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SL.NO . CONTENT 1 INTRODUCTION 2 TERMMINOLOGIES 3 CONTENT A. FAMILY NURSING Definition of Family Definition and Meaning of Family Health Nursing Views on Family Objectives of Family Health Nursing Goals of Family Health Nursing Principles of Family Health Nursing Advantages of Family Health Nursing Disadvantages of Family Health Nursing Range of Family Health Nursing Approaches to Family Nursing Practice Steps in Family Health Nursing Family Health Nursing Process Nurse’s Responsibility in Family Health Care Barriers to family Health Care Challenges For Family Nursing B. HOME NURSING Definition Unique Aspects of Home Health Nursing The Home Health Care System Roles of the Home Health Nurse Perspectives of Home Care Clients Selected Dimensions of Home Health Nursing Applying the Nursing Process in the Home 1

Transcript of Family Nursing and Home Nsg

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SL.NO. CONTENT

1 INTRODUCTION

2 TERMMINOLOGIES

3 CONTENT

A. FAMILY NURSING

Definition of Family Definition and Meaning of Family Health Nursing Views on Family Objectives of Family Health Nursing Goals of Family Health Nursing Principles of Family Health Nursing Advantages of Family Health Nursing Disadvantages of Family Health Nursing Range of Family Health Nursing Approaches to Family Nursing Practice Steps in Family Health Nursing Family Health Nursing Process Nurse’s Responsibility in Family Health Care Barriers to family Health Care Challenges For Family Nursing

B. HOME NURSING

Definition Unique Aspects of Home Health Nursing The Home Health Care System Roles of the Home Health Nurse Perspectives of Home Care Clients Selected Dimensions of Home Health Nursing Applying the Nursing Process in the Home The Future OF Home Health Care

4 CONCLUSION

5 JOURNAL ABSTRACT

6 BIBLIOGRAPHY

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FAMILY NURSING AND HOME NURSING

INTRODUCTION

FamilyThe family is often called the basic social institution because of its important functions of procreation and socialization and because it is found, in some forms in all societies. Family is a term used in everyday language whose meaning is cognate with the culturally and historically specific social practices to which it refers. The family as a universal social institution refers to a distinctive characteristics of the social life of particular culture and epochs. Its activity and their effects on the maintenance of the social structure of the society, of which it is a part, concentrating on biological and demographic features. The structure of the family varies from society to society. The smallest family unit is known as nuclear family and consists of a husband and wife and their immature offspring .Units larger than the nuclear family are usually known as extended families.

Family Health Nursing

Family nursing refers to nursing care that is holistically directed toward the whole family as well as to individual members.

“Family health nursing is the practice of nursing directed towards maximizing the health and wellbeing of all individuals within in a family system. It incorporates two views of family, family as a unit of care and family as a contact. Family health nursing views the family as a system existing within larger system. Levels of intervention are the individuals the personal, the family system, and the environmental level. The goals of the family health nursing include optimal functioning for the individual and for the family as a unit.”

Home Health Nursing Historically, home care considered primarily of nurses providing private duty care in clients’ homes and care of the ill by their own family members. However the delivery of professional nursing services in home settings has increased in frequency, scope and complexity in the past two decades. A number of factors have contributed to this trend, among them rising health care costs, an aging population, and a growing emphasis on managing chronic illness and stress, preventing illness, and enhancing the quality of life. In the not- too- distant past, home health care occurred at the end of the client care continuum- that is, after discharge from an acute care facility. Today the trend is changing to use of home health care services to avoid hospitalization. Home nursing care is one of the fastest growing sectors of the health care system. Factors that have contributed to the growth of home health care include

The increase in the older population, who are frequent recipients of home care. Third party payers who favour home care to control costs. The ability of agencies and institutions to successfully deliver high technology

services in the home. Consumers who prefer to receive care in the home rather than in an institutio

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TERMMINOLOGY

Baccalaureate : An examination intended to qualify successful candidates for higher education, the university degree of Bachelor

ANCC : American Nurses Credentialing Center

Hospice nursing : An interdisciplinary program of palliative care and supportive services that addresses the physical, spiritual, social, and economic needs of terminally ill patients and their families. This care may be provided in the home or hospice center.

Home Assessment : An evaluation of the home environment of person with disability, usually by an occupational therapist or Home care specialist, for purposes of identifying Architectural barriers and safety hazards and Recommending modifications or devices for improving mobility, safety, and independent function

Terminal illness : An illness that, because of its nature, can be expected to Cause the patient to die. Usually a chronic disease for which there is no known cure.

Procreation : The act or state of conceiving and giving birth to an infant, reproduction

Accreditation : The voluntary process of recognizing that a facility or institution has met established standards, Official recognition given to an institution

Appraisal : A formal evaluation of the performance of an employee over a particular periodAccountability : Responsibility of health care professionals for the actions and judgments involved in patient care.

Therapeutic Recreation: A specialized field within recreation whose specialists plan and direct recreational activities for patients

recovering from physical or mental illness or who are attempting to cope with a permanent or temporary disability

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B. HOME NURSING

DEFINITION OF HOME NURSING

The delivery of nursing services in the home has been called a variety of terms, including home health nursing, home care nursing, and visiting nursing. Home health care includes the services and products provided to the clients in their homes that are needed to maintain, restore, or promote their physical, psychological and social wellbeing. The focus of home health nursing is individuals and their families. This differs somewhat from the focus of the community health nursing, which focuses on individuals, families and groups.

UNIQUE ASPECTS OF HOME HEALTH NURSING

Home care nurses must function independently in a variety of unfamiliar home settings and situations. Because the home is the family’s territory, power and control issues and delivering nursing care differ from those in the institution. For example, entry into a home is granted, not assumed, the nurse must therefore establish trust and rapport with the client and family. Health care that is provided is often given with other family members present. Families also may feel more free to question advice, to ignore directions, to do things differently, and to set their own priorities and schedules.

