Family Health Nursing

 Introduction

Family

The family is the unit of services in all community health nursing. Family is a basic and vital unit of all society. A family consists of people who are related by blood or adaptation or marriage and are dependent upon one another for survival. It is a primary unit in all societies. It is a group of biologically related individuals living together and eating from a common kitchen. The family is also an epidemiological unit for providing social services as well as comprehensive medical care. The family therefore has engaged the attention of sociologists, demographers, epidemiologists, medical scientists and all those who are concerned with family and family welfare.

Concept

Family is the basic social and productive unit of the community. Nepalese family is strongly family centered. Its traditional norms and values are changing gradually due to rapid urbanization and industrialization. Due to this, new health problems are arising in the community day by day e.g. drug abuse, HIV/AIDS, cancer and other problems of elderly etc.

The global aim is to achieve ‘’ Health for all by the year 2000 AD’’ it would be appropriate to start a family centered care. Except for acute diseases critical illnesses and mental diseases with bizarre behaviour, rest of all convalescence and chronic diseases can be cared for at home under the supervision of medical care providers.

Biological concept: based on the biological functions of the family.

Psychological concept: concerned with family relationship and prevention of mental illness..

Ecological concept: concerned with how the family works together to meet their material needs.

Sociological concept: looks at how the family as a group functions socially using the group process and dynamics. 

System theory: more applicable for community health nurse coz of the focus on internal and external relationship and dynamics.

Definition
“Family is a group of two or more persons related by birth, marriage or adoption and residing together in a household”. US Bureau of census (1980)

“Family is represented by two or more individuals, belongings to the same or different kinship groups, who are involved in a continuous living arrangement, usually residing in the same household, experiencing common, emotional bonds and sharing certain obligations towards each other and towards others”.  (Stanhope, Lancaster 1992)

Types

1. Nuclear family: husband, wife,  one or more children. For children, family of origin and for the parents  family of procreation.
2. Joint extended/extended family: members of the nuclear family and other relatives’ aunts, uncles, grandparents and cousins.
3. Blended families: formed when parents bring unrelated children from prior marriages into a new, joint living situation because of remarriage or cohabitation.
4. Single parent families: are formed when one parents leaves the nuclear family because of divorce, disruptions or death. The circumstances of the separation influence its impact on the family.

Role and functions of the family

Role of family in health and disease

1.Child rearing

• It differ from society to society,  time to time but it is important to note the pattern of child care (feeding nutrition, hygiene, sleep, clothing, habit training etc.) which is passing from one generation to another and also it is socially determined.

2.  Socialization

• It includes teaching the young about the values of the society and transmitting information regarding culture, belief, norms, values attitudes, behaviour etc. It is important for every individual from young to introduce the society and also individuals develop qualities essential for functional affectivity in the society.
• In some societies the young are given freedom to develop into individuals to take initiative.

3. Personality formation

• Every individual has own coping strategies or capacity to withstand stress and strain which may learn from interaction with other people.
• Capacities of an individual to withstand stress and strain are determined by the early experiences in the family. So family act as a protective barrier to filter off ill influences.

4. Care of dependent adults

Care of sick and injured

Care of women during pregnancy and childhood

• Recognition of pregnancy, antenatal care; diet and nutrition supplement and decrease workload including financial help.
• Family should provide care to the postnatal mother- support breast feeding, care of baby, provide nutrition and diet, provide adequate rest etc.

Care of the aged

• Biological aging (changes in structure and functions of the body; physiological aging (individual and behavioral changes) emotional aging (changes in one’s attitude and lifestyle dependent on one’s self-perception of being old)
• Functional aging , unable to maintain their functions in society.
• Changes are not harmful but bodily function is gradually being decline so elderly care has been the responsibilities of family’s members for adjustment of their life because families are resilient and resourceful groups that connect us to the past and to the future in personality meaningful ways.
• The importance of family rises with advance age as elderly need more support and help in their later life.
• During chronic illness or crisis, the demand may even exceed in everyday life of old people.
• Family provides care to elderly people to promote physical and emotional support and also they should be properly supported with a good care, bathing, dressing, giving medication and feeding them appropriate diet etc.

Care of the handicapped

• Impairment restricts or limits normal functioning. Physical or mental condition that limits a person’s movements, senses or activities.
• Life with handicapped is not always easy so supports is needed from family because one of the most important factors in an recovery after a handicapped, injury, illness is involvement and support of family.
• Usually family as a caregiver, plays a vital part in healing process for a like positive attitudes and reinforcement from family members can inspire commitment to recovery and help them adapt to new physical challenges or limitations.
• Family support and encouragement help to deal with issues of self-esteem related to their condition because family members know the individual best they can assist and determining ways to motivate the disabled individual.
• Family members support the individual in following ways; making safety and independence home environment, helping personal care- grooming, personal hygiene, dressing etc., enhanced social activity and companionship while doing light household tasks.

5. Stabilization of adult personality

• The family should act as a shock absorber to cope stressful situation and strain of life. The stress could be injury, illness, birth, death, tension, worry, anxiety etc.
• The family should provide opportunity to release tension to the individual and provide mental equilibrium for the prevention from stress disease like peptic ulcer, colitis, high B.P etc.
• Function in stabilization of personality of both adults and children in meeting their emotional needs.

6. Familial susceptibility to disease

• The members of family share a pool of genes, common environment and decide their susceptibility of disease.
• Certain diseases such as hemophilia, color blindness, diabetes mellitus, mental illness including communicable disease (TB, measles etc.) known to run through family. So it is important for early screening to maintain deteoriation of health of every individual.

Functions of family

All families have certain functions that are performed to maintain the integrity of the family unit and to meet the family unit needs, the individual family member needs, and society’s expectations.

