In order to be a successful nurse, assessment skills are vital. During my career as a student nurse, I have done many assessments on patients. The real skill, though, is to be able to assess any situation. Below, I have a family visit I conducted. I did a full assessment of this family and formulated plan of care for certain health problems I noticed during my assessment.
Family Visit- Background Data
I received permission from R.G. to conduct a family visit with her. The consent form is signed and on file at Middle Tennessee State University School of Nursing. R.G. is a 27-year-old female. She is married to R.G. and they just celebrated their five year wedding anniversary. They are both currently employed full-time and have been in the same professions for several years now. R.G. and her husband live in the neighborhood where I conducted my windshield survey, which is Blackman Farms in Murfreesboro, Tennessee. They have lived there for about one and a half years. They do not currently have any children. The couple is currently going through fertility treatments to conceive a child. They are both in good health with the exception of R.G. being overweight and they both smoke.
As mentioned, they live in Blackman Farms. They are the only people to have lived in their current home. They actually had the home built to suit their needs. It is a two story brick home. There are stairs leading to the front door as well as inside the home. It has a two car garage and the lawn and flowers are well kept. The lighting is adequate and the home has several windows to let in natural light. There are no immediate hazards found in the home. The family has a small dog that lives indoors with them. They have immediate access to a vehicle and a telephone if needed in an emergency situation. Most of their family live local with the exception of a few relatives in South Carolina. They have a large family with whom they are close to. They have an excellent support system.
Assessment Tools and Results
The two assessment tools I chose to use with R.G. were a spiritual assessment tool and a family genogram. The spiritual assessment tool I used consisted of several religion based questions to determine a religious status as well as identify any disparities that may be present. The assessment revealed that R.G. is a Southern Baptist who considers herself and her family to be very spiritual. She stated that “God, family, and her friendships” give her meaning in life. Religion is important in her life. When it comes to her health, she states that “God will heal me when I am suffering.” R.G. is involved in a church. Her church uplifts her with prayer and support thru hard times she has faced. She feels close to her church family and they are very important to her. Overall, R.G. seems to be set firm in her beliefs. The only disparity noted is her difficulty conceiving a child. She does believe that God will give her a child when the time is right and she has a positive outlook on this sensitive subject. The second tool used was a family genogram. A genogram is a tool used to map out ones family and identify committed, broken, biological, and special relationships. R.G. still has all four grandparents living which are all in committed relationships. Her father and mother divorced while R.G. was in high school. R.G. has one brother who is two years younger than her. She has a good relationship with both parents as well as her brother. R.G. has three aunts and one uncle on her father’s side of the family and three uncles and one aunt on her mother’s side of the family. All of the above relatives are living and are in good standings with one another. I enjoyed using this tool because I have never used this on a client before. It was a good experience for the client to sit down and think about her family tree and try to remember birthdates, etc.
Nursing Diagnosis and Plan of Care
The nursing diagnoses chosen for this family are health-seeking behaviors and imbalanced nutrition: more than body requirements.
Health-seeking behaviors related to smoking as a risk factor for coronary artery disease as evidenced by a desire to seek a higher level of wellness. Goals for this family related to this diagnosis are the client will state the need to stop and/or decrease smoking, to know the hazards of smoking, and to learn about different ways to stop smoking. Nursing interventions include: determine the client’s ability and motivation to promote a higher level of wellness, discuss hazards of smoking, and suggest ways to stop smoking (cutting back, get support, perform alternate activities).
The reason this diagnosis was chosen, is because at this time smoking is the greatest risk factor in their personal lives. Cardiovascular disease is a major concern for a client who smokes. R.G. is also overweight, which puts her at a higher risk for developing cardiovascular disease. They are also trying to get pregnant and smoking may decrease the chance of pregnancy occurring.
The second diagnosis used is imbalanced nutrition: more than body requirements related to excessive intake as evidenced by the client’s weight being greater than 200 pounds and the food choices she makes are poor. Patient goals related to this diagnosis are to identify internal and external cues that increase food consumption, state the need to lose weight, and to identify a weight loss plan that will be appropriate for her lifestyle. Nursing interventions include: help the patient identify the need to lose weight, help come up with realistic healthy food choices, and provide emotional support and positive feedback as the client starts weight loss regimen.
This diagnosis was chosen because as mentioned before, the client smokes and is overweight which put her at greater risk for cardiovascular disease. This is a life threatening disease that can be avoided if one chooses a healthy lifestyle. The above diagnoses may help the patient live a longer and healthier life. By losing weight and quitting cigarettes, R.G. and her husband may be able to easily conceive their first child.
Self Reflection of Family Visit
R.G. was very receptive to my questions and willing to provide me with complete and accurate answers. This family seems to be functional and content. With the exception of the smoking and the weight gain, both individuals are healthy and active in the community.
This family visit was enjoyable and informative. I was able to assess a younger couple, which I have not done before, and help them come up with a plan for a healthier lifestyle. As a community health nurse, it is important to realize that many members of our community can use our help, even if they don’t seem to need help. There is always some way we can improve our lifestyles. It is important to be able to identify problems within the community and come up with a plan of care for these issues.
