General Care Plans
PART I: Medical-Surgical Nursing
ADDITIONAL NURSING DIAGNOSES/PROBLEMS:
“Palliative and End-of-Life Care,” as appropriate for issues facing patients who are dying p. 103
“Anxiety Disorders” for Ineffective Coping p. 704
“Bipolar Disorder” for Risk for Other-Directed Violence p. 710
“Major Depression” for Hopelessness p. 727
Risk for Suicide p. 727
Grieving p. 729
for the Patient’s Family
and Significant Others 6
Note: The Health Insurance Portability and Accountability Act of 1996 (HIPAA) restricts who may request and receive health care–related information about a patient in order to protect confidentiality. Health care providers must be sensitive to and aware of expressed patient prefer- ences before discussing the patient with others, including family. This includes divulging informa-tion regarding a patient’s presence in the hospital.
Nursing Diagnosis:
Fear
related to the patient’s life-threatening condition and knowledge deficit
Desired Outcome:
Following intervention, significant others/family members report that fear has lessened.
ASSESSMENT/INTERVENTIONS RATIONALES
Assess the family’s fears and their understanding of the patient’s clinical situation.
Some fears may be realistic; others may not be and need clarification.
Evaluate verbal and nonverbal responses. Some family members may not readily verbalize their fears but may give nonverbal cues such as withdrawing emotionally (evidenced by body position, facial expression, attitude of disinterest), refusing to be present during discussion, or disrupting discussion.
Acknowledge the family’s fear. Simple acknowledgment and giving more information can go a long
way toward decreasing fear. For example, “I understand these tubes must frighten you, but they are necessary to help nourish your son.”
Assess the family’s history of coping behavior. How a family has coped with fear in the past often is a reliable predictor of how they will cope in the current situation. For example, “How does your family react to difficult situations?”
Awareness of maladaptive responses may assist the nurse in fostering more productive methods of coping.
Provide opportunities for family members to express fears and concerns. Verbalizing feelings in a nonthreatening environment can help them deal with unresolved/unrecognized issues that may be
contributing to the current stressor. Anger, denial, withdrawal, and demanding behavior may be adaptive coping responses during the initial period of crisis.
Identifying fears also enables the nurse to dispel inaccuracies, which
Interrupted Family Processes
Psychosocial Support for the Patient’s Family and Significant Others85
General Care Plans
PART I: Medical-Surgical Nursing
ASSESSMENT/INTERVENTIONS RATIONALES
Provide information at frequent intervals about the patient’s status, treatments, and equipment used.
This information increases the family’s knowledge of the patient’s health status, helping alleviate fear of the unknown.
Explain implications of HIPAA to the family and how this affects the type of information that can be given and how it can be given (e.g., no specific information can be given by phone or email).
Protection of patient privacy is critical. Helping families to understand what information can be provided and why will help alleviate anxiety.
Encourage the family to use positive coping behaviors by identifying fears, developing goals, identifying supportive resources, facilitating realistic perceptions, and promoting problem solving.
When under stress, the family may not recall sources of support without being reminded. For example, “Who usually helps your family during stressful times?”
Recognize anxiety, and encourage family members to describe their feelings.
Before family members can learn coping strategies, they must first clarify their feelings. For example, “You seem very uncomfortable tonight. Can you describe your feelings?”
Be alert to maladaptive responses to fear. Provide referrals to a psychiatric clinical nurse specialist or other staff member as appropriate.
Violence, withdrawal, severe depression, hostility, and unrealistic expectations for the staff or of the patient’s recovery are maladaptive responses to fear, and they require expert guidance.
Offer realistic hope, even if it is hope for the patient’s peaceful death. Even though family members may have feelings of hopelessness, it sometimes helps to hear realistic expressions of hope.
Explore the family’s desire for spiritual or other counseling. People often derive hope and experience a decrease in fear and dread from spiritual counseling.
Assess your own feelings about the patient’s life-threatening illness. Without personal awareness of one’s beliefs, a health care provider’s attitude and fears may be reflected inadvertently to the family.
For other interventions, see Interrupted Family Processes and Disabled Family Coping listed later in this care plan.
