Family Nursing Plan of Care: The Orem’s Self-Deficit Nursing Model
The Healthy People 2010 objectives mirror the major health concerns in regard to the United States population at the beginning of the 21st century. The idea of the project is to engage diverse groups into building healthy community nationwide in both individual and collective efforts. Besides, by the current moment the acuteness of a healthy family structure has been reinforced. Therefore, effective family nursing strategies need to be implemented under holistic and family-centered guidelines.
As Grandine stressed, “‘Care that is family-focused requires a shift in the way that nurses think about and practice nursing from a mainly linear (cause and effect) perspective to a broader systemic (circular) perspective” (Grandine, 1995, p. 32, qtd. in Baggaley, 1997, pp. 29-30). Within the current trend, the data on family problems and health concerns is carefully selected and assessed to design and implement a teaching plan of care and information support for the family.
The current plan of care for the D family is structured within a supportive-educative nursing system. The purpose of the present family-focused plan of care includes four goals: first, to demonstrate an understanding of Orem’s theory in nursing care planning; second, to demonstrate an understanding of family theory; third, to integrate this knowledge and application to a specific family situation; and, fourth, to help promote the Healthy People 2010 national agenda for families.
Assessment data for the teaching plan derives from both direct and indirect observations in the home environment, Family Genogram / Ecomap, and personal interviews. One Healthy People 2010 objective and two nursing diagnoses in regard to the family are identified to complete plan of care.
Nursing Assessment
Family profile LD, 44 years old, is the single mother of a 17-year-old son VD. The woman married to V’s father a month and ten days before the baby was born. L and her husband divorced after seven years of family life. The ex-husband has not been present in L and V’s lives since then. For the past two years L has been dating with a boyfriend who did not support her either financially or emotionally. They started experiencing a tenuous relationship with each other for the past couple of months because of V’s substance abuse.
Being a college graduate, L used to work in several major Libraries in NY and Vermont area. Seven years ago the woman made up her mind to start a private book business. It seems that L’s job means a lot for her being the source of financial stability for the family and the source of adequate self-esteem. She travels a lot and often her traveling is a balanced mix of business and pleasure. To summarize, L is an intelligent woman, very active, physically fit and independent.
Son VD is a high-school senior with no particular devotion to studying. It is not that the young man is of poor talents but he is not oriented towards either career- or self-realization. V has been dealing with drug problem for the past two years. His mother is aware for the past year. The teenager is attending an anonymous anti-drug program. There he has met his mentor whom V chooses not to disclose any information about.
The mother and the son are Caucasian and do not stick to any religious rituals. English is their mother-tongue language.
Current health orientation L seems to consider herself to be healthy. She does not have any major illnesses and smokes less than half a pack a day, though her smoking history extends over 20 years. She keeps to a healthy style of life traveling and visiting a fitness center twice a week when her job lets her do so. Though it is impossible for LD to keeping to any diet due to the extensively occupied life mode, she tries to abstain from junk food rich with cholesterol and fat because of the diabetes disposition on her mother’s side. She is proud of being exclusively moderate in drinking alcohol (alcohol abuse became one of the reason for divorce; besides, L’s brother died of alcoholism).
V found inner resources to start controlling the situation with his own drug addiction. His drug problem includes marihuana and cocaine abuse; however, he is happy to report that he has never tried stronger chemically synthesized drugs, especially intravenously. He used to like active sports including basketball and biking. Upon the whole the adolescent seems to be rather healthy showing no disposition towards tobacco or alcohol abuse, obesity, cordial or other problems.
Health goals Both mother and son are enthusiastic about eliminating substance abuse problem out of their lives. Once Whyte paraphrased the observation (Ross 1994) that, “Meaning, purpose and fulfillment in life, suffering and death have been identified […] as crucial to health, well-being and quality of life” (1997, p. 18). It seems that V’s instability affects his mother private life and spirit equilibrium. She receives no support from her partner or friends as well as from extended family. L experiences high rates of anxiety and powerlessness over V’s lack of motivation. The family members cannot find consensus about the specific measures to overcome substance abuse and to improve family communication.
Family characteristics The community of researchers agrees that there is no single and dominant definition of family in its richness of characteristics; however, the structural functionalist (Parsons and Bales, 1955; Gouldner, 1970; Anderson et al., 1988; Hayford, 1988; Cheal, 1991; etc.) and the family developmental (Erikson, 1950; Duvall, 1977; Golan, 1981; Carter and McGoldrick, 1989; Dallos, 1991; etc.) approaches are reported to be the most influential. Recently, eclectic treatment of family institution with its multiple types, structures and functions gained importance (Wright and Leahey, 1990; Grandine, 1995; etc.).