Duvall and Miller identified six family functions that are generally applicable to all types of family structures.

1. Generating affection: – between spouses, between parents and children and among member of generations. 
2. Providing personal security and acceptance: -The family provides a home base with the stability that allows the family members to develop naturally in their own way and their own pace.
3. Giving satisfaction and sense of purpose: – In the family setting the family members enjoy life with each other through satisfying activities.
4. Ensuring continuity of companionship-In most cases family associations that provide that provide sympathetic companionship and encouragement can be expected to endure.
5. Providing social placement and socialization: -The family serves as the transmitter of culture from one generation to the next and prepares family members for their place in social hierarchy.
6. Imposing control and sense of what is right: Within the family, members first learn the rules, rights, obligations and responsibilities and characteristics of human society.

The health related functions and task of the family are;

• Provision of adequate food, shelter and clothing
• Maintenance of health supporting physical and psychosocial home environment
• Provision of resources for maintenance of person hygiene
• Provision for meeting spiritual needs
• Health education, health promotion
• Health and illness decision making
• Recognition of health disruption
• Seeking health care, illness care and dental care
• First aid and management
• Supervision of medications
• Illness care, Rehabilitation care
• Involvement with community’s health

Concept of Family-Centered Care

Family-Centered Care (FCC) involves collaboration between healthcare professionals, patients, and their families. It recognizes the pivotal role families play in supporting the patient’s health and well-being and integrates them into the care process. Core principles include:

• Respect for family roles and perspectives.
• Collaboration in care decisions and planning.
• Information sharing to ensure informed decisions.
• Support for family needs and preferences.

Family-centered care

Family-centered care is an approach to the planning, delivery and evaluation of health care that is governed by mutual beneficial partnerships between health care providers, patients and families.

In our societies; the family interface between societal and individual health. The economic interface between the family and society determines what resources are available for a family’s health. For example, in some families the father is the primary income earner, in such families, members may have adequate financial resources for healthful living because of the father’s stable employment.

In healthy communities, many families will benefit from resources available in the community. Further, it is in families that individuals learn about and are exposed to, behaviours and patterns of living that may be key to their own health. Such learned patterns may include diet, exercise patterns, orientation to social support, religious practices, substance use or abuse, and domestic violence. And it is in families that individuals share a genetic makeup that may influence their individual and collective health-related decisions such as those related to genetic screening

Benefits of family-centered care 

• Promotes the overall health and well-being of children and families.
• Empowers families with knowledge to make informed choices.
• Recognizes and strengthens the unique abilities of families.
• Delivers personalized care tailored to individual family needs.

Definition of Family health

Family Health is described as a state of positive interaction between members which enables each member of the family to enjoy optimum physical, mental social and spiritual wellbeing not just the absence of disease or deformity, when there is healthy interaction among family members, society gets healthy individuals. Healthy members in a society are a good sign of national prosperity.

Definition of Family Health Nursing

Family health nursing is a care /service provided to the family members for the prevention, promotion and maintenance of physical, mental, spiritual, and social health for the family unit and the individual family members irrespective of age and sex. 

Freeman’s typology of health problems

Family health problems, according to Freeman’s have been classified in;

Health threats: are the condition, factor and or actions that may bring the family’s health at risk if not corrected on time. Because of these actions/conditions or agent, one or more than two family members or sometimes the whole family may be affected.  Health threats may be due to family physical or social environment, health beliefs and family traditional and cultural practices, e.g. poor ventilation, drinking unsafe water, knowledge deficit etc. It may advance to the condition of health deficit if not corrected on time.

Examples for health threats are the following;

1. Family history of heredity disease e.g. diabetes
2. Threat of cross infection from communicable disease case
3. Family size beyond what family resources can adequately provide
4. Accident hazards e.g. broken stairs, pointed sharp objects, poisons medicines improperly kept, fire hazard, fall hazard
5. Nutritional (inadequate, excessive, faulty eating habit)
6. Stress provoking factors (unhappy marital relationship, unhappy parents sibling relationship.
7. Poor environment sanitation
8. Personal habits/practices

Health deficit: certain conditions may lead to failure in health maintenance or deviation from the normal functioning of the family development and health tasks or those conditions that may lead to failure in health maintenance.

These include;

1. Illness states, regardless of whether it is diagnosed or undiagnosed by medical practitioner.
2. Failure to thrive/develop according to normal rate.

It may result suddenly or by series of warning. Person or the family needs help in order to bring this deficit back to normal.

Crisis situation: Crisis is a stressful situation and disruptive event that comes with or without warning and disturbs the equilibrium of the family. It is an unexpected event happening to an individual may lead to problem in adjustment or it also occur when usual problem solving methods fail, e.g. hospitalization of a family member, death of the family member, diagnosed with serious illness, loss of job, retirement, loss of home or property from natural disaster. Also includes marriage, pregnancy, labour, parenthood and others.     

  People respond to crisis differently, some approaches them as challenges; other are overwhelmed and feel defeated or give up. Some seek help if needed and come through the experience and perhaps even stronger than before while others who are unable to cope with it, may suffer severe psychological damage. Regardless of their response, families in crisis need help and community health nurse have a unique opportunity and responsibility to provide that help in a broad variety of situation.               

Family crisis are of three different types:

a. Developmental crises: periods of disruptions that occur at transition points during normal growth and development, e.g. marriage, child bearing and rearing, retirement etc.

b. Situational crises: stressful disruptions event arising from an external event that occurs suddenly often without any warning, e.g. accidents, divorce, natural disaster etc.

c. Multiple crises: different types of crises can overlap, e.g., a woman give birth to a baby with congenital malformation, illegitimacy (giving birth before marriage) etc.

Note: A crisis is not an event itself but rather a person’s perception of the event.