Home health nurses have identified significant advantages in caring for individuals and families in the home. The home setting is intimate, this intimacy fosters familiarity, sharing connections, and caring between clients, families and their nurse. Behaviours are more natural, cultural beliefs and practices are more visible and multigenerational interactions tend to be displayed.

Home health nurses have also identified issues that negatively affect care in the home. More than any care providers, these nurses have first hand knowledge and experience about the burden of care giving. In the interest of cutting health care costs, policy makers, third party payers, and medical providers are placing increasingly complex responsibilities on clients’ families and significant other(s). Care giving demands may go on for months or years, placing the caregivers themselves (many of whom are elders) at risk for physiologic and psycologic problems. Additionally, nurses enter homes where the living conditions and support systems may be inadequate.

ROLES OF THE HOME HEALTH NURSE

Historically, nurses who provided direct services in the home were strong generalists who focused on long term preventive, educational, remedial and rehabilitative outcomes. Today many health nurses are generalists or specialists possessing high technology skills that were formerly used only in acute care settings. For example the nurses provide a variety of intravenous therapies in the home setting and monitor clients who are dependent on technologically complex medical equipment,

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such as ventilators and central lines. These nurses collaborate with physicians and other health care professionals in providing care.

Major roles of the home health nurse are:-

Advocate Caregiver Educator Case Manager or Coordinator

Advocate

Advocacy begins in the first visit. The nurse explores and supports the client’s choices in health acre, all viable options are considered. Advocacy includes having discussion about the client’s rights, advance medical directives, living wills and durable power of attorney for health care. It also usually involves assistance to access community resources, to make informed decisions, to recognize and cope with necessary changes in lifestyle, to negotiate medical insurance, and to understand ways to effectively use the complex medical system. Advocacy can be a particular challenge when family members’ or other caregivers views differ from those of the client. In the event of conflict, the nurse, being the client’s primary advocate, ensures that the client’s rights and desires are upheld.

Caregiver

The home health nurse’s major role as caregiver is to assess and diagnose the client’s actual and potential health problems, plan care, and evaluate the client’s outcomes. Direct personal care activities such as bathing, changing linens, feeding, and light housekeeping activities to maintain a clean and safe home environment are usually provided by a family member or a home health aide arranged by the nurse. The home health nurse, however, will provide direct care for specific procedures and treatment such as ostomy care; wound care, intravenous therapy, and so on according to agency policies and practices. Much of the home health nurse’s time is spent teaching others to provide required care.

Educator

The educative role of the home health nurse focuses on illness care, the prevention of problems, and the promotion of optimal wellness or well-being. Education is ongoing and can be considered the crux of home care practice; its goal is to help clients learn to manage as independently as possible. All home health nurse need to be skilled in teaching and learning principles and strategies that facilitate learning.

Being an educator or teacher is an important and primary role for the nurse. Clients and families have the right to health education in order to make informed decisions about their health. The nurse is in a position to promote healthy lifestyles through the application of health knowledge, the change process, learning theories and the nursing and the teaching process when teaching clients and their families.

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Case Manager or Coordinator

The home health nurse coordinates the activities of all other home health team members involved in the client’s treatment plan. Coordination can occur individually, in person or by telephone, with a specific team member such as the dietitian or respiratory therapist, or during a team conference where each team members provides information about the client’s health status. The nurse is the main contact with the physician or nurse practioner to report any changes in the client’s condition and to bring about a revision in the plan of care as needed. Documentation of care coordination is a legal and reimbursement and must be recorded on the client’s medical record.

SELECTED DIMENSIONS OF HOME HEALTH NURSING

Selected dimensions of home health care include

Safety Features Client Safety Nurse Safety Infection Control Caregiver Support

Safety Features

Client Safety

Hazards in the home are major causes of falls, fire, poisoning and other accidents such as those caused by improper use of household equipment (e.g. tools and cooking utensils). The appraisal of such hazards and suggestions for remedies is an essential nursing function.

Obviously home health nurses cannot expect to change a family’s living space and lifestyle. However they can express their concern and react appropriately when a situation suggests that an injury is imminent. Nurses must document information they provide and the family’s response to instruction, and make ongoing assessment about the family’s use of safety precautions.

Home Care AssessmentHome Hazard Appraisal for Adults

Client and Environment

Walkways and stairways ( inside and outside

Not uneven sidewalks or paths, broken or loose steps, absence of handrails, congested hallways or other traffic areas, and adequacy of lighting at night.

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Floors

Note uneven and highly polished or slippery floors and any unanchored rugs or mats.

Furniture

Note hazardous placement of furniture with sharp corners. Note chairs or stools that are too low to get into and out of or that provide inadequate support.

Bathrooms

Note presence of graph bars around tubs and toilets, nonslip surfaces in tubs and shower stalls, handheld showerhead, adequacy of night lighting, need for raised toilet seat or bath chair in tub or shower, ease of access to shelves and water temperature regulated at a maximum of 49 degree(120 degree F).

Kitchen

Note pilot lights (gas stove) in need of repair, inaccessible storage areas, and hazardous furniture.

Bedrooms

Note adequacy of lighting, in particular the availability of night- lights and accessibility of light switches, ease of access to commode, urinal, or bedpan, and need for hospital bed or bed rails.

Electrical

Note unanchored or frayed electrical cords and outlets that are overloaded or near water.

Fire Protection

Note presence or absence of smoke detectors, fire extinguisher, and fire escape plan, improper storage of combustibles (e.g. gasoline) or corrosives (e.g. rust remover)

Toxic Substances

Note improperly labeled cleaning solutions.

Medications

Note medications kept beyond date of expiration, adequacy of lighting for medication cabinet or storage, and method of disposal of sharp objectives such as needle used for injections.

Communication devices

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Note presence of method to call for help, such as a telephone or intercom in the bedroom and elsewhere (e.g. kitchen), and access to emergency telephone numbers.

Other aspects of client safety relate to emergency situations. The home health nurse can assist the client and caregivers as follows:-

Post a list of emergency telephone numbers (ambulance, fire, police, and physician) at each telephone.

