THE FAMILY NURSING PROCESS

The family nursing process is the same nursing process as applied to the family, the
unit of care in the community. These are the common assessment cues and diagnoses
for families in creating Family Nursing Care Plans.

DEFINITION
 It is the blue print of the care that the nurse designs to systematically minimize or
eliminate the identified health and nursing problem through explicitly formulated
outcomes of care (goals and objectives) and deliberately chosen set of
interventions, resources and evaluation criteria, standards, methods and tools.
 Characteristics, which are Based on the Concept of Planning as a Process:
 The nursing care plan focuses on actions, which are designed to solve or
minimize existing problem.
 The cores of the plan are the approaches, strategies, activities, methods and
materials, which the nurse hopes, will improve the problem.
 The nursing care plan is a product of the liberate systematic process.
 The nursing care plan as with all other plans relate to the future.
 It utilizes events in the past and what is happening in the present to determine
patterns. It also projects the future scenario if the situation is not corrected.
 The nursing care plan is based upon identified health and nursing problems.
 The nursing care plan is a means to an end, not an end in itself.
 The goal in planning is to deliver the most appropriate care to the client by
eliminating barriers to the family health development.
 The nursing care plan is a continuous process not a one shot deal.
 The results of evaluation of the plan’s effectiveness trigger another cycle of the
planning process until the health and nursing problems are eliminated.
 Desirable Qualities of a Nursing Care Plan
 It should be based on clear, explicit definition of the problem(s).
 A good plan is realistic.
 The nursing care plan is prepared jointly with the family.
 The nursing care plan is most useful in written form.
 Importance of Planning Care
 They individualize care to clients.
 The nursing care plan helps in setting priorities by providing information about
the client as well as the nature of his problem.
 The nursing care plan promotes systematic communication among those involve
in the health care effort.
 Continuity of care is facilitated through the use of nursing care plans.
  Gaps and duplications in the services provided are minimized, if not totally
eliminated.
 Nursing care plans facilitate the coordination of care by making known to other
members of the health team what the nurse is doing.

STEPS IN DEVELOPING CARE PLAN

 The prioritized conditions of the problem
 Goals and objectives of the nursing care
 The plan of interventions
 The plan for evaluating care
 Prioritizing Health Problems

FOUR CRITERIA FOR DETERMINING PRIORITIES:

 Nature of the condition or problem – categorized into wellness state/potential,
health threat, health deficit of foreseeable crisis.
 Modifiability of the condition or problem-refers to the probability of success in
enhancing the wellness state improving the condition minimizing, alleviating or
totally eradicating the problem through intervention.
 Preventive potential-refers to the nature and magnitude of future problem that
can be minimized or totally prevented if interventions are done on the condition
or problem under consideration.
 Salience-refers to the family’s perception and evaluation of the condition or
problem in terms of seriousness and urgency of attention needed or family
readiness.

FACTORS AFFECTING PRIORITY SETTING

 Nature of the problem
 The biggest weight is given to the wellness state or potential because of the
premium on client’s effort or desire to sustain/maintain high level of wellness.
 The same weight is given to health deficit because of its sense of clinical
urgency, which may require immediate intervention.
 Foreseeable crisis is given the least weight because culture linked
variables/factors usually provide our families with adequate support to cope with
developmental or situational crisis.
 Modifiability if the problem
 Current knowledge, technology and interventions to enhance the wellness state
or manage the problem.
 Resources of the family
 Resources of the nurse
  Resources of the community
 Preventive potential
 Gravity or severity of the problem-refers to the progress of the disease/problem
indicating extent of damage on the patient/family; also indicates prognosis,
reversibility or modifiability of the problem. In general, the more severe the
problem is, the lower is the preventive potential of the problem.
 Duration of the problem-refers to the length of time the problem has existed.
Generally speaking, duration of the problem has a direct relationship to gravity;
the nature of the problem is variable that may, however, alter this relationship.
Because of this relationship to gravity of the problem, duration has also a direct
relationship to preventive potential.
 Current management-refers to the presence and appropriateness of intervention
measures instituted to enhance the wellness state or remedy the problem. The
institution of appropriate intervention increases condition’s preventive potential.
 Exposure of any vulnerable or high risk group-increases the preventive potential
of condition or problem