In overall the D family represents the so-called incomplete (in reference to the classical “mother-father-child” type) family with a single mother and an adolescent sibling being raised without father’s participation. Grounding on Moroney’s definition, this is a nuclear isolated family type “with few or no contacts with other family units” (1986, p. 60). At the same time, this is “a psychologically interconnected, interdependent system, ‘operating within specific social contexts’” (Minuchin, 1974, p. 51, qtd. in Robertson, 1997, p. 119). The non-blood kinship (L’s friends and V’s mentor) plays a no lesser important role than blood relationships including extended family.
Whyte after Satir (1972) and Friedman (1992) stressed the important role of communication in the systematization of “family power structure, emotional closeness, roles and the popularity of individuals within the family” (1997, p. 19). In the D’s case, the mother and the son experience impaired communication and cannot exchange messages clearly.
To begin with, the absence of the father in the family is likely to affect affirmative microclimate. Being brought up in a traditional family of both parents present with two children, L thinks that the lack of father in her son’s life is one of the major dysfunctions. As Whyte acknowledged, “The quality of the father’s involvement in family life, and his support for his spouse or partner, are critical factors in family functioning, particularly where there is an additional caretaking task” (1997, p. 20). V is evidently seeking for the “father”-substitutes outside the family.
The role prescription inside the family is evidently modified due to internal and external factors. Living in a big city in the rather prosperous area, L took the role of money-earner, which has been traditionally performed by the father of the family. In this context, traditionally female affirmative background is left void in the family. In personal conversation, L opened to the interviewer her feeling of guilt for not having enough time for the son. She thinks that his drug addiction is partially her fault.
Scientific research did not prove that maternal employment always negatively affects children’s emotional supervision and support. Hoffman and Nye (1974) proved that in some cases the fact of mother earning family living enables the child to feel and behave more independently, increases his or her academic achievement and aspirations. However, Moroney observed that “working mothers are often made to feel guilty” (1986, p. 58). Both Moroney and Poloma (1970) emphasized that though women have penetrated deeper into the traditional area of male role functioning, professional occupation, they were not dismissed from their assigned feminine task of maintaining the household and childrearing. This overoccupation causes additional stresses both in full and single-parent families.
Meanwhile, V seems to be too mature for his age. So far as L is a busy woman, her son has to make a lot of decisions which require experience and life wisdom far exceeding the scope of a 17-years-older. He describes his relationship with his mother as “friendly co-inhabiting,” meaning that they function more like partners than the child and the mother.
Relying on Maccoby and Martin’s (1983) fourfold scheme of parental characteristics in regard to children socializing and competence pattern, L belongs to the type of indulgent-undemanding parents who are permissive, tolerant and accepting toward children’s impulses, make few demands and do not impose restrictions on children (Pellegrini, 1998, p. 181). Children, meanwhile, are allowed to regulate their own lives. According to Baumrind (1967, 1971, qtd. in Maccoby & Martin, 1983), it may result in children lacking impulse control, self-reliance, independence, and social responsibility.
L had very hard times having learnt about V’s drug addiction. The family had the experience of living through the crisis earlier. The case of abortion in 1990 five years prior to divorce affected L mostly, whereas the divorce itself, which has happened because of the spouse’s addiction to alcohol, influenced both L and V. That stress could be termed as developmental transition (Pittman, 1988) having formed “a predictable pattern in the family developmental life cycle” (Whyte, 1997, p. 42). The crisis was little discussed between L and V, so the hidden reaction was confusion and isolation. The drug abuse was more like a case of structural transition having been caused by the previous one. Whyte defines it as “a defect in family structure which makes it resistant to change and predisposes it to conflict” (1997, p. 43). According to Bailey and Clarke’s classification (1989), first, both family members used palliative coping mechanisms. This type of coping “similarly does not change the problem, but may temporarily reduce the feelings of threat to the individual” (Whyte, 1997, p. 50). While the son has been hiding the truth from his mother for about a year, L pretended that nothing was happening though she sensed the danger.
As Whyte noted, “Coping is a dynamic process, since it is initiated by change and is integral to resolution of crisis and adaptation to loss” (1997, p. 48). On the current moment, V seems to change his palliative coping pattern for direct making “reality-based efforts to deal with the demands of the situation by direct action, with a view to reducing the demand or threat” (Whyte, 1997, p. 49). L supports him in the initiative though she does not try to participate more fully in her son’s efforts shifting the authority onto the anonymous mentor.
Environmental characteristics L and V live together in the economically stable neighborhood in Queens, NY. This is a modern building with a doorman and an elevator. The house is located near the famous Forest Hills which is situated in the ecologically clear zone with developed city infrastructure.