Post a list of all the client’s medications and potential side effects in a central location, such as on the refrigerator.

Help the client and family apply for a medical alert system such as bracelet or necklace.

Nurse Safety

Some less desirable living locations pose additional safety concerns for the nurse. Many home health agencies have contracts with security firms to escort nurses needing to see clients in potentially unsafe neighborhoods. The nurse should avoid taking any personal belongings during these visits and have a reestablished mechanism to signal for help. Home health agencies provide training for nurses in ways to decrease personal risk.

Infection Control

The goal of infection control is to protect the clients, caregivers and the general community from the transmission of disease. This is particularly important for clients who are immuno compromised, who have infectious or communicable diseases, or who have draining wounds, drainage tubes, or other invasive access devices. The nurse’s major role in infection control is health teaching. Clients and caregivers need to learn about effective hand washing, use of gloves, handling of linens, disposal of wastes and soiled dressings, and the practice of infection control (standard precautions). Infection control can present a challenge to the home health nurse, especially if the home care An important aspect of infection control involves handling the home health nurse’s equipment and supplies. Supplies may include materials for hand washing, assessment equipment such as stethoscope, blood pressure cuff and monitor, thermometer, and tape measure, infection control items such as gowns, goggles, masks, gloves, and blood spill kit, and antimicrobial cleaning agents. Nurses need to follow agency protocol in regard to aseptic practice with these.

Caregiver Support

Care giving may be directed to individuals of any age and varies from short term to long term according to the physical or mental disabilities of the care receivers. The home health nurse needs to recognize signs of caregiver role strain and suggests ways to minimize or alleviate this problem. Signs of caregiver overload include the following.

Difficulty performing routine tasks for the client.

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Reports of declining physical energy and insufficient time for care giving. Concern that care giving responsibilities interfere with other roles such as those

of parent, spouse, work, friend. Anxiety about ability to meet future care needs of client. Feelings of anger and depression. Dramatic change in the home environment’s appearance.

APPLYING THE NURSING PROCES IN THE HOME

The application of the nursing process is focused on the needs of individual clients and their caregivers. The nursing process is used to identify, diagnose and treat human responses to health and illness. The skills required for nursing process are as follows:-

Cognitive/ intellectual skills Interpersonal skills Technical skills

Nursing Management

The elements or steps of nursing process are:- Assessment(of client’s problem) Diagnosis ( of client response needs that nurse can deal with) Planning ( of client’s care) Implementation (of care) Evaluation (of the success of implemented care)

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AssessmentDiagnosis

PlanningEvaluation

Implementation

NURSING PROCESS

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Assessment(of client’s problem)

The home health nurse assesses not only the health care demand of the client and family but also the home and community environment. Assessment actually begins when the nurse contacts the client for the initial home visit and reviews documents received from the referral agency. The goal of the initial visit is to obtain a comprehensive clinical picture of the client’s need.

Most agencies have an admissions or intake packet that includes forms for consent to treatment, physical, psychosocial, and spiritual assessments, medications, pain assessment, family data, financial assessment including insurance verification, client’s bill of rights, care plan and daily visit notes. During the initial home visit, the home health nurse obtains a health history from the client, examines the client, observe the relationship of the client and caregiver, and assess the home and community environment. Parameters of assessment of the home environment include client and caregiver mobility, client ability to perform self care, the cleanliness of the environment, the availability of caregiver support, safety, food preparation, financial supports and the emotional status of the client and caregiver.

Diagnosis ( of client response needs that nurse can deal with)

As in other care environments, the nurse identifies both actual and potential client problems. Examples of common nursing diagnoses for home care include Deficient Knowledge, Impaired Home Maintenance, and Risks for caregiver Role strain. Client education is considered a skill reimbursed by Medicare and other commercial insurance carriers, it is important for the nurse to include Deficient Knowledge in the plan of care .The deficit in knowledge may relate to client’s lack of information about their disease process, medications, self- care skills and so on.

Planning ( of client’s care)

During the planning phase the nurse needs to encourage and permit client’s to make their own health management decisions. Alternatives may need to be suggested for some decisions if the nurse identifies potential harm from a chosen course of action.

Strategies to meet the goals generally include teaching the client family techniques of care and identifying appropriate resources to assist the client and family maintaining self-sufficiency.

Implementation (of care)

To implement the plan, the home health nurse performs nursing interventions, including teaching, coordinates and uses referrals and resources, provides and monitors all levels of technical care; collaborates with other disciplines and providers; identifies clinical problems and solutions from research and other health literature, supervises ancillary personnel, and advocates for the client’s right to self –determination. Technical skills commonly performed by home health nurses include blood pressure measurement; body A large part of the nurse’s implementing role involves teaching the client and caregiver the necessary skills for self care- for example, administering insulin injections, measuring blood glucose, and administering medications. Medication instruction about

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dosage, frequency of administration and possible side effects is of particular concern for many clients. The clients who are receiving high technology interventions are often anxious about their ability to manage such sophisticated equipment. The home health nurse is challenged to alleviate the client’s fears and to provide through instructions and demonstration and periodic evaluation of the client and family’s performance of such skills. Members of the home care team specially trained in the skill such as intravenous nurses and respiratory therapists, generally make periodic visits to service the equipment and to monitor the client’s skills.

Evaluation and Documenting (of the success of implemented care)

Evaluation is carried out by the nurse on subsequent home visits, observing the same parameters assessed on the initial home visit and relating findings to the expected outcomes or goals. The nurse can also teach caregivers parameters of evaluation so that they can obtain professional intervention if needed. Documentation of care given and the client’s progress toward goal achievement at each visit is essential. Notes also may reflect plan for subsequent visits and when the client may be sufficiently prepared for self care and discharge from the agency.

THE FUTURE OF HOME HEALTH CARE

What is the future for home health care? Experts in the home health care industry have identified some trends:

Establishing ethics committees to handle ethical issues that arise in the home. These committees may be necessary for agencies to receive accreditation.