Nurse and Family contact

Introduction

It is defined as the meeting of nurse and family with its members with an aim to identify and solve and their health problems.

The nurse family contact is made for the preventive, promotion, curative and rehabilitative health services of the family.

Types of nurse family contact

1. Home visit
2. Clinic visit
3. Group conference
4. Written communication
5. Industrial visit
6. School visit

1. Home visit

Home visits are a crucial component of public health services, offering a direct and effective approach to family-centered care. This practice involves meeting individuals and families at their homes to address their specific health needs and concerns. By bringing essential services directly to people’s doorsteps, home visits play a vital role in improving accessibility, promoting health, and fostering a deeper connection between healthcare providers and the community.

Purpose

• To identify the needs of individuals, families, and communities.
• To investigate sources of infections or diseases.
• To provide health education based on the needs of individuals, families, and communities, such as personal hygiene, environmental sanitation, and nutrition.
• To motivate couples to adopt family planning methods.
• To follow up on the health of mothers, children, or adults after visits to health centers, maternity and child welfare clinics, or hospitals.
• To encourage early detection and management of chronic conditions such as diabetes, hypertension, and respiratory diseases.
• To build trust and strengthen the relationship between healthcare providers and the community to improve healthcare access.
• To advocate for the importance of mental health and provide emotional support when needed.
• To identify and utilize available community resources effectively to support individuals and families.
• To provide basic nursing care in the home to address immediate health needs.
• To do follow up on previous activities to evaluate progress and ensure that the set objectives are met.
• To refer cases requiring specialized care to appropriate healthcare facilities or agencies.

Principles

1. Home visit should be planned with purpose and should be beneficial to clients.
2. The purpose should be clear and must meet the needs of the clients.
3. It should be regular and flexible according to the needs of the clients.
4. Self introduction, introduction to the agency and purpose of the visit should be clearly stated at the time of visit.
5. The nurse should be flexible and most respect the client’s right to accept or reject care and to participate in goal setting and goal achievement.
6. Proper health message should be communicated to the clients in every contact.
7. The nurse should use technical skill and nursing procedures.
8. The nurse should make attempt to include each family member while using nursing process.
9. The nurse should develop positive interpersonal relationship with families to achieve the goal.
10. Evaluate periodically the work performance and health education provided.
11. Home visit should be recorded in the diary and family folder.

2. Clinic visit

A clinic visit offers several advantages for both the nurse and the community. It allows the nurse to attend to multiple individuals in a short period, maximizing the reach of healthcare services. Beyond addressing the needs of a single family, the clinic provides an opportunity to educate and support a broader segment of the community. Additionally, the availability of medical equipment and supplies ensures comprehensive assessment and treatment of patients, enabling efficient and effective care delivery.

Purpose

• To identify and address the health problems of clients in a clinical setting.
• To provide symptomatic treatment and nursing care for both major and minor illnesses.
• To maintain and promote the overall health and well-being of individuals and the community.
• To offer health education tailored to the specific needs of the people.
• To deliver routine health services such as immunizations, weight monitoring for children, antenatal checkups, family planning, and care for minor illnesses.
• To ensure efficient healthcare delivery by providing maximum health services with minimal effort.
• To refer complicated cases to higher-level and better-equipped healthcare facilities.
• To facilitate early detection and management of chronic diseases.
• To promote preventive health practices and offer counseling for healthier lifestyles.

Principles

1. Gather all relevant information to accurately identify problems and set priorities.
2. Provide healthcare services without discrimination based on age, sex, income, religion, or other factors.
3. Respect the client’s feelings, attitudes, culture, customs, values, and beliefs.
4. Ensure the use of safe technical skills and evidence-based scientific procedures.
5. Offer appropriate health education and guidance tailored to the client’s needs.
6. Maintain accurate and thorough records of relevant facts and information.
7. Refer complex or critical cases to appropriate higher-level healthcare facilities or agencies.

3. Group conference or Family discussion

A group conference, or family discussion, typically includes all family members and can take place in various settings such as the home, clinic, school, or workplace. This approach is particularly effective when addressing chronic problems that negatively impact the entire family, fostering a collaborative environment for problem-solving and support.

Purpose

• To identify the challenges or problems faced by a family or group.
• To encourage all family members to agree on solutions and collaborate during the implementation of the plan.
• To foster a sense of unity and cooperation among family members or group participants.
• To provide health education or counseling tailored to the needs of the family or group.

Principles

1. All relevant information should be gathered to identify the problems and set priorities.
2. Consider families’ or groups’ feelings, attitudes, culture, customs, values, and practices.
3. Provide health education and counseling without any bias.
4. Make regular follow-up visits to evaluate the effectiveness of the group conference.
5. Be aware of the locally available community resources and use them wisely and appropriately.

4. Written communication

Written communication is useful for minor problems that do not need any direct attention from a nurse. Written communication can be followed when a record of communication is necessary.

For example, written communication would be:
“Your son, Ram, has completed 9 months. He needs to take the measles vaccine. Monday is the immunization day at the health post. Please bring your son to the immunization clinic for vaccination on Monday between 10 AM and 2 PM.”

Purpose

• To instruct people to seek health care services.
• To reinforce the clients to follow instructions regarding health care and practices such as, when and how much medicine to take.
• To inform the family about the condition of the client.
• To delivery the information on mass campaigns or awareness programmes.
• To enable the client of memorize the instructions for  longer period of time.

Principles

1. Check if someone in the family can read before giving written instructions.
2. Use pictures along with written instructions to make communication easier and more effective.
3. Giving written instructions helps family members follow them correctly.
4. Use simple words so the family can easily understand the message.
5. Ensure the family fully understands the written instructions.
6. Include all important details and clearly explain what to do.

