Selected Family Health Promotion Assessment and Initiative - Research Paper Example

Selected Family Health Promotion Assessment and Initiative Many families are benefitting from community health care because they can see the health practitioner in their homes. Community nursing is important also because the nurse can assess the situation in the environment in which the family is accustomed. The family that I have chosen has a member who is about to undergo bariatric surgery. The family and I will discuss some of the goals of the surgery, some of the needs for the family and for the client as well, and any resources that may be needed. I will use "A Developmental Model of Health and Nursing" (Allen and Warner, 2002) as well as several other academic journal articles. I will also take the family through the Freidman Assessment Model. Because this family member is going in for surgery soon, our visits will be arranged just before surgery, a few weeks post surgery and a few weeks after the surgery. I am particularly interested in making sure that the family understands how differently their lives will be once their mother has this surgery. Teaching Philosophy The way that I enjoy teaching others is to allow them to talk while I take notes and ask questions. I find that when I just allow the client to talk, they are prone to give more information. I will talk to supervisors if necessary in order to get their feedback on situations where I am not sure of a situation. I want feedback from all people involved with the process as well. Friedman Assessment Model Identifying Data My interviews were with the Randall family. They are a nuclear family with two adult children and a mother and father. The father is the only one working at this time because Mrs. Randall is overweight with several health problems. The two children are grown, with and 18 year old daughter and a son who is 22 years old. Both children live at home with the son going to college and the daughter working in an elementary school as a teaching assistant. The family is Caucasian and they say they come from a melting pot in their heritage. They were dressed casually for all three visits. The family is used to having mom make full meals for breakfast and dinner, but everyone eats out for lunch (except mom) during the week and they usually eat fast food. Family members try to eat three meals together on Sundays when everyone is usually home. The family has no real religious affiliation although they say they are non-denominational. They do not attend church regularly but they sometimes go to a local Baptist church on special occasions because they like the music. As stated previously, the father is the major wage earner who works as a licenses mechanic. The daughter works part-time as a teaching assistant in an elementary school. Developmental Stages and History of the Family The family's current developmental stage is Stage IV, families launching young adults. The son is already going to college and although he stays in a dorm during the week, he is home on the weekends. If he gets bored in the dorm, he sometimes comes home during the week and stays overnight. The daughter is thinking about going to college in the next two years but she cannot decide between community college or one of the local universities. The family seems to get along well and they are close to one another. The family also has to adjust to the fact that their lives will change and may be in an uproar once their mother goes through the surgery. Schedules will change along with eating and cooking habits. Developmentally, this may change some of the behaviors of the other family members. The family is fulfilling developmental tasks by helping both children as they are ready to leave the home and move into their own apartments. Mr. and Mrs. Randall have helped their son find the university and get settled in. They have helped their daughter find information on colleges and they suggested working in a school because their daughter wants to work with children. Their son will be a junior in college next year and he is already talking about moving into his own apartment. Both parents are close to their children and they have an extended family comprised of grandparents and several close friends. Environmental Data The family lives in a two story home that has plenty of room for everyone. The house is about 20 years old. The home is free of safety hazards, the windows all have locks and the family locks doors if they are out or at night before they go to bed. The home is well ventilated and they have air conditioning for the summer. They have three smoke detectors that they check regularly to make sure the batteries are working properly. There is a small fire extinguisher in the kitchen and an evacuation plan is posed in several locations throughout the house. The major form of heating in the home is gas and they have a gas fire place that is maintained regularly. There is a combination smoke detector and carbon monoxide detector in the home. They maintain a first aid kit in the hall closets on both floors. Medication is stored properly and labeled. Cleaning products are also stored properly. The driveway and walkways to and from the home are in excellent condition. There are two large outside lights, one in the back of the house and the other in front to mark the way to the home. The lights are motion detectors that can be regulated to detect only certain motions. They have someone who cuts the lawn for them and in the warmer months and they have someone to shovel the snow in the winter. The car doors are always locked if they are in the driveway; they do have a two car garage. The family paid off their mortgage two years ago so they did not have to worry about losing their home during the current economic crisis. The family loves their home because it fits their needs: there are enough bathrooms and living space for everyone. Everyone in the family has chores to do each week and the house is kept neat and clean. The home sits within a community of many friendly neighbors. The mother's sister lives nearby. The larger community is friendly and quiet and it is also very clean. They alive at the end of the street in a cul de sac and their street has eight other houses on it. Everyone's yards are clean and uncluttered, lawns are kept mowed, and snow removal in driveways and sidewalks