Providing third party reimbursement for community clinical nurse specialists and psychiatric nurse specialists. These advanced practice nurses can provide education, support, counseling and therapy for clients and their families.

Providing third party reimbursement for social workers. Social workers can assist clients and their families in the home with financial and household problems, freeing the nurse to focus on nursing care.

Utilizing nurse pain specialists to assess and manage pain in the home, thus avoiding costly hospitalizations and procedures.

Providing pet care for clients who may become too ill to care for them. Clients can make arrangements for the care of a pet if they are hospitalized or die.

Utilizing electronic home visits. A computerized system can obtain information, such as blood pressure readings, allowing case managers to review a client’s progress from offsite.

A. FAMILY NURSING

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DEFINITION

Family

“Family is a social group characterized by common residence, economic cooperation and reproduction. It includes adults of both sexes, at least two of whom maintain a socially approved sexually relationship and one or more children.”

- Murdock GP 1965

“Family is the co-existence of more than one human being involving continuous presumably permanent sharing of living facilities, a perception of reciprocal obligations, a sense of commonness, and sharing of certain obligations towards others.”

- Mauksch 1974

DEFINITION AND MEANING

Family Health Nursing

Family health nursing aspects of organized family health care services which are directed or focused on the family as the unit of care with health as the goal.

Family health nursing is thus synthesis of nursing care and health care. It helps to develop self care abilities of the family and promote, protect and maintain its health. Family health nursing is generalized, well balanced and integrated comprehensive and continuous are requiring comprehensive planning to accomplish its goal. Family health nurse works with the family with co- operation and active participation to help deal with its health needs and health problems effectively. The family is considered capable to deal with its health needs and health problems effectively when the family is able to:-

Maintain home environment conducive to personal development and health promotion.

Recognize its health needs and presence of any health problem. Make decisions about appropriate actions. Provide care to the sick, disabled and dependent members of the family. Maintain wholesome reciprocal relationship with the community and family.

In family health nursing, the primary concern of community health nurse is to help family develop and strengthen these abilities and give care until the family is not able to do so. The nurse makes use of nursing process in helping family meet its health needs and solve health problems.

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OBJECTIVES OF FAMILY HEALTH NURSING

To identify health and nursing needs and problems of each family. To ensure family’s understanding and acceptance of these needs and problems. To plan and provide health and nursing services with the active participation of

family members. To help families develop abilities to deal with the health needs and health problems

independently. To contribute to family’s performance of developmental functions and tasks. To help family make intelligent use of promotive, preventive, therapeutic and

rehabilitative health and allied facilities and services in the family and community. To educate, counsel and guide family members to cultivate good personal health

habits, practice safe cultural practices and maintain wholesome physical, psychosocial and spiritual environment.

GOALS

To help the family and its individual members reach and maintain maximum health through out and beyond the illness experience.

PRINCIPLES OF FAMILY HEALTH NURSING

Family health nursing is family focused, it is therefore essential to know the family from various aspects which include family structure and characteristics, socioeconomic and cultural factors, environmental factors and health and medical history of family members. Various methods are used for collecting information from the family. The data has collected are analysed and health needs and health problems are identified and prioritized.

Must establish good working relationship with the family. A good working relationship helps the nurse and the family knows each other and work together to plan, implement and evaluate family health and nursing care. Thus it helps in achieving family health goals and objectives. Working relationship is developed by knowing the family, giving due respect in culturally acceptable ways, listening to them, communicating intentions to help and the nature of help that can be extended, meeting their immediate felt need, considering their views and opinions etc.

Family health nursing is part of family health care services and based on identified family health and nursing needs. The community health nurse working in community health settings needs to know family health care policies, goals, objectives and the nature of family health care services. Accordingly she needs to plan and provide family health nursing services with active participation of the family members.

Family health nursing services should be realistic in terms of resources available. This requires proper estimation of health needs, health problems and resources in terms of money, manpower, material and time, prioritization of health needs/ health problems, mobilizing and developing more resources.

Family relates to community where it lives and depends on community in various ways. It is therefore essential to attain working knowledge of the community to help

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family to develop favorable attitude towards community and utilize community resources. She can also encourage families to contribute towards community health and welfare by active participation in such activities in the community.

Family as a unit is responsible for their members’ health and has a right to make health care decisions. Therefore, family must fully participate in all decision making relating to attainment of health. The community health nurse must recognize and respect this right and encourage active participation of the family in making health care decisions.

Health education, guidance and supervision are integral part of family health nursing. Information, education, guidance and supervision are very important because these help family to improve knowledge, develop competences, create interest and become self dependent. These elements must be included in the family health nursing care plan and implemented accordingly.

Continuous services are effective services. The community health nurse must maintain continuous contact with the family and provide care not only when the family is sick but also to promote and maintain health and prevent diseases etc.

Effective system of record and report of family health nursing service is essential. Proper maintenance of family health nursing record serves effective means for continuous care and its evaluation and further planning. Records must give information about family’s structure and characteristics, family environment, socio-economic and cultural factors, health and medical history of all members. It should give informations about health care planned, care implemented, objectives achieved, problems encountered and summary evaluative report over some period and suggestions for further plan.

Periodic and continuous appraisal and evaluation of family health situation and health services are basic to family health nursing care. Family is dynamic. It grows and develops with time and changes with place. The health needs and problems keep changing from time to time. These changes need to be assessed as the family grows and develops through various stages of development. This helps in meeting changing needs of the family.Evaluation of health and nursing care rendered is done on the basis of objectives, care planned and implemented and recorded. Evaluation gives feedback for further planning.

Family health nursing services should be rendered to all families without any discrimination. Every family has a right to attain optimum health and an environment conducive to healthful living so as to lead productive and useful life. Every family contributes to health of the community. Therefore family health nursing services should be available to all families based on their health needs and health problems.

ADVANTAGES OF FAMILY HEALTH NURSING

Family health nursing of patients saves hospital beds that can be utilized for critical cases.