Nursing Diagnosis:
Interrupted Family Processes
related to the situational crisis (the patient’s illness)
Desired Outcome:
Following intervention, family members demonstrate effective adaptation to change/traumatic situation as evidenced by seeking external support when necessary and sharing concerns within the family unit.
ASSESSMENT/INTERVENTIONS RATIONALES
Assess the family’s character: social, environmental, ethnic, and cultural factors; relationships; and role patterns.
Having this detailed information will help the nurse develop an individualized care plan.
Identify the family’s developmental stage. The family may be dealing with other situational or maturational crises, such as managing an elderly parent or a teenager with a learning disability.
Assess previous adaptive behaviors. How the family has dealt with problems in the past may be a reliable predictor of how they will adapt to current issues. For example, “How does your family react in stressful situations?”
Discuss observed conflicts and communications. Awareness of this information will assist with development of an individualized plan of care, including referral for specialized care if appropriate. For example, “I noticed that your brother would not visit your mother today. Has there been a problem we should be aware of? Knowing about it may help us better care for your mother.”
Acknowledge the family’s involvement in patient care and promote strengths. Encourage the family to participate in patient care conferences. Promote frequent, regular patient visits by family members.
This reinforces positive ways of dealing with the crisis and promotes a sense of involvement and control for the family. For example, “You were able to encourage your wife to turn and cough. That is very important to her recovery.”
continued
PART I: Medical-Surgical Nursing
Provide the family with information and guidance related to the patient. Discuss the stresses of hospitalization, and encourage the family to discuss feelings of anger, guilt, hostility, depression, fear, or sorrow. Refer to clergy, clinical nurse specialist, or social services as appropriate.
Encouraging expressions of emotion helps family members begin the process of grieving. For example, “You seem to be upset since being told that your husband is not leaving the hospital today.” Acknowledging their feelings promotes acceptance and facilitates therapeutic communication.
Evaluate patient and family responses to one another. Encourage the family to reorganize roles and establish priorities as appropriate.
These actions will help facilitate the family’s adaptation to the situation regarding the patient and prevent unnecessary conflict. Helping family members redefine their roles may reduce confusion and provide direction.
For example, “I know your husband is concerned about his insurance policy and seems to expect you to investigate it. I’ll ask the financial counselor to talk with you.”
Encourage the family to schedule periods of rest and activity outside the hospital and to seek support when necessary.
Persons undergoing stress sometimes require guidance of others to promote their own self-care. For example, “Your neighbor volunteered to stay in the waiting room this afternoon. Would you like to rest at home? I’ll call you if anything changes.”
Nursing Diagnoses:
Compromised Family Coping/
Caregiver Role Strain
related to inadequate or incorrect information or misunderstanding, temporary family disorganization and role change, exhausted support persons or systems, unrealistic expectations, fear, anxiety, or financial burden
Desired Outcome:
Following intervention, family members begin to verbalize feelings, iden-tify ineffective coping patterns, ideniden-tify strengths and positive coping behaviors, and seek information and support from the nurse or other support persons or systems outside the family.
ASSESSMENT/INTERVENTIONS RATIONALES
Establish open, honest communication within the family. Help family members identify strengths, stressors, inappropriate behaviors, and personal needs.
These actions will help promote positive, effective communication among family members while enabling them to examine areas that contribute both to effective and ineffective coping in a nonthreatening environment. For example, “I understand your mother was very ill last year. How did you manage the situation?”
“I know your loved one is very ill. How can I help you?”
Assess family members for ineffective coping and identify factors that inhibit effective coping.
Ineffective methods of coping (e.g., depression, chemical dependency, violence, withdrawal) can interfere with ability to deal with the current situation. Awareness of barriers to effective coping (e.g., inadequate support system, grief, fear of disapproval by others, and deficient knowledge) is the first step toward promoting changes and healthy adaptation. For example, “You seem to be unable to talk about your husband’s illness. Is there anyone with whom you can talk about it?”
Assess the family’s knowledge about the patient’s current health status and treatment. Provide information often, and allow sufficient time for questions. Reassess the family’s understanding at frequent intervals.
By providing information frequently and answering questions, stress, fear, and anxiety can be attenuated.
Provide opportunities in a private setting for family members to talk and share concerns with nurses. If appropriate, refer the family to a psychiatric clinical nurse specialist for therapy.
The family may need additional assistance in working through their issues.