues pending or foreseeable disputes within this family. No one is challenging the handling of C.H., her finances, or her property. The county Developmentally Disabled Services case manager for C.H. meets with the family and the Executive Director of our organization at least once a year to discuss her individual service plan, and to agree upon the plan and the goals for the upcoming year. The only other family member is a brother who is only minimally involved with the family, and wants no part of any legal obligations or dealings of any kind. His wishes are in C.H.’s EMR, signed and notarized. All treatments and medications are ordered by her primary care physician, and absolutely nothing is done by her caregivers without Dr.’s orders, or authorization by her case manager who protects C.H.’s rights, even when they run counter to the family’s ideas. My assessment of the family’s values This family is a wonderful supportive family, and their main objective is to take care of C.H., and to live as well as possible. There are some obvious gaps in their self-care management but their disabled sister is in perfect health despite her disabled condition. The home is clean and in good condition, and their brother does come and do some of the work in the yards and on the outside of the house. The problems that this family has can be managed with behavior modification, and through utilizing the health management objectives outlined in Healthy People 2020, in addition to regular primary medical attention. The resources recommended and made available through their community, public health providers, and with our organizations’ support, we can restore them to a better and more healthful quality of life. What remains to be seen is the extent of their willingness and tenacity to make these positive changes into a way of life. As is often the case in family caregiver living circumstances, they have put their own needs last after their obligations to their disabled loved one. I emphasized with them the importance of taking good care of themselves, or eventually, they will have nothing left to give her. Watson’s Theory of CaringJean Watson’s theory of human caring is a method of combining the healing science of nursing with the caring art. A “caring moment” is described as a transpersonal interaction between nurse and patient, when the nurse looks beyond the physical to the spirit/soul of the inner being. In these types of “caring occasions” the nurse and patient make a human-to-human connection (Watson, 2011, p. 87). The goal is to encourage faith and hope, and to restore harmony within the mind/body/spirit, self-knowledge, self-healing and self-care. Relating Jean Watson’s carative theory to my interactions with this family allows the cultivation of sensitivity to myself, and therefore to all of them. The human factor is the main focus in not only my nurse-patient, relationships, but in all situations such as this which call for the instillation of faith and hope. Dr. Watson advocated for the therapeutic value of making a connection with the client, and validating their concerns and make teaching more of a mutual growth experience. (Watson, 2011 p. 43) In my practice, I find her philosophy useful because I am often the first and sometimes only person who brings my own humanity into the equation, and speaks to the person, not just the patient with the illness. I made a real connection with this family, and they responded to my intervention with gratitude and enthusiasm.Interview questions:1) How did your family handle C.H.’s disability when she was a child?2) How well adjusted is she now?3) How is her mental and physical health? Yours and your sister’s?4) Do you get regular primary medical care?5) What do you think are your family’s main issues; physical, emotional, financial?6) In which areas do you think your family needs the most help? 7) Is there anyone you can turn to for help and support?8) How are the responsibilities of C.H.’s care divided?9) What happens in your home on an average day?10) What sacrifices do you feel you’ve had to make in order to care for your sister?11) What are your goals for yourself and this family12) What assistance can I provide for your family that you see as most beneficial?Smoking cessation information and supportAmerican Lung Association7420 SW Bridgeport Rd, #200, Portland, OR 97224 * Cross Streets: Between SW Upper Boones Ferry Rd/SW Rivendell Dr and SW Hazelfern Rd(866) 661-5864lungoregon.orgAmerican Heart Association4380 SW Macadam Ave, #480, Portland, OR 97239 * Cross Streets: Between SW Hamilton Ct and SW Moody Ave * Neighborhoods: Corbett, Southwest(503) 233-0100americanheart.orgAmerican Cancer Society0330 SW Curry St, Portland, OR 97239 * Neighborhoods: Corbett, Southwest(503) 295-6422cancer.org Oregon Quit Smoking Hotline and Free Phone CounselingQuitline Phone Number: 1(800) QUIT-NOW (+1-8007848669)Related Products: Nicotine patch, nicotine gum free for those who qualify Articles and information for encouragement of smoking cessation:“The Quit Smoking Blog—When you’re ready…this blog is about helping you stop smoking. That's it”. Ciggyfree.com http://www.ciggyfree.com/cigblog Caregiver support group meeting locations call for schedule informationPatty Brost Legacy Mount Hood Medical Center
24800 S.E. Stark
Gresham OR 97030
503-413-7348
Pbrost0212@yahoo.com Alisha Van Lom
Mt. Hood Adult Day Center
376 NE 219th Ave
Gresham, OR 97030
503-512-7373
alisha@mthoodadultdaycenter.commounthoodadultdaycenter.comKaren Wilson, RN, MA
Memory Health Center at Summit Research
2701 NW Vaughn St., Ste 350
Portland, OR 97210
503-972-9821
kwilson@summitnetwork.comChristen Moore
Legacy Health System
1040 NW 22nd Ave
Portland, OR 97210
503-413-7841
chmoore@lhs.orgHealthful cooking and eating education classesOregon Food Bank Nutrition Education Program at Reynolds Middle School in a partnership with the Metropolitan Family Service (MFS) SUN Program. Planning and cooking healthful meals.Reynolds Middle School 1200 Ne 201st Ave Fairview, Oregon 97024 Phone Number: 503-665-8166ReferencesAckley, B.J., & Ladwig, G.B. (2014) Nursing diagnosis handbook: An evidence based guide to planning care (10th ed.). St. Louis, MO: Mosby Elsvier.Anderson, L.K. (2014, May 30). Cooking Matters at Reynolds Middle School. Outlook. Retrieved from http://www.pamplinmedia.com/go/42-news/222642-83873 -cooking-matters-at-reynolds-middle Community Vision Incorporated. (2014). Retrieved from http://cvision.org/our-programs/family-partnership-program/ Healthy people 2020: LHI (2014). Retrieved from http://www.healthypeople.gov/2020/LHI/injuryViolence.aspxOregon.gov; Aging and people with disabilities: Family caregiver programs (2012) http://www.oregon.gov/dhs/spwpd/pages/sua/fmly-crgvr-prgms.aspx Oregon Health Authority: Public health (2014) Oregon tobacco quit line. http://public.health.oregon.gov/PreventionWellness/TobaccoPrevention /GetHelpQuitting/Pages/oregonquitline.aspx Today's caregiver: Caregiver.com. (2014). Retrieved from http://www.caregiver.com/regionalresources/states/OR/support/multnomah.htm Watson, J., (2011). Human Caring Science: A Theory of Nursing (2nd ed.). Retrieved from University of Phoenix eBook Collection database. FEEDBACK Overall Impression | Your submission was interesting and informative. I want to encourage you to continue to improve your writing and critical thinking skills as you undertake the weekly assignments. | Corrective Feedback | See comments in paper. Advocacy? How do your values differ from the family’s? Would like to have seen more discussion on the role of community / public health nursing in this community. | Informative Feedback | Good assessment data on the family. Good job! | | |