Family health nursing is cheaper than hospital nursing. Patient under family health nursing enjoys privacy and emotional support. Patients on family health nursing can continue with their routine pursuits. If the patient resides in a sanitary house, family health nursing is better than hospital

nursing since he can control inimical environmental influences better.

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DISADVANTAGES OF FAMILY HEALTH NURSING

Family health nursing requires the nurse to carry portable laboratory machinery to the patent’s home.

If the patient resides in a substandard house, family health nursing could delay his recovery.

RANGE OF FAMILY HEALTH NURSING SERVICES

Therapeutic

The nurse carries out treatment of the patient as per the instructions of the physician.

Prognostic

The nurse notes the progress or lack of it in the patient’s condition and provides feedback to the physician.

Nursing care proper

The nurse helps the patient with feeding, dressing, application/ change of dressing or bandages, and so on, depending on the nature of illness.

Educative

She educates the patient and the family about the disease, its causes, treatment and the measures to avoid contracting it. She trains the family in caring for the patient.

Counseling

The nurse counsels the patient and assists him cope with physical and psychological complications of the disease. She helps the patient develop a positive and optimistic attitude.

Social assistance

Where necessary, the nurse arranges with the welfare organizations in the community to provide assistance in cash or kind to the patient.

Family diagnosis

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The family health nurse assesses the interactions between the patient and the family members. If she finds these are adverse and delaying patient’s recovery, she tries to correct them through suitable counselingAPPROACHES TO FAMILY NURSING PRACTICE

There are four approaches or ways to view families that have legitimate implications for nursing assessment and intervention. The approach that nurses use is determined circumstances, and nurse resources. The four approaches included in the family health nursing care views are:-

Family as the context Family as the client Family as a system Family as a component of society

Family as the context

When the nurse views the family as context, the primary focus is on the health and development of an individual member existing within a specific environment (i.e., the client’s family).Although the nurse focuses the nursing process on the individual’s health status, the nurse also assesses the extent to which the family provides the individual’s basic needs. These needs vary, depending on the individual’s development level and situation. Because families provide more than just material essentials, their ability to help the client meet psychological needs must also be considered. Family members may need direct interventions themselves.

Family as the client

The family is the foreground and individuals are in the background. The family is seems as the sum of individuals family members. The focus is concentrated on each and every individual as they affect the whole family. From this perspective, a nurse might ask a family member who has just become ill. Tell me about what has been going on with your own health and how your perceive each family member responding to your mother’s recent diagnosis of liver cancer.

When the family as client is the approach, family process and relationships (e, g.parenting or family care giving) are the primary focuses of nursing care. The focus of nursing assessment is usually on family patterns versus individual characteristics. The nursing process concentrates on the extent to which these patterns and processes are consistent with reaching and maintaining family and individual health.

Family as a system

The focus is on the family as a client and it is viewed as an international system in which the whole is more than the sum of its parts. This approach focuses on the individual and family members become the target for nursing interventions. For example, the direct interaction between the parent and the child. The system approach to the family always implies that when something happens to one affected.

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It is important to understand that although theoretical and practical distinctions can be made between the family as context and the family as client, they are not necessarily mutually exclusive, and both are often used simultaneously, such as with the perspective of the family as system. Family as a component of society

The family is seen as one of many institutions in society, along with health, educational, religious, or economic institution. The family is a basic or primary unit of society, as are all the other units and they are all a part of the larger system of society. The family as a whole interacts with other institutions to receive exchange or give communications and services. Community health nursing has drawn many of its clients from this perspective as it focuses on the interface between families and communities.

Improvement in the functioning of an individual will elicit improvement in the functioning of the whole family.

Because of the systematic nature of family, interventions can be directed at any of several levels with a resultant change in family operation.

The nature of the nurse client interaction is a crucial part of family nursing intervention.

Family nursing intervention needs to be modified to match different family needs, family styles, and levels of family functioning.

STEPS IN FAMILY HEALTH NURSING

a. Pre-visit Planning

Before making home visit, the nurse finds out the following: Address of the patient, including the near by landmarks. Information on the patient’s family. Information about the supportive services in the community.

b. Visit Proper

On the day of the visit, the family health nurse takes precautionary care against possible robbery by not putting on gold ornaments, by not wearing costly wrist watch, and by not carrying her money purse. She verifies her identify card is in her purse. While going to the patient’s house she avoids lonely lanes and deserted roads.

c. Commencement of Family Health Nursing

On reaching the client’s home, she introduces herself after greeting the patient and his family with folded hands. She explains the purpose of her visit. She creates trust in them and establishes rapport with them. She projects herself as a knowledgeable and competent person. This way she can ensure their cooperation and respect. She then interrogates and examines the patient. She enters the findings in the patient.

d. Termination of Family Health Nursing

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When nursing has concluded, the family health nurse fixes a date and time of her next visit. If, however, the patient’s condition has improved considerably, she announces she would not be visiting again.

FAMILY HEALTH NURSING PROCESS

Family health nursing process is a systematic approach to help family to develop and strengthen in capabilities to meet its health needs and solve health problems. It is deliberate process which facilitates standardized nursing actions to achieve family health nursing goals and objectives. The nursing process makes use of investigative approach to identify health needs and health problems and hypothetical solutions to identified problems. It is a tool which can be implemented at primary, secondary and tertiary level of care.

Family health nursing process is a problem solving and follows series of systematic steps to analyze health problems and find their solutions. Whether the problem is simple or complex, the process remains the same.. The process helps in providing systematic need based comprehensive health care services to the entire family within the resources available with their active involvement. It helps in achieving desired goals of health promotion, prevention and control of health problems.