FORMULATION OF GOALS AND OBJECTIVES

GOAL-is a general statement of condition or state to be brought about by specific
courses of action.
OBJECTIVE-refers to a more specific statement of the desired results or outcomes of
care. They specify the criteria by which the degree of effectiveness of care is to be
measured.
*A cardinal principle in goal setting states that goal must be set jointly with the family.
This ensures family commitment to realization.

* Basic to the establishment of mutually acceptable goals is the family’s recognition and
acceptance of existing health needs and problems.

BARRIERS TO JOINT GOAL SETTING BETWEEN THE NURSE AND THE FAMILY:
 Failure on the part of the family to perceive the existence of the problem.
 The family may realize the existence of the health condition or problem but is too
busy at the moment.
 Sometimes the family perceives the existence of the problem but does not see it
as serious enough to warrant attention.
 The family may perceive the presence of the problem and the need to take
action. It may however refuse to face and do something about the situation.
 Reasons to this kind of behavior:
 Fear of consequences of taking actions.
 Respect for tradition.
 Failure to perceive the benefits of action.
 Failure to relate the proposed action to the family’s goals.
 A big barrier to collaborative goal setting between the nurse and the family is the
working relationship.
 Focus on Interventions to Help The Family Performs Health Tasks:
 Help the family recognize the problem
 Increasing the family’s knowledge on the nature, magnitude and cause of the
problem.
 Helping the family see the implications of the situation or the consequences of
the condition.
 Relating the health needs to the goals of the family.
 Encouraging positive or wholesome emotional attitude toward the problem by
affirming the family’s capabilities/qualities/resources and providing
information on available actions.
 Guide the family on how to decide on appropriate health actions to take.
 Identifying or exploring with the family courses of action available and the
resources needed for each.
 Discussing the consequences of action available.
 Analyzing with the family of the consequences of inaction.
 Develop the family’s ability and commitment to provide nursing care to each
member.
 Contracting-is a creative intervention that can maximize the opportunities to
develop the ability and commitment of the family to provide nursing care to its
members.
 Enhance the capability of the family to provide home environment conducive to
health maintenance and personal development.
 The family can be taught specific competencies to ensure such home
environment through environmental manipulation or management to minimize or
eliminate health threats or risks or to install facilities of nursing care.
 Facilitate the family’s capability to utilize community resources for health care.
 Involves maximum use of available resources through the coordination,
collaboration and teamwork provided by effective referral system.
CRITERIA FOR SELECTING THE TYPE OF NURSE FAMILY CONTACT
 Effectivity
 Efficiency
 Appropriateness
 Types of Nurse Family Contact
 Home Visit

While it is expensive in terms of time, effort and logistics for the nurse, it is an effective
and appropriate type of family nurse contact if the objectives and outcomes of care
require accurate appraisal of family relationship, home and environment and family
competencies. i.e. The best opportunity to serve the actual care given by family
members.

CLINIC OR OFFICE CONFERENCE

It is less expensive for the nurse and provides the opportunity to use equipment that
can’t be taken to the home. In some cases, the other team members in the clinic may
be consulted or called in to provide additional service.

TELEPHONE CONFERENCE
May be effective, efficient, and appropriate if the objectives and outcomes of care
require immediate access to data given problems on distance or travel time. Such data
include monitoring of health status or progress during the acute phase of an illness
state, change in schedule of visit or family decision, and updates on outcomes or
responses to care and treatment.

WRITTEN COMMUNICATION
It is another less time consuming option for the nurse in instances when there are large
number of families needing follow-up on top of problems of distance or travel time.