5. School visit

School visits are conducted to assess the health of students, teachers, staff, and their families within the school environment. Regular visits help monitor and promote healthy attitudes, behaviors, and practices among students. Child-to-child school health programs can effectively deliver health education and influence the attitudes, knowledge, and behaviors of families and the community through students. For example, a measles outbreak in a school could spread to families through children attending the school if not addressed.

Purpose

• To assess the health and identify health problems of school children.
• To assess the safety measures and spread of infection in the school area.
• To provide basic health services to the school children, teachers, and other staff.
• To provide health education and counseling.
• To conduct child-to-child school health programs.
• To communicate health messages and information to the family and the community through school children.
• To bring about positive changes in the knowledge, attitudes, and practices of school children regarding their health.
• To provide information and care at school that can also be applied at home.
• To make regular follow-up visits to evaluate the effectiveness of the program.
• To refer cases appropriately.

Principles

1. The visit should be planned with a purpose and should be beneficial to clients.
2. The purpose should be clear and must meet the needs of the client.
3. All relevant information should be gathered to identify problems and set priorities.
4. Health education should be provided based on the needs and the level of knowledge of the children.
5. The nurse should establish good interpersonal relationships with the children to achieve the goal.
6. Record relevant facts and information appropriately.

6. Industrial visit

An industrial visit is conducted to assess safety measures and evaluate the spread of infectious or communicable diseases within the industrial area. The primary objective is to prevent workplace accidents and the transmission of diseases, as these can significantly impact the daily lives and well-being of employees and their families.

During the visit, nurses play a crucial role by providing health education on safety protocols, monitoring the health status of workers, offering basic healthcare services, and ensuring appropriate referrals for specialized care when necessary. Additionally, nurses assist in the rehabilitation process to help affected individuals regain their health and productivity. These efforts collectively contribute to creating a safer and healthier industrial environment.

Purpose

• To assess the health status of workers and identify any existing or potential health problems.
• To evaluate workplace safety measures and monitor the spread of infections within the working environment.
• To promote occupational health and create awareness of its importance among workers.
• To provide basic healthcare services to address immediate health concerns.
• To deliver tailored health education and counseling based on the specific needs of workers.
• To ensure appropriate referrals for cases requiring specialized medical attention.
• To conduct regular follow-ups to monitor and encourage positive health changes among workers.

Principles

1. Plan the visit with a clear purpose that addresses the specific needs of the clients.
2. Utilize safe technical skills and follow proper nursing procedures while providing care.
3. Gather complete and accurate information to identify the health problems effectively.
4. Ensure thorough preparation before the visit, including essential items like a first aid kit.
5. Possess adequate knowledge and skills in infection prevention and injury management.
6. Provide health education and counseling tailored to the individual needs of the clients.
7. Maintain proper documentation and recording of observations and interventions during the visit.
8. Conduct regular follow-ups and evaluate the outcomes of the visit to ensure effectiveness.

Nursing process in relation to Family Health Care

The nursing process is defined as “a systematic scientific clinical judgment focusing on identifying and treating responses of individuals or groups to actual or potential alterations in health” (NANDA).

In the context of family health care, this systematic approach is utilized to assess, plan, implement, and evaluate nursing interventions aimed at promoting the health and well-being of families as a unit. It involves addressing health issues that affect individual family members while considering the interconnected dynamics of the family.

Phase of nursing process

The nursing process consist of 5 sequential and interrelated phase.

1. Assessment phase
2. Diagnosis phase
3. Planning phase
4. Implementation phase
5. Evaluation phase

Assessment in Family Health Care

Definition
Nursing assessment is a set of actions by which the nurse measures the status of her client against personal and social norms of health, system integrity, and the ability to resolve system problems.

The foundation of assessment lies in comparison, measurement, or judgment of the client’s current condition against a standard or norm. These standards or norms are derived from values, beliefs, principles, rules, or expectations that guide health outcomes.

When assessing the family as a client or patient, the standards or norms used to evaluate the family’s status can be categorized into the following three types:

1. Normal health of individual members

• Physical, social, and emotional well-being of each family member.
• Identifying individual health conditions that impact the family unit.

2. Home and environmental conditions conducive to health development

• Type and quality of housing: Safety, hygiene, and adequacy of living conditions.
• Adequacy of living space: Space available for all family members to live comfortably.
• Adequacy of facilities: Availability of basic amenities, both in the home and community, such as water, sanitation, and healthcare access.
• Kind of neighborhood: Supportive or detrimental environmental factors within the community.
• Environmental sanitation: Hygiene and cleanliness of the surroundings to prevent health risks.

3. Socio-cultural norms and expectations

• Values and beliefs: Family norms that influence health behaviors.
• Modes of life: Practices and lifestyles that promote health or contribute to illness tendencies.

This comprehensive assessment helps the nurse identify the health status, potential risks, and resource gaps affecting the family as a unit and provides the foundation for planning appropriate nursing interventions.

Assessment consists of 3 separate activities.

a) Data collection

Data are facts or realities either expressed by the client or patient him/ herself or collected by the health personnel by using systematic method. It is very important part of the nursing process. The collected data should be complete, accurate and comprehensive so that an appropriate nursing care plan can be developed. The systematic approach in gathering data that is best to follow step by step.

Data can be collected by two ways

• Subjective data – information given by patient
• Objective data- observation, records, interview

Types of data needed

• Family structure and characteristics
• Socio-economic & cultural factors
• Environmental factors
• Health and medical history of family members

1. Family structure and characteristics

It include members of the household and their relationship to the family’s needs, demographic data such as age, sex, social status, and position in the family, place of residence (whether living with the family or elsewhere), type of family structure (matriarchal, patriarchal, nuclear, or extended), dominant family members in decision-making, especially regarding healthcare, general family relationships with any observable conflicts, and activities of daily living (sleeping patterns, eating habits, and leisure time activities).