Nurses interact with families in a variety of community based and clinical settings. The nurse uses the nursing process to care for an individual within a family (e.g. the family as a context) or the entire family (e.g. the family as the client). When initiating the care of families, there are three factors that organize the family approach to the nursing process. That all individuals must be viewed within their family context. Those families have an impact on individuals. That individual has an impact on families. The nursing processes are as follows:-A. Establishing a working relationshipB. Assessment of health needsC. Planning for nursing actionD. Implementing the programmeE. Evaluation of programme action

Steps of Family Health Nursing Process

A. Establishing a working relationshipB. Assessment of health needs Data collection Personal history Family history Home and environmental historyC. Planning for nursing action Goal setting and selection of appropriate strategy Formulation of nursing diagnosis Resources available Alternative plan of actionD. Implementing the programme

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E. Evaluation of programme action Formative Summative

A. Establishing a working relationship

The family and nurse maintain a working relationship. It is relationship which is maintained while working together by developing trust, confidentiality and empathy. These are essential components or elements to find out the facts from families and making correct decisions. A working relationship must have scope of two way communication. The family members must be given equal opportunity to give their views and ideas and express the feelings and vice versa. The nurse must have enough interactions with family members to guide and help them to solve the problem.

B. Assessment of health needs

Assessment is primarily concerned with first level or initial assessment which helps to know and explore family and health needs/ health problems and it refers to family identification. Assessment is a continuous process which becomes more accurate as knowledge of people deepens. As defined by Heparin,

“Nursing assessment is a continuous, systematic, critical, orderly analyzing and interpreting information about physical, psychological and social needs of a person, the nature of self care deficient and other factors influencing condition and care.”

Data collection

Collection of basic information – the information regarding family composition is collected about each family member’s name, age, sex, educational level, marital status, occupation and health status.

Methods of data collection

The information can be collected by various methods at home:

Observation

The family health nurse must be good observer, during home visit. Collection of information by observation gives realistic situation of health practices. Observation of home environment (physical, psychological and economical) and living condition will help to assess the general condition. Interpretation of the data will help for nursing interventions.

In family health nursing certain situations need direct observation. It is important to get acquainted with family/ environment along with patient and many things can be learnt by observation.

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e.g., in a family how mother holds the infant, the feeding techniques and how safe the environment is for child to prevent from hazards and the cooking methods for food hygiene can only be done by home visiting and observation. Interpersonal relationship of husband and wife, mother- child can be observed and make interpretations to find different health problems

Interviewing

Interviewing is a face to face conversation with a purpose. Interview is a method of securing information such as facts, opinion and personal history. Through interview process an individuals can mutually clarify feelings, attitudes and meaningful information. In this way family health nurse can gain increased understanding of behaviour and personal reactions of individual they serve. Thus, interview process can help individuals to recognize and understand their own problems.

Any type of successful interview includes a satisfactory environment, privacy and assurance of confidentiality. The home is suitable place for the community health nursing to interview the clients, especially when she has to interview for the first time, as the client will feel more comfortable, secure and relaxed in her own environment. Interviews can also be conducted in the clinics, offices, health centers and the place of work.

Techniques of data collection

Family health nurse should have the knowledge of various techniques of data collection, which can be used to collect information on family health, family environment and other factors affecting health of families. The techniques/ tools used can be:-

Questionnaire Structured Unstructured

Observation checklist Rating scale Interview schedule

Structured Unstructured

Assessment of Health Problems

Health problems can be identified into three categories:-

Health Deficits

Health deficits refer to instances of failure in health maintenance and development. Health deficits includes:-

Diagnosed/ suspected illness states of family members Sudden or premature or untimely death illness or disability and failures to adapt

reality of life emotional control and stability. Deviations in growth and development

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Personality disorders.

Health Threats Practices

Health threats refers to conditions which predispose to disease, accident, poor or retarded growth and development and personality disorder and a failure to realize one’s health potentials. The possible health threats are as under:-

Large family size Lack of/ inadequate education Ignorance Immature parents Strained family relation, conflicts, inappropriate role distribution Broken family/ single parent family Family history of congenital/ hereditary problems Unbalanced diet, improper dietary practices Poor hygiene and health practices Previous history of illness and obstetrical conditions Incomplete/ lack of immunization Strange/ inadequate relations with neighbourhood/ community Poor environmental conditions Inadequate housing facility Inadequate basic amenities Poor sanitation Environment pollution Accident hazards Unsafe water supply

Foreseable Crisis or stresses

Foreseable crisis situations or stress points, refers to anticipated periods of unusual demands on the individual or the family in terms of adjustment or family resources. These possible foreseeable crisis situations and stress points are as under:-

Marriage Pregnancy, labour, postnatal period, abortion, miscarriage Additional members in the family New born, guests Developmental stages New jobs, loss of jobs, retirement Death Menopause Change of residence

C. Planning for nursing action

Goal setting and selection of appropriate strategy

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A good assessment will make the selection of appropriate goals and strategies easier. Families determine the degree of change required. Often people can easily identify their own goals. However community health nurse has to assist in making a clear goal statement by achievable means. Be sure that neither community health nurse nor families are too ambitious. Goal should be clear and concise statement. Clearly written goals give a sense of direction in how to proceed in the care of the family. This increases the self confidence and trust and confidence of the family in you and your ability to provide care.

A goal must state a measurable outcome. This gives you the tool for determining whether or not your goal has been achieved. It is important to state one measurable outcome per goal. It helps you to keep the desired outcome separately and can be measured easily. There are three types of goals. They are as follows:-

Immediate Goals

The goals which require action within a short period of time as per need and crisis in the family. One of the positive effects of setting and achieving and immediate goal is that the nurse and the client will both feel a degree of satisfaction and sense of accomplishment because it has been achieved. This also gives confidence to both nurse and the family, as they continue towards the achievement of their short and long term goals.

E.g. If the mother starts antipartum haemorrhage, you have the immediate goal to care the mother with APH to save the life of mother and fetus.

Short Term Goals

The goals that are to be achieved over a specific period of time. These are the steps towards achievement of long term goals. They have specific time limit to accomplish the goals through in certain circumstances they may be some variation in time.

E.g. For mother, the long term goal is that she produces a healthy baby and she remains healthy till the end of the delivery and even after delivery. To achieve this goal various short-term goals are established like to assess the general condition, to do the investigation, regular antenatal check up and give health education etc. These short term goals have specific time period to achieve them.