Universal Self-Care Requisites are listed in the Orem care plan in details. The symptoms of fluid volume deficit and breathing problems in regard to V are supported by research that proves: people abusing stimulants (Sullivan and Thompson, 1994, in Heaven, 1996, p. 114) such as cocaine and amphetamines irritate nasal passageway and may destroy nasal mucous membrane (Heaven, 1996, p. 115). The habit of cocaine and cannabis abuse may cause paranoid-type reaction, manic states, severe depression, or panic states (Sullivan and Thompson, 1994, in Heaven, 1996, p. 115). The neurosensory problems such as risk for peripheral neurovascular dysfunction, visual, auditory, kinethetic, gustatory, and tactile sensory-perceptual alterations may also be observed.
Developmental Self-Care Requisites Baggaley stressed that. “The family is also a dynamic entity which, while it maintains some form of structure and identity, is constantly adapting and evolving to accommodate change brought about from within and without” (1997, p. 31). According to Carter and McGoldrick (1989), V is on the stage before the developmental period when “It is a time to formulate personal life goals and to become a ‘self’ before joining with another to form a new family sub system” (Carter and McGoldrick, 1989, p. 13, qtd. in Baggaley, 1997, p. 31). Besides, V seems to experience the psycho-developmental period of implicit “breakdown” meaning that he “omnipotently avoid[s] the conflict and therefore not work it out – through drugs, crime, a kind of narcissism about adolescence that implies that one does not have to adapt to adult life, the counter-culture, the denial of the need for adult adjustment” (Laufer, 1997, p. 78). On her side, L is the subject for decisional and parental role conflict. She seems to acknowledge that her coping and communication patterns are ineffective and verbally demonstrates readiness for improvement. Upon the whole, the D family is on the stage of families with adolescents, though, the chronology of family development is corrupted.
Health Deviation Self-Care Requisites Using the Roper et al. (1990) model both V and L seem to be the “clients,” although they need to be assisted in perceiving themselves as the family. Both horizontal stressors (“the developmental stressors concerned with life cycle transitions,” Carter and McGoldrick, 1989, Baggaley, 1997, p. 32; partially unpredictable stressor of substance abuse on V’s side) and vertical stressors (impaired family structure, uncompleted family and personal value expectations) intersect to create a non-healthy environment in both physical and spiritual sense. Thus, the family may also be treated as the “client.”
Plan of Care (see Appendix)
To draw a bottom line, the D family is assisted to eliminate substance abuse problem and to improve family structure and communication within the Orem self care health plan designed after supportive-educative nursing system requirements. The nursing assessment was conducted in direct and indirect observation, personal conversation, and Family Genogram / Ecomap.
The investigation of the D family helped to identify the following diagnoses: (a) substance abuse on VD’s side related to developmental and structural transitions in the family as evidenced by client’s and his mother’s verbalization of ineffective coping and communication as well as by indirect observation (there are impaired power relations and impaired family roles); impaired family relations related to inadequacy of intra-family and social communication and weakened self-concept on both the family members’ sides; (c) high level of anxiety on LD’s side related to her son’s substance abuse, lack of support from either extended family or partner, sense of powerlessness and impaired caregiver function as reported by the woman in personal conversations and both direct and indirect observation.
Nursing interventions include both nurse- and family assigned methods such as circular questioning, agreeing goals and tasks, reframing, promoting positive communication within the family, reducing the role strain for the client, supporting the family’s strengths. The family is encouraged to participate in counselling and model programs aimed at substance abuse elimination, academic and self-motivation improvement, decision-making and stress management. The supposed period of intervention is six months.
References
Baggaley, S. E. (1997). The family: Images, definitions and development. In D. A. Whyte (Ed.) Explorations in Family Nursing (pp. 27-39). London: Routledge.
Heaven, P. C. L. (1996). Adolescent Health: The Role of Individual Differences. New York: Routledge.
Laufer, M. (1997). Defining breakdown. In M. Laufer (Ed.) Adolescent Breakdown and Beyond (75-87). London: Karnac Books.
Moroney, R. M. (1986). Shared Responsibility: Families and Social Policy. New York: Aldine De Gruyter.
Pellegrini, A. D., & Bjorklund, D. F. (1998). Applied Child Study: A Developmental Approach. Mahwah, NJ: Lawrence Erlbaum Associates.
Robertson, A. (1997). A systemic approach to supporting the families of children with learning disabilities. In D. A. Whyte (Ed.) Explorations in Family Nursing (pp. 118-131). London: Routledge.
Whyte, D. A. (1997). Family nursing: a systemic approach to nursing work with families. In D. A. Whyte (Ed.) Explorations in Family Nursing (pp. 1-27). London: Routledge.
—. Coping with transitions: Crisis and Loss. In D. A. Whyte (Ed.) Explorations in Family Nursing (pp. 39-54). London: Routledge.