2. Socio-economic and cultural factors

Socio-economic and cultural factors include income, expenses, educational status, ethnic background, and religious affiliation. These factors influence the family’s living conditions, lifestyle choices, and access to resources.

3. Environmental factors

Environmental factors include housing conditions such as living space, sleeping arrangements, food storage, cooking facilities, refuse disposal, water supply, and locality; availability of social services and health facilities; and accessibility of communication and transportation facilities.

4. Health and medical history

Health and medical history includes the medical history of each family member, past significant illnesses, current illness stages (diagnosed or undiagnosed), and health actions taken. It also considers the value placed on disease prevention, immunization status of children, utilization of other preventive services, and sources of medical care. Additionally, it includes the perception of health professionals and their services, expectations from community health nurses, and past experiences with healthcare professionals.

Methods of gathering data

Direct observation is a method of data collection through the uses of all sensory capacities (sight, hearing, smell, touch, and taste). Through direct observation, the nurse gathers information about the family’s status and behavioral responses, including the physical makeup of each member, communication and language patterns, role perception and task assumptions, decision-making patterns, and conditions in the home and environment.

Another method of data collection is the interview, which involves gathering information through direct verbal interaction.

Analysis of data and identification of family health problem

The nurse organizes and categorizes the collected data into patterns that help explain the family’s health status and the underlying causes or contributing factors. By analyzing the implications of these data and their interrelationships, the nurse assesses their impact on individual family members and overall family development. Through logical reasoning based on evidence, the nurse identifies and formulates conclusions, which are then stated as family nursing problems.

A health problem is defined as a situation or condition which interferes with the promotion and or maintenance of health and recovery from illness and injury.

A health problem becomes a nursing problem when it can be modified through nursing intervention.

The typology of nursing problem in family health care

First level Assessment

The process of determining existing and potential health conditions or problems of the family. These health conditions are categorized as:

I. Presence of wellness condition

Stated as “Potential” or “Readiness”; a clinical or nursing judgment about a client in transition from a specific level of wellness or capability to a higher level. Wellness potential is a nursing judgment on wellness state or condition based on client’s performance, current competencies, or performance, clinical data or explicit expression of desire to achieve a higher level of state or function in a specific area on health promotion and maintenance

Examples of this are the following

A. Potential for enhanced capability for:

• Healthy lifestyle-e.g. nutrition/diet, exercise/activity
• Healthy maintenance/health management
• Parenting
• Breastfeeding
• Spiritual well-being-process of client’s developing/unfolding of mystery through harmonious interconnectedness that comes from inner strength/sacred source/God
• Others. specify.

B. Readiness for enhanced capability for:

• Same categories as above

II. Presence of Health threats

Are conditions that are conducive to disease and accident, or may result to failure to maintain wellness or realize health potential. Examples are the following:

A. Presence of risk factors of specific diseases (e.g. lifestyle diseases, metabolic syndrome, smoking)

B. Threat of cross infection from communicable disease case

C. Family size beyond what family resources can adequately provide

D. Accident hazards specify.

• Broken chairs
• Pointed /sharp objects, poisons and medicines improperly kept
• Fire hazards
• Fall hazards
• Others specify.

E. Faulty/unhealthful nutritional/eating habits or  feeding techniques/practices. Specify inadequate food intake both in quality and quantity

• Excessive intake of certain nutrients
• Faulty eating habits
• Ineffective breastfeeding
• Faulty feeding techniques

F. Stress provoking factors. specify.

• Strained marital relationship
• Strained parent-sibling relationship
• Interpersonal conflicts between family members
• Care-giving burden

G. Poor home/environmental condition/Sanitation. specify.

• Inadequate living space
• Lack of food storage facilities
• Polluted water supply
• Presence of breeding or resting sights of vectors of diseases
• Improper garbage/refuse disposal
• Unsanitary waste disposal
• Improper drainage system
• Poor lightning and ventilation
• Noise pollution
• Air pollution

H. Unsanitary food handling and preparation

I. Unhealthy lifestyle and personal habits/practices. specify.

• Alcohol drinking
• Cigarette/tobacco smoking
• Walking barefooted or inadequate footwear
• Eating raw meat or fish
• Poor personal hygiene
• Self-medication/substance abuse
• Sexual promiscuity
• Engaging in dangerous sports
• Inadequate rest or sleep
• Lack of /inadequate exercise/physical activity
• Lack of/relaxation activities
• Non-use of self-protection measures (e.g. non-use of bed nets in malaria and filariasis endemic areas).

J. Inherent personal characteristics

• e.g. poor impulse control

K. Health history, which may participate/induce the occurrence of health deficit

• e.g. previous history of difficult labor.

L. Inappropriate role assumption

• e.g. child assuming mother’s role, father not assuming his role.

M. Lack of immunization/inadequate immunization status especially of children

N. Family disunity

• Self-oriented behavior of member(s)
• Unresolved conflicts of member(s)
• Intolerable disagreement

O. Others. specify.

III. Presence of health deficits

These are instances of failure in health maintenance.

Examples include:

A. Illness states, regardless of whether it is diagnosed or undiagnosed by medical practitioner.

B. Failure to thrive/develop according to normal rate

C. Disability

Whether congenital or arising from illness; transient/temporary (e.g. aphasia or temporary paralysis after a CVA) or permanent (e.g. leg amputation, blindness from measles, lameness from polio)

IV. Presence of stress points/foreseeable crisis situations

Are anticipated periods of unusual demand on the individual or family in terms of adjustment/family resources. Examples of this include:

A. Marriage

B. Pregnancy, labor, puerperium

C. Parenthood

D. Additional member-e.g. newborn, lodger

E. Abortion

F. Entrance at school

G. Adolescence

H. Divorce or separation

I. Menopause

J. Loss of job

K. Hospitalization of a family member

L. Death of a member

M. Resettlement in a new community

N. Illegitimacy

O. Others, specify.

Second-level Assessment

Second level assessment identifies the nature or type of nursing problems the family experiences in the performance of their health tasks with respect to a certain health condition or health problem.