Long-term Goals

The goals that are oriented towards the future and state the ultimate level of health care can be achieved. It is important that goals are realistic in order to achieve them. Unrealistic goals can lead to frustration, discouragement and waste of all efforts towards maximum health.

After assessment, the ultimate or long-term goals must be set as to what has to be achieved to keep the health status of the family.

The nursing needs which do not require immediate attention or action, the goals can be set as late priority than immediate or short term goals.

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E.g. A child having diarrhea requires immediate action to teach for oral rehydration solution (ORS) supplementation and control diarrhea is an immediate goal and providing immunization and health status to child is long term action or can be taken laterin long term, where the nurse will find the result in later stage. Hence the has to prioritise short and long term goals to provide efficient and effective health care to family.

Development of strategy

In many stances there may be more than one possible course of action that appear suitable to the solution of the problem. Community health nurse must look for all possible ways of accomplishing a goal, make a selection. Along with the family select the strategy which you feel will best serve to achieve the goal. Once it has been selected, then review the reason for the choice made and record the rationale. Do not discard the other strategies which might be helpful further.After selection of strategy, choose one or two alternatives, so that you can choose another one, if initial fails. Record the strategies together with the goals set. These strategies and alternatives must be discussed with family members.

These strategies become successful, when the family is encouraged to take the responsibility for selecting a course of action, even though the action selected may be less productive than one the nurse would have chosen. But it enhances the ability of family to make decisions and solve their own problems in health matters.

Formulation of nursing diagnosis

Once assessment is complete, review all the data, compile the risk factors and formulate nursing diagnisis.Since assessment is an ongoing process, it should be periodically reviewed, deleted and revised as per need. It is important to look at assessment data in totality and compile as overall functioning and health of the family.

The final step of family assessment is formulation of nursing diagnosis. The nurse, who practices in the community just like those practicing in other health care settings, formulates nursing diagnosis based on assessment data with complete data available. She can formulate more accurate and scientific diagnosis. This forms the foundation for development of a health care plan.

Resources available

Availability of health related resources and financial resources used by family members. Sometimes families need help in identifying these resources; they may not define as broad as community health nurse can do.Discussing the family’s financial status may be difficult initially, and family may be reluctant to disclose their finances, to a stranger. The community health nurse must be sensitive to such possibilities. The primary reason to know financial resources is to know whether or not they are to meet their basic needs and able to meet the needs during crisis. It is important to know the significance of strengths and weaknesses related to resources. Sources of the family’s income must be noted whenever possible.

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Alternative plan of action

D. Implementing the programme

Implementation of nursing process in family health care is foundation of nursing practice. Nurse uses family health care process to promote the health of families and differentiate from work with individual events. Implementing the health care requires home visits, working closely with families, community leaders, health workers, and other related agencies like social welfare and educational institution, etc. for comprehensive system to care.

Implementation is an ongoing process. Implementation of nursing care includes all activities that community health nurse undertaken to carryout the nursing care plan designed to improve the health of family and individual. In case of crisis situation in family, she should be prepared to crisis intervention by helping on appropriate resolution.

Implementing a nursing care plan implies that a careful assessment and planning process has been accomplished. After goals and strategies have been set-up family is ready to implement the plan. At the beginning the family is ready to implement the plan and may be enthusiastic and eager to accomplish the goals. The role of nurse is to be supportive and advocating these positive behaviours.

As the implementation process goes on, it may be necessary to change or omit certain strategies according to situation. Nurse can also facilitate the growth of the well- planned programme. Family’s satisfaction serves as the stimulus for adding further goal. Sometimes nurse observes the family’s readiness and raises the possibility of care.

E.Evaluation of programme action

“Evaluation is a process by which results are compared with the intended objectives or more simply the assessment of how well a programme is being performed.” Evaluation should be always considered during planning and implementation of programme or activity. Planning and evaluation must be viewed as an interactive process leading to continuous modification both of objectives and plans.

Evaluation of the family problems resolution and nursing strategies for interventions occurs throughout the nurses’ contact with families and at the point of terminating the relationship.Evaluation is not an end to family health care programme, it is continuing process integrated in the other phases. The ultimate goal of community health nurse is for the family to be self- supporting and independent in identifying the presence or absence of preventive health behaviour and skills in determining strategies and using appropriate resources.

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The nurse should observe for change in attitude during and after the intervention of care. If she notices the failure brings to the desired change, then she needs to go back to reset the objective, replan and reimplement the programming.

Types of Evaluation

a) Formative

Formative type of evaluation evaluates family health and nursing care plan as it is planned and implemented to determine its strengths and weaknesses at each stage and its progress towards meeting its objectives. As the plan is implemented, the community health nurse evaluates the family’s and or individual member’s response to determine the effectiveness of the actions planned and implemented and accordingly identify the need for change and or modify the nursing care plan. Formative evaluation is ongoing evaluation of day to day progress towards meeting health goals.

b) Summative

Summative type of evaluation concludes the progress or lack of progress towards the goal after several objective based actions are implemented. The reasons for the same are identified and modified and further actions are suggested.

Tools of Evaluation

These scales are used to elect the opinion, behaviour and attitude towards healthy practice. The tools which are used are as follows:-

Questionnaire

It is a tool in which the questions are formed in predetermined fashion, which are to be filled up by the respondents. Questionnaire can either be closed (yes/No response) or open ended (response from people)

Interviewing Schedule

A tool for responses which are recorded simultaneously. It can be structured or unstructured. It is useful to get responses from illiterate people when written questionnaire is not possible.

Techniques of Evaluation

Questioning

The questionnaires are prepared to evaluate the programme. The questions are asked verbally for the programme participants who are illerate and or are unable to read and write and responses are recorded, tabulated, analysed and interpreted to find the impact of the programme.

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Pen-pencil TechniqueThe questionnaires are given to programme participants to get the responses and interpret the results to evaluate the effectiveness of the programme. The technique is limited to educate people only.

