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Mr. R., an 80-year-old retired pipe fitter, lives with his wife; he has had diabetes for 15 years. Although his diabetes has been moderately controlled with diet and daily insulin, some complications have occurred. He experiences arteriosclerotic cardiovascular disease and peripheral neuropathy, and he recently spent 2 months in the hospital due to circulatory problems in his left leg. The progressive deterioration of circulation resulted in an amputation below the knee. Although fitting him with a prosthesis would be possible, he has refused this and is wheelchair bound. Mr. R. currently depends on someone else to help with transfers. He is cranky, irritable, and demanding to almost everyone. He recently has stopped following his diabetes regimen because he claims, “It just doesn’t matter anymore.” Mr. R.’s wife, Doris, is a 74-year-old woman who has been a homemaker most of her life. She has always been the “watchdog” for Mr. R.’s health. Mostly through her changes in food preparation and her lifestyle adjustments, Mr. R.’s diabetes has been managed. She schedules his physician appointments, buys his medical supplies, and administers his insulin. He is now refusing to accept her help, and she is anxious and angry about his behavior. They frequently have arguments, after which Mrs. R. retreats to her room. Mr. and Mrs. R. have three children and four grandchildren who live in the same city. The eldest daughter, Patricia, calls or stops by about once a week. The other children, Tom and Ellen, are busy with their families and see their parents mostly on holidays; they have very little communication with Patricia or their parents. When the children do come to visit, Doris tries to put on a happy expression and pretend that everything is going well to avoid worrying them. She is also embarrassed about Mr. R.’s behavior and does not want anyone from outside the family to see what is happening. On her initial home visit to this family, the community health nurse notes that Mr. R. appears somewhat drowsy and unkempt. Mrs. R. looks anxious and tired, her skin color is slightly ashen, and she has circles under her eyes. When the nurse asks them what they hope to get out of the nursing visits, Mrs. R. says, “Actually, you don’t need to keep visiting. In a few weeks we’ll be back to normal and doing fine.” Based on a thorough assessment of the family, the community health nurse may begin to develop a mutually acceptable plan of care with the family. Assessment In the initial interview, the community health nurse completes a genogram and an eco-map with the family (see Figures 13-3 and 13-4). After the second family interview, the nurse also completes a family map that describes the members’ interactions with each other (see Figure 13-2). A family guide to help structure a family assessment is presented in Box 13-7. Completing the genogram helps break the ice to get the family to talk about their situation. The genogram provides a safe and thought-provoking way for Mrs. R. to supply appropriate information about the situation. During this process, the nurse obtains information about other family members, their general levels of functioning, and the possibility of acting as resources. She identifies family members’ patterns of closeness and distance. The eco-map presents a picture to both the nurse and Mr. and Mrs. R. of a family that is not well connected to outside resources. Little energy is coming in or going out of the immediate family system, with the exception of intervention by the health care system, which the family wants to discontinue. When the community health nurse later completes a family map, she becomes aware of Mrs. R.’s tendency to act as a parent and Mr. R.’s tendency to act as a child. This blurring of boundaries has set up a behavior pattern in which Mr. R. gives away responsibility for his own health. At the same time, however, the rigidity of these boundaries keeps the children out of these interactions. After assessing the family, the nurse tries to guide her practice with some questions. She asks herself about the family’s needs, strengths, functioning, and style. She examines the family’s priorities and the resources they are using or are potentially able to use. She looks at her own skills and abilities and attempts to define her responsibility to the family system. These questions help her begin to analyze the family data. This analysis leads to several determinations. Family Health Needs The family needs help coping with this illness and connecting with resources and sources of support. Some minor disturbances in internal dynamics are influencing the way the family is dealing with the problem. The nurse assigns the family the nursing diagnosis of “Family Coping: Compromised.” Family Style This family is a distancing family that prefers to keep its problem-solving activities to itself. However, this isolation limits family members’ ability to support each other. The community health nurse must adjust her nursing interactions to accommodate this family’s style of operating. The nurse should respect the family’s need for distance, approach them cautiously, and observe for cues that indicate that they are becoming anxious. Family Strengths This family has some ability to organize activities that need to be accomplished to maintain Mr. R.’s health. Family members are concerned about each other and may be able to adjust schedules or routines. Mrs. R. is committed to Mr. R.’s health care and will try to do what is required. The family has a long history together and in the past has developed a sense of identity and common purpose. Family Functioning Even though the family is currently stressed, long-term functioning is fairly healthy. No one member has consistently been a problem or has failed to fulfill her or his role. The adult children are not acting in their age-appropriate roles of support to parents. This status seems to reflect the family style but can possibly be modified. Targets of Care The community health nurse believes several levels of this family— the individuals with health problems (both Mr. and Mrs. R.), the couple, and the family as a unit—are potential targets for care. When she reviews who the most likely person in the family is to be able to change behavior, she looks for someone who seems willing to change. She decides this person is Mrs. R. and potentially the children. Nurse’s Contribution The community health nurse reviews her own caseload and her available time and attempts to make an accurate assessment of her skills. She is fairly comfortable in dealing with families and decides she will intervene on three levels: individual, subsystem, and family unit. Her contribution will be to offer information, counseling, and connection with other resources. She can visit one time per week and will try to schedule these visits when some of the children can be present. Priorities The family has several needs. Which one is the most crucial? Any life-threatening situation must be top priority, but nothing will be accomplished without the family’s agreement that this is their concern. After discussing these ideas with the family, the nurse and the family decide to first address individual health concerns. Mr. R.’s hyperglycemia is noted, and he admits it is making him feel bad. Mrs. R.’s cardiac status is to be assessed next week at an appointment with the family physician. Although Mr. R. seems agreeable to resuming his insulin injections, he has no desire to change his diet or learn how to walk with a prosthesis. The community health nurse puts aside these problems for the time being and addresses Mrs. R. She wonders if Mrs. R. would be interested in exploring her current care for herself. Mrs. R. tentatively agrees. Using additional resources to help Mr. R. transfer in and out of his wheelchair is something that can be accomplished, but the family is still reluctant about this course of action. This problem, too, is put off to a later time.