I. Inability to recognize the presence of the condition or problem due to:

A. Lack of or inadequate knowledge

B. Denial about its existence or severity as a result of fear of consequences of diagnosis of problem, specifically:

• Social-stigma, loss of respect of peer/significant others
• Economic/cost implications
• Physical consequences
• Emotional/psychological issues/concerns

C. Attitude/Philosophy in life, which hinders recognition/acceptance of a problem

D. Others specify.

II. Inability to make decisions with respect to taking appropriate health action due to:

A. Failure to comprehend the nature/magnitude of the problem/condition

B. Low salience of the problem/condition

C. Feeling of confusion, helplessness and/or resignation brought about by perceive magnitude/severity of the situation or problem, i.e. failure to break down problems into manageable units of attack.

D. Lack of/inadequate knowledge/insight as to alternative courses of action open to them

E. Inability to decide which action to take from among a list of alternatives

F. Conflicting opinions among family members/significant others regarding action to take.

G. Lack of/inadequate knowledge of community resources for care

H. Fear of consequences of action, specifically:

• Social consequences
• Economic consequences
• Physical consequences
• Emotional/psychological consequences

I. Negative attitude towards the health condition or problem-by negative attitude is meant one that interferes with rational decision-making.

J. In accessibility of appropriate resources for care, specifically:

• Physical inaccessibility
• Costs constraints or economic/financial inaccessibility

K. Lack of trust/confidence in the health personnel/agency

L. Misconceptions or erroneous information about proposed course(s) of action

M. Others specify.

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

A. Lack of/inadequate knowledge about the disease/health condition (nature, severity, complications, prognosis and management)

B. Lack of/inadequate knowledge about child development and care

C. Lack of/inadequate knowledge of the nature or extent of nursing care needed

D. Lack of the necessary facilities, equipment and supplies of care

E. Lack of/inadequate knowledge or skill in carrying out the necessary intervention or treatment/procedure of care (i.e. complex therapeutic regimen or healthy lifestyle program).

F. Inadequate family resources of care specifically:

• Absence of responsible member
• Financial constraints
• Limitation of luck/lack of physical resources

G. Significant persons unexpressed feelings (e.g. hostility/anger, guilt, fear/anxiety, despair, rejection) which his/her capacities to provide care.

Different between health problems and nursing problems
Health problem	Nursing problem
It is made by physician	It is a statement of nursing judgment
It deals with disease or medical conditions	It deals with human response to actual or potential health problems and life processes
It is a condition that interferes with the promotion or maintenance of health and recovery from illness and injury.	It is a condition which interferes with the promotion or maintenance of health and recovery of client.
It requires medical intervention	It does not always require medical intervention.
Focus is usually curative	Focus is usually preventive
e.g. pneumonia, diabetes mellitus, CVA etc.	e.g. ineffective airway clearance, disturbed body image, impaired urinary elimination etc.

Family nursing problems should be identified by using Freeman’s Typology

Nursing Diagnosis

Nursing diagnosis involves identifying the patient’s nursing problems, forming a critical link between the assessment and planning phases of the nursing process. It is the outcome of a thorough nursing assessment, and the effectiveness of interventions relies on the accuracy of the nursing diagnosis. Achieving accuracy requires a clear understanding of data collection and the ability to exercise judgment based on the obtained data.

The nursing diagnosis consists of two essential components:

1. The statement of the unhealthy response.
2. The statement of factors maintaining the undesirable response and preventing the desired change.

The specificity of the problem definition, determined by the depth and breadth of the assessment, enhances the utility of the nursing diagnosis in determining appropriate nursing interventions.

For instance, in a family with a prenatal patient who is also the primary breadwinner and is not receiving adequate care or supervision, the nursing problems may be identified as follows:

General nursing problem– Inability to utilize community resources for healthcare due to inadequate family resources (Financial, manpower, time).

Specific nursing diagnoses– A nursing diagnosis may be either actual or potential depending upon whether the problem is existing now or is likely to develop in near future.

• Risk for impaired maternal and fetal health related to lack of prenatal care and supervision.
• Risk for maternal injury or complications due to absence of regular prenatal care.
• Risk for impaired family functioning related to the dual role of the prenatal patient as both breadwinner and expectant mother.
• Anxiety related to financial instability and lack of social support for the prenatal patient.
• Risk for ineffective health maintenance due to the patient’s inability to prioritize self-care because of work responsibilities.

Ranking problems

After data analysis, the nurse may realize that the family faced with a number of health and nursing problems which cannot be taken up all at the same time considering the available resources of both the family and the nurse. Considering this situation, she can rank the identified problems into priorities.

Principles for ranking the problem

Give higher priority to common health problems over rare ones (e.g., diarrhea, malnutrition, jaundice).Give more priority to severe health problems over less serious ones (e.g., dehydration over cough, pneumonia over mild infections).Prioritize health problems that are more easily preventable over those that are difficult to prevent (e.g., cholera over genetic disorders).Give priority to health problems showing an upward trend over those that are static or declining (e.g., meningitis, encephalitis, or other emerging diseases).Consider the community’s priorities, preferences, and concerns when ranking health problems.

Establishing priorities

After data analysis the nurse may realize that the family is faced with the number of health and nursing problems which cannot be taken up all at the same time considering the available resources of both the family and the nurse. Considering this situation, she can rank the identified problems into priorities. It is called Scale for Ranking Family Health Problems according to Priorities.