SCHOOL VISIT OR CONFERENCE

It is done to work with family and school authorities on how to appraise the degree of
vulnerability of and worked out interventions to help children and adolescence on
specific health risks, hazards or adjustment problems.

INDUSTRIAL OR JOB SITE VISIT

It is done when the nurse and family need to make an accurate assessment of health
risks or hazards and work with employer or supervisor on what can be done to improve
on provisions for health and safety of workers.
IMPLEMENTING THE NURSING CARE PLAN
 During this phase, the nurse encounters the realities in family nursing practice
that motivates her to try out creative innovations or overwhelm her to frustration
or inaction. A dynamic attitude on personal and professional development is,
therefore, necessary if she has to face up challenges of nursing practice.
 Implementation Phase: A Phenomenological Experience
 Meeting the challenges of this phase is the essence of family nursing practice.
During this phase, the nurse experiences with the family a lived meaningful world
of mutual, dynamic interchange of meanings, concerns, perceptions, biases,
emotions and skills. Just as the self aims to achieve body-mind integration to
achieve wholeness in the experience of “being” and “becoming” in expert caring.
Unless there is such a dynamic and active involvement between the nurse and
the family in understanding and making choices in this meaningful world of
coping, aspirations, emotions and skills the nurse can’t hope to achieve expert
caring.

EXPERT CARING: METHODS AND POSSIBILITIES

Expert caring in the implementation phase is demonstrated phase is
demonstrated when the nurse carries out interventions based on the family’s
understanding of the lived experience of coping and being in the world. Expert caring is
developing the capability of the family for “engage care” through the nurses skilled
practice, the family learns to choose and carry out the best possibilities of caring given
the meanings, concerns, emotions and resources(skills & equipments) as experienced
in the situation. While the challenge for expert caring is a reality, the nurse is enriched
as a result of such an experience (Benner & Wrubel 1989).
By being experts in caring, nurses must take over and transform the notions of
expertise. Expert caring has nothing to do with possessing privileged information that
increases one’s control and domination of another. Rather, expert caring unleashes the
possibilities inherent in the self and the situation. Expert caring liberates and facilitates
in such a way that the one caring is enriched in the process.
While expert caring does not happen overnight to the novice nurse, there are
methods and possibilities that can enhance learning towards expert caring. Such
methods and possibilities need to be carried out and experienced in real contexts and
real relationships to achieve skillfully comportment and excellence in the current
situation.

TWO SUCH MAJOR METHODS AND POSSIBILITIES:

 Performance-focus learning through competency-based teaching
 Maximizing caring possibilities for personal and professional development
 Competency-Based Teaching
  A substantive part of the implementation phase is directed towards developing
the family’s competencies to perform the health tasks. Competencies include the
cognitive (knowledge), psychomotor (skills) and attitudinal or affective(emotions,
feelings, values). The following are examples of these family health
competencies using the corresponding health task in our case illustration:
 Health Task: The family recognizes the possibility of cross-infection of scabies to
other family members.

COGNITIVE COMPETENCY:
 The family explains the cause of scabies
 The family enumerates ways by which cross-infection of scabies can occur
among the family members.
 Health Task: The family provides a home environment conducive to health
maintenance and personal development of its members.

PSYCHOMOTOR COMPETENCY:
 The family carries out the agreed-upon measures to improve home sanitation
and personal hygiene of family members.
 Health Task: The family decides to take appropriate health action.

ATTITUDINAL OR AFFECTIVE COMPETENCIES:

 Family members express feelings or emotions that act as barriers to decision-
making
 Family members acknowledge the existence of these feelings or emotions.
 In order to systematically work towards development of the family’s
competencies, such competencies need to be explicitly defined. Cognitive and
psychomotor competencies are reflected explicitly as objectives in the family
nursing care plan. The attitudinal or affective competencies may also be
translated into objective of care as feelings, emotions or philosophy in life that
enhance the family’s desire or commitment to behavior change and sustain the
needed action.