Observation Technique

It is effective tool in community health, because many things can be interpreted by observational skills, while tally which may not be interpreted by persons like housing condition and sanitation, breastfeeding practices and child care etc. Observer must develop the skills of accurate and correct observation and timely recording. If good observation is made it gives an effective information regarding health, which can supplement to the interview or questionnaires. The opinionnaire is used to find the opinion of people regarding satisfaction level of health services available and helps to improve the health care facilities.

The observation checklist is prepared on the items to be observed, e.g., housing conditions

Child care Food hygiene

Demonstration of Oral Rehydration Therapy (ORT)

Interviewing

It is a direct conversation between interviewer and interviewee. In interviewing the interviewer asks a set of questions to the interviewee and gets responses on the interview schedule (prepared before hand) and the responses are recorded simultaneously.

NURSE’S RESPONSIBILITY IN FAMILY HEALTH CARE

The promotion of health care of families is a unique responsibility of a nurse. Nurses help them to identify the weaknesses. The nurse must be able to assess the family as a unit of health service of an integral

part. The nurse should functions as a problem solver, resource link and health educator to

promote family health.

BARRIERS TO FAMILY HEALTH CARE

Multiproblem family and difficult to prioritise the needs. Barrier to change: - The family may not understand to the concept of need. Language may be barrier, especially in rural population. They may not understand

the community health nurse’s language. Sociocultural: - The cultural of a family might interfere in providing family health

care. Hence, community health nurse needs to study such cultural and social patterns and adjust to those and try to remove such barriers by assurance.

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CHALLENGES FOR FAMILY NURSING

Delegation in the management of nursing care activities can become a challenge in family nursing. Often nurses are trying to make an impact on family health by delegating duties to family members or to other members of the health care team. For example the nurse helps family members learnhow to provide certain types of procedures to care for an ill family member. With earlier discharge and more complex family needs at the time of discharge, planning for discharge begins with the initiation of care by the registered nurse.

Discharge planning with a family involves an accurate assessment of what will be needed for care at the time of discharge, along with any shortcomings in the home setting. For example, if a postoperative client will be discharged to the home and the older adult husband doesn’t feel comfortable with the dressing changes required, the nurse first finds out if there is anyone in the family or neighborhood who would or could do this. If not the nurse arranges for a home care service referral. If the clients also need exercises and strength training, then perhaps a physical therapy referral is required.

Cultural sensitivity in family nursing requires recognizing not only the diverse ethnic, cultural, religious backgrounds of clients, but also the differences and similarities with in the same family. In family centered care, nurses learn how to integrate cultural practices, religious ceremonies, and rituals into family centered care. Using effective and respectful communication techniques enables the nurse to determine the family’s cultural practices and collaborate with the family to determine how best to integrate these beliefs and practices with in the prescribed health care regimen.

CONCLUSION

“Family health nursing is the practice of nursing directed towards maximizing the health and wellbeing of all individuals within in a family system. It incorporates two views of family, family as a unit of care and family as a contact. Family health nursing views the family as a system existing within larger system. Levels of intervention are the individuals the personal, the family system, and the environmental level. The goals of the family health nursing include optimal functioning for the individual and for the family as a unit.”

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.JOURNAL RESEARCH ABSTRACT

“Family Nurse Practitioner is a nurse who has received additional education and training necessary to function in the role of a primary care provider, performing many of the same tasks as a family doctor. In India, 80% of the health facilities are concentrated in urban areas. The rural areas where nearly 74% of the populations live do not enjoy the benefits of modern curative and preventive health care services. There is concentration of doctors’ upto 73.6% in urban areas where only 26.4 % of the population live. In the college of Nursing Community Health Programme (CONCH), Christian Medical College, Vellore, nurse run clinics are conducted by community Health Nurses with some experience. They examine, diagnose and prescribe treatment for the patients in the programme area as per standing orders. This research study was undertaken to study the extent to which the nurse in the role of a family nurse practitioner meets the primary care needs of the people and do recommend additional preparation needed by the nurse to function as a family nurse practitioner. The study revealed that the graduate nurses need additional preparation to function as family nurse practitioners in the field of community health.”

BIBLIOGRAPHY

Barbara Kozier Glexora Erb Audrey Berman Shirlee Snyder, “Fundamentals of Nursing” (Concepts process and practice), 7th edition, chapter- 9,Home Care, published in Indian by Saurabh printers pvt.Ltd,published by Pearson Education (Singapore) pvt.Ltd, Indian Branch,482 F.I.E patparganj Delhi 110092, India, 2004,page no.-140- 151.

BT Basavanthapa, “Community Health Nursing”, 2nd edition, chapter-6, Family Health Nursing, published by Jaypee Brothers Medical publishers, 2008, page no.-108-136.

Potter Perry, “Fundamental Of Nursing” 6th edition, chapter – 9, Caring for Families, page no. - 140-152.

Marcia Stanhope and Jeanette Lancaster, “Foundations of Nursing in the Community” (community- Oriented Practice), 2nd edition, chapter-18, Family Development and Family Nursing Assessment, published by Mosby Elsevier, page no. - 321-339.

Sunita Patney, “Textbook of Community Health Nursing”, First edition, Chapter – 8, Family Health Care, published by Modern Publishers, 2005, page no: 88-103.

Krishna Kumari Gulani, “Community Health Nursing (Principles and Practices)”, 1st Edition, Chapter-11, Maternal and Child Health, published by Kumar Publishing House, 2005, page no.: 354 – 366.

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JOURNALS

Dr. Jayanthi Milka Bai, M.Sc. (N), Chellarani Vijayakumar,M.Sc (N),Ph.D, Rosaline Jayakaran,M.Sc (N), Rajarathnam Abel, M.B.B.S, MPH, FICN., “Indian Journal of Continuing Nursing Education”, Role of the community health nurse as a family nurse practitioner January – December 2005, volume 6 , no. 2, page no: 24.

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