There are four criteria for determining priorities among health problems.

1. Nature of problem presented– categorized into health threat, health deficit and foreseeable crisis  .
2. Modifiability of the problem- refers to the probability of success in minimizing, alleviating or totally eradicating the problem through nursing intervention
3. Preventive potential- refers to the nature and magnitude of future problems that can be minimized or totally prevented if interventions is done on the problems under consideration.
4. Salience– refers to the family’s perception and evaluation of the problem in terms of seriousness an urgency of attention needed.

Scale for ranking health conditions and problems according to priorities
Criteria	Score	Weight
Nature of the condition Wellness state Health threat Health deficit Foreseeable crisis	3    3   2  1	1
Modifiable of the conditions Easily modifiable Partially modifiable Not modifiable	2 1 0	2
Prevention potential High Moderate low	3 2 1	1
Salience A condition needing immediate attention A condition not needing immediate attention Not perceived as a condition needing change	2 1  0	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

……………………… X weight

Highest score

3. Sum up the scores for all the criteria. The highest score is 5, equivalent to the total weight

After scoring for each criterion, the number is divided by the highest possible score in the scale. The quotient is multiplied by the weight indicated for the criterion being considered.

Example for establishing priorities

During clinical practicum of community student went for home visit where one student identified high risk family by obtaining following data.

• The total number of family members is six, including parents and siblings.
• There are two children under five years old.
• One child, aged five, is suffering from skin itching.
• Another child, aged three, looks lean and thin with inappropriate height and weight.

The Assessment process

The available data gathered during the first-level assessment revealed the following problems:

Health deficits

• Scabies – A 5-year-old child is suffering from skin itching due to poor personal hygiene.
• Malnutrition – A 3-year-old child weighs only 10 kg.

Health threats

• Risk of cross-infection from a communicable disease.
• Inadequate family resources – Only one earning member is supporting a family of six.
• Insufficient living space for the family.

Establishing priorities

The scoring for each health problem is presented below.

a. Scabies

S. N	Criteria	Computation	Actual score	Justification
1	Nature of the problem	3/3 X 1	1	It is a health deficit that requires immediate attention and adequate management to reduce the likelihood of disease transmission to the rest of the family members
2	Modifiability	1/2 X 2	1	The family does not have adequate resources to address the problems.
3	Preventive potential	3/3 X 1	1	The transferability of scabies to other family members is reduced or eliminated if the condition is managed promptly and adequately.
4	Salience	1/2 X 1	1/2	The family recognizes that it is a problem but has not consulted health personnel.

b. Malnutrition

S. N	Criteria	Computation	Actual score	Justification
1	Nature of the problem	3/3 X 1	1	It is a health deficit that requires immediate management to prevent adverse consequences.
2	Modifiability	2/2 X 2	2	The problem is easily modifiable. The nurse can help the family with effective budgeting and time management. She can also develop the skills of other family members to achieve good nutrition, proper food selection, preparation, and feeding practices.
3	Preventive potential	3/3 X 1	1	Eliminating malnutrition can prevent susceptibility to other diseases and infections, ensuring normal growth and development
4	Salience	0/2 X 1	0	It is a not a felt problem.

Writing nursing goals

After setting priorities for the problems, the nurse should write the nursing goal for each of the problems. a goal is use to describe the desired change in the health status of individual, family and the desired outcome of nursing intervention. A goal is designed to reduce or eliminate the client’s problems identified in assessment.

Goals are essential for the nursing care plan because a goal

• Gives direction to the nursing intervention
• Serve as a guide for nursing action
• Motivates the individual or family as well as nurse to continue their effort
• Serve as a criteria to evaluate the effectiveness of nursing intervention.

When writing a goal, the following criteria should be considered:

• A goal must be stated clearly.
• It should have a defined end result to evaluate the client’s achievement.
• The timing may range from a few minutes to several days, depending on the nature of the goal and problem.
• The goal must be realistic, observable, and measurable.
• Separate goals should be written for different nursing diagnoses.
• Goals may be short-term or long-term, depending on the time required for achievement.

Short terms and long terms goal

• Short-term goals: These are goals that can be achieved fairly quickly, usually within a few hours or days.
  Example:
  • Problem: High fever (101°F)
  • Goal: The body temperature will be reduced to 99°F within half an hour after nursing intervention.
• Long-term goals: These goals take days, weeks, or months to achieve.
  Example:
  • Problem: Malnutrition (low body weight)
  • Goal: Normal body weight will be maintained within two weeks after nursing

Planning nursing actions/interventions

Nursing actions are specific activities planned to achieve the desired goals. While planning these interventions, consultation with the individual and family is essential to ensure their participation, which contributes to the effectiveness of the intervention.

The choice of nursing intervention depends on two major factors:

1. The nature of the problem – Understanding the severity and type of health issue.
2. The resources available – Utilizing the necessary tools, staff, and materials to solve the problem effectively.

In family nursing practice, health problems often arise due to the family’s inability to assume health-related tasks. Nursing interventions aim to minimize or eliminate the factors preventing the family from fulfilling these responsibilities. To encourage recognition and acceptance of health needs, nurses can implement the following actions:

• Broaden the family’s knowledge base by providing relevant health information.
• Help the family understand the implications of their situation and the possible consequences of their condition.
• Relate health needs to family goals, both health-related and non-health-related.
• Encourage positive emotional attitudes toward addressing health problems.

Planning is an essential component of the nursing process because it:

1. Ensures that nursing care is given according to the priority of patient needs.
2. Promotes individualized care by addressing each patient’s unique circumstances.
3. Incorporates the needs of the family and community for a holistic approach.
4. Makes nursing interventions realistic and suitable for the specific care setting.
5. Facilitates continuity of care across different healthcare environments.
6. Assists in evaluating the effectiveness of care through clear, measurable goals.