LEARNING PRINCIPLES AND TEACHING- LEARNING METHODS AND

TECHNIQUES THAT THE NURSE CAN USE IN COMPETENCY-BASED TEACHING:
 Learning is both intellectual and emotional process.
 Learning is facilitated when experience has meaning.
 Learning is individual matter.
 Learning is Both Intellectual and Emotional Process
SIX GENERAL METHODS AND TECHNIQUES:
 Provide information to shape attitude
 Provide experiential learning activities to shape attitudes
 Provide examples or models to shape attitudes
 Providing opportunities for small group discussion
 Role playing exercises
 Explore the benefits of power of silence

LEARNING IS FACILITATED WHEN EXPERIENCE HAS MEANING

 Analyze and process family members all teaching-learning based on their grasp
on the live experience of the situation in terms of the meaning for the self.
 Involve the family actively in determining areas for teaching-learning based on
the health tasks that members made to perform.
 Used examples or illustrations that the family is familiar with.

Learning is Individual Matter: Ensure Mastery of Competencies for Sustained

Actions:
SOME TECHNIQUES TO DEVELOP MASTERY:
 Make the learning active by providing opportunities for the family to do specific
activities, answer questions or apply learning in solving problems.
 Ensure clarity. Use words, examples, visual materials and handouts that the
family can understand.
 Ensure adequate evaluation, feedback, monitoring and support for sustained
action by:
 Explaining well how the family is doing
 Giving the necessary affirmations or reassurances
 Explaining how the skill can be improved
 Exploring with the family how modifications can be carried out to maximize
situated possibilities or best options.

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
(NANDA 2001)
Others. Specify.

B. Readiness for Enhanced Capability for:

Healthy lifestyle
Health maintenance/health management
Parenting
Breastfeeding
Spiritual well-being
Others. Specify.

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.
H. Philosophy in life which negates/hinder caring for the sick, disabled, dependent,
vulnerable/at risk member

I. Member’s preoccupation with on concerns/interests

J. Prolonged disease or disabilities, which exhaust supportive capacity of family

members.

K. Altered role performance, specify.

 Role denials or ambivalence
 Role strain
 Role dissatisfaction
 Role conflict
 Role confusion
 Role overload

L. Others. Specify._________

IV. Inability to provide a home environment conducive to health maintenance and

personal development due to:
A. Inadequate family resources specifically:
 Financial constraints/limited financial resources
 Limited physical resources-e.i. lack of space to construct facility

B. Failure to see benefits (specifically long term ones) of investments in home

environment improvement

C. Lack of/inadequate knowledge of importance of hygiene and sanitation

D. Lack of/inadequate knowledge of preventive measures

E. Lack of skill in carrying out measures to improve home environment

F. Ineffective communication pattern within the family

G. Lack of supportive relationship among family members

H. Negative attitudes/philosophy in life which is not conducive to health maintenance

and personal development
I. Lack of adequate competencies in relating to each other for mutual growth and
maturation

Example: reduced ability to meet the physical and psychological needs of other
members as a result of family’s preoccupation with current problem or condition.

J. Others specify._________

V. Failure to utilize community resources for health care due to:

A. Lack of/inadequate knowledge of community resources for health care

B. Failure to perceive the benefits of health care/services

C. Lack of trust/confidence in the agency/personnel

D. Previous unpleasant experience with health worker

E. Fear of consequences of action (preventive, diagnostic, therapeutic, rehabilitative)

specifically:
 Physical/psychological consequences
 Financial consequences
 Social consequences

F. Unavailability of required care/services

G. Inaccessibility of required services due to:

 Cost constraints
 Physical inaccessibility

H. Lack of or inadequate family resources, specifically

 Manpower resources, e.g. baby sitter
 Financial resources, cost of medicines prescribe

I. Feeling of alienation to/lack of support from the community

 e.g. stigma due to mental illness, AIDS, etc.
J. Negative attitude/ philosophy in life which hinders effective/maximum utilization of
community resources for health care
K. Others, specify __________