Planning The community health nurse and the family together develop both long-term and short-term goals. Mr. R.:

• Will monitor and record blood glucose levels every morning
• Will accept administration of insulin by Mrs. R
• Will begin range-of-motion and strengthening exercises to promote mobility for eventual transfer of self to chair
• Will communicate to Mrs. R. his ability to take care of any of his own needs as each opportunity arises
• Will demonstrate improved blood glucose levels within 1 month Mrs. R.:
• Will have her cardiac status evaluated within 2 weeks
• Will self-monitor her health and record her health status for 1 week
• Will decide on one goal to take care of herself within 2 weeks
• Will practice this behavior for 1 month
• Will allow Mr. R. to care for himself when he desires Mr. and Mrs. R. together:
• Will experience decreased frequency of arguments within 1 month
• Will spend some relaxed time together every evening The family:
• Will discuss new ways of coping with this situation as a group
• Will try out two behaviors that use different family members within 2 weeks
• Will accept one resource to help within 1 month Implementation

The community health nurse is aware that the disturbances in the family’s coping ability are fairly recent. The behaviors they have used in the past—self-reliance, appropriate action, distancing, and some denial of the problem—are not working in this situation. The first goal for nursing implementation addresses individual health needs. The second goal involves helping Mr. and Mrs. R. think about the crisis and identify their present coping strategies. Because the nurse knows that the family style is distant, she will proceed slowly with this step, adjusting to suit the family’s pace. She will initially keep the discussion focused on thoughts and facts rather than feelings. Mr. R. perceives the situation as hopeless. It is important to help the family reframe this perception so that the current crisis is seen as being able to be modified. Subsequent plans with regard to family coping would include identifying alternative coping behaviors and practicing them. Because significant strengths are present and the family level of functioning is fairly high, the community health nurse would expect the family to use information to appropriately problem-solve in this crisis. The family may also use the situation as a way of growing into new behaviors that foster family health. Connecting the family with resources must be done in a way that allows this family to make the choice about outside care. Providing information about the extent to which other modern families use these resources may help them accept this intrusion into their world. Internal resources that are available to the family include the adult children, who may be able to offer instrumental or emotional support simply by being made aware of the extent of the need. The internal dynamics of the family, in which the couple’s roles are unbalanced, given that the wife has assumed more and more responsibility for the husband, are likely to be long-term patterns. Expecting a family at this stage of life to change a formerly effective pattern of relating to each other is unrealistic and ill advised. Instead, helping Mrs. R. focus on herself more so that she can care for her own needs and helping Mr. R. increase his awareness about his responsibility for his health and to his wife are more appropriate interventions. Evaluation The community health nurse reviews the care plan periodically with the family and at the end of the contact. This evaluation includes examination of goals. As the family crisis subsides, goals are quickly accomplished and revised weekly. The family also examines the effect of the interaction on the member who is ill (Mr. R.). His hyperglycemia is modified the first week, and his blood glucose levels drop to a normal range within several weeks of contact. He accepts his insulin and even expresses interest in administering it himself. His stance with regard to eating whatever he wants also changes, and he begins to follow his diet recommendations more closely. He continues to resist attempts to be fitted for a prosthesis but eventually learns to assist with his transfers. When the community health nurse leaves this family, a goal still to be accomplished is Mr. R.’s learning to use a walker. Examination of the intervention’s effect on individuals includes looking at Mrs. R.’s health status and that of the adult children. Mrs. R.’s cardiovascular status has deteriorated. She begins some cardiotonic medication and is urged to moderate her activity and stress level. All three of the adult children begin sharing in the care of their father. Although the children are busier than before, the impact on them is manageable. Examination of the effects on the subsystem includes effects on the interactions of the marital couple. Mr. and Mrs. R. both begin to assume more appropriate responsibility for themselves. The arguments and anger lessen, although their long-term way of relating to each other does not change a great deal. The effect on the whole family is also examined. Incorporating additional resources lead to a decreased perception of the crisis and an increased calm in the family. As the members begin to renew connections with each other, they discover new sources of emotional support. Following Mr. R’s death due to a pulmonary embolus several months later, the children are able to support their mother during the time of loss. In examining the family’s interaction with the environment, it becomes apparent that the family members have become more aware of the community resources available to them. The family members are still very private but begin to use available resources appropriately. Their home environment is relatively safe. As she is working with this family, the community health nurse continually seeks feedback to evaluate her own performance. She carefully monitors the family’s reactions to her interventions and her reactions to the family. She is frustrated at the need to proceed slowly with the family but is satisfied with her choice when she sees that the strategy has worked. Her contact with the family leads her to enroll in a course about client nondherence. She learns to be patient during this experience and takes these behaviors with her in her future contacts with families.