Implementation
Implementation refers to the process of providing nursing care according to the established plan. The primary aim of implementation is to achieve the stated healthcare goals and improve patient outcomes.

During the implementation phase, nurses encounter the realities of family nursing practice, which can either motivate them to explore creative innovations or lead to frustration and inaction. As nurse practitioners work with clients, they experience varying degrees of demands on their time, skills, and resources. To effectively navigate these challenges, a dynamic attitude toward personal and professional development is essential. Continuous learning, adaptability, and resilience enable nurses to provide high-quality care while addressing the evolving needs of patients, families, and communities.

While implementing care, the nurse should continuously collect data regarding the client’s condition and environmental factors. This ongoing assessment helps in revising, updating, and evaluating the nursing care plan to ensure it aligns with the set goals. Proper documentation of all implemented care is essential to prevent duplication of work and to assess the effectiveness of the nursing interventions.

Evaluation

Evaluation is the process of assessing the effectiveness, appropriateness, and adequacy of nursing interventions in achieving the set goals of patient care. It determines whether the client has attained the expected outcomes as planned during the nursing process.

To ensure accurate evaluation, various methods should be used, including direct observation, record review, and interviews:

• Direct observation: Involves physical examination to assess the patient’s condition and response to care.
• Interview: Includes history-taking to gather patient feedback and assess behavioral and attitudinal changes.
• Record review: Examines documented nursing interventions and progress notes.
• Laboratory investigations: Supports clinical assessment by providing objective data.

The nurse should carefully observe any changes in the patient’s attitude and health status during and after implementing care. If the expected outcomes are not achieved, it is essential to reassess the objectives, modify the care plan, and re-implement appropriate interventions. Additionally, proper documentation of all nursing actions is necessary to prevent duplication of work and ensure continuity of care.

Role/responsibilities of nurse in the family health care

The roles and functions that a nurse has in a family centered care depend upon the needs of the family. Therefore, she needs to use the principle of nursing process and primary health care to determine what these needs are. Her role is basically the same as those of a community health nurse, especially as a health care provider, educator, researcher and evaluator. In assessing the needs of the family, the nurse has to assess family members, the environment, beliefs, social structure and health behaviours of the entire family.

She needs to assess both the strengths and weaknesses of each person. The nurse should tell the family whether they have healthy habits and encourage them to continue those practices. She then has to teach them how to prioritize their needs and choose a problem to work on. After her intervention, the nurse has to return to the family and evaluate the effectiveness of her intervention.

Health Monitor: Through the periodic contact and sustained relationship with the family the nurse is provided the opportunity to monitor more effectively the concepts of illness and health among family members. The continuous process of assessment provides reliable information to detect deviations in normal health. The family cannot take actions to solve health problems if it does not know that there are interruptions of health development among its members in the first place. The nurse helps the family detect these deviations in health by making an objective appraisal of data and making the family realize the implications or consequences of these data on family development.

Care provider: Despite the emphasis placed on the role of the nurse in disease prevention, health maintenance and promotion, the nurse is called upon to provide personal care to the sick member of the family. Most of the time, the nurse family contact is initiated by an illness situation in the family. This is the time when the family feels that it needs the services of the nurse. Provision of the nursing care to the sick, disabled or dependent member of the family is one of the family’s health tasks. The nurse caring for the sick member at the same time develops the family’s capabilities on health care by giving actual demonstration and teaching to responsible members in ways of coping with the situation.

Coordinator: The nature of family health problems requires the services of other disciplines. With the reorientation of health service delivery from the hospital to the community, all health care providers consider as one of their functions is provisions of services at the family level. The physician, dentist, nutritionist and lately, the physical therapist render family health care. Each discipline brings along its expertise. It needs proper coordination of all these services for maximum utilization of resources with minimum or no overlapping.

Facilitator: One of the important roles of the nurse is to remove barriers to care or make services available and accessible to the family. Sometimes the family hesitates to avail itself of the services of existing community resources because it does not know how to go about it. The nurse can facilitate utilization of an agency by making necessary arrangements or proper referrals. Lack of knowledge about existing resources and social or cultural barrier is another reason for non-utilization of services. For e.g. refusal by some women to be examined by a male physician, refusal by their stigma like TB or mental clinic. The nurse can influence the behaviour of the family by providing necessary support and motivation through proper health education.

Teacher: Health education is one of the most frequently used interventions by the nurse. There is always an opportunity for teaching in the clinic, home, school or place of work. Every contact with the family is an educational experience. Thus the role of nurse as a health educator is as a health educator is as important as any other role.

Counsellor: When the family has developed trust and confidence in the nurse, the family consults or seeks advice for the most intimate and personal problem related with heath at that time the nurse assumes the role as a counsellor.

Family advocate: The family nurse advocates for families with whom they work; the nurse empowers family members to speak with their own voice or the nurse speaks out for the family.

Consultant: The family nurse serves as a consultant to families whenever asked or whenever necessary. In some instances, he/she consults with agencies to facilitate family centered care.

Researcher: The family nurse should identify practice problems and find the best solution for dealing with these problems through the process of scientific investigation.

Role model: The family nurse is continually serving as a role model to other people through his or her activities. A school nurse who demonstrates the right kind of health in personal self-care serves as a role model to parents and children alike.

Case manager: Although case manager is a contemporary name for this role, it involves coordination and collaboration between a family and the health care system. The case manager has been formally empowered to be in charge of a case.

References

Basheer, S. P., & Khan, S. Y. (2022). A concise textbook of advanced nursing practice (3rd ed.). EMMESS Medical Publishers.

Gulani, K. K. (2019). Community health nursing (3rd ed.). Kumar Publishers