are kept clear in the winter. The family lives in a small town and the larger community has several restaurants, a bookstore, coffee house and a small strip mall about 15 minutes from the family's home. The streets around their area are in good condition and the sanitation is clean. Very little traffic comes down their street or on the main street that leads to their home; there are no traffic jams to speak of and no problems with air or water pollution. They also live in a very quiet neighborhood. The family perceives that they live in a safe neighborhood and they do not see a lot of crime in their area. Both adult children went to the local elementary, middle and high school and the family knows everyone in their neighborhood; the neighbors are friendly. Family Structure The family generally has conversations when everyone is home and having their meals. They all have cell phones so communication during the week is often via phone or email, depending on who wants to talk and the subject matter. The family's culture is open to free expression and they make good eye contact with each other when communicating. They are able to express their emotions usually but the bariatric surgery has created some communication challenges. Gender differences show that the father communicates well but he can hurt feelings because he speaks frankly. Mrs. Randall has been more open in her communication, but her decision for bariatric surgery has created a few challenges for her self-esteem in discussing this with the family. The power structure of the family seems to be equal. When there are important topics to discuss, they hold family meetings. As an example, when Mrs. Randall wanted to pursue bariatric surgery, she brought the information to the family meeting. If there is something the children want to do that may have an affect on the entire family, they bring it to the family meeting and mom and dad together make the final decision. Financial decisions are made by mom and dad, especially when it is a large ticket item like a car or an appliance. If there is something that is a concern for the whole family, everyone has a voice and they cook for a solution that will be of benefit to everyone. Family Functions This is a family that was raised with a foundation of love and trust. They are nurturing towards one another and they are open to showing love and affection easily. They are a very close knit family and because they have this foundation of love and affection, they are also able to show their love to others, which means they have many close friends. There is love and mutual respect with the family and their friends. In Friedman's Model, this is an example of Affective Function. The parents raised confident and competent children because they did not believe in spanking their children. Instead, they talked to them. When they did something that they were not supposed to do, they were talked to and given consequences for their actions. If they did well in school or at home, they were praised. The family is very social and together formed a bond of affection and mutual respect. Both parents taught their children the difference between acceptable and non-acceptable behavior. In the healthcare function, the family believes that health is important and they visit doctors regularly as needed; they also attend the dentist. The family used to go on bike rides and did lots of walking until Mrs. Randall began to gain weight and could not do the walking easily. Mrs. Randall is doing the bariatric surgery so she can "get my life back". The family from time to time will eat healthy meals, but there is also a lot of fast food or snacking. The family talks to their doctors about any health issues that may come up and they have a very good friend that is a nurse. They also use the Internet to find information about any health issues they may experience. Family Stress, Coping and Adaptation The Randall family is experiencing stress because of Mrs. Randall's decision to do bariatric surgery. They have been given all of the technical information they need but they are not sure about what will happen after the surgery. They understand that their mother and wife will go through changes on many levels, but they are not sure what those changes will mean to the family. Although Mr. Randall understands that his wife will lose weight, which may change the way she sees life, he has grown to lover her the way she is and she has been obese for many years. He is not sure what her weight loss will mean to him. The children do not cook very well and they are afraid they will now have to cook for themselves or that their mother will not be able to cook the meals they have enjoyed. The family has the information they need and they have attended two support groups with their mother before the surgery, but they are hesitant in terms of what will happen to her as she begins her weight loss program. The family states that their coping style is usually to find out all the facts about something that is stressing them and then to talk about the stress as a family. They have done this to the best of their ability with the surgery. They usually are very flexible to change, but some of the changes they will have to make after the surgery will depend on their ability to be flexible from one day to the next. In other words there are some aspects of the surgery that they will not be able to predict ahead of time. Overall Assessment and Planning Martha Randall is a 56 year old female who has elected to have bariatric surgery. She is going to have the Roux-en-Y gastric bypass in just a few weeks. Martha has done as much as she can to prepare her family and herself. The reason she is doing this is because she has a BMI of 67, which is considered "super obese." (Grindel and Grindel, p. 130). In addition to her obesity, Martha has sleep apnea and sleeps with a bipap machine. She also has high blood pressure, asthma and poor circulation in her legs. Her doctor has told her that she must "do something drastic" or her health will continue to be compromised. Martha did all the footwork and weighted her options before she decided on the surgery; she felt she would have the most success with the Roux-en-Y. The health problems that Martha has are considered the co-morbidities that made her a candidate for the surgery. According to Grindel and Grindel, "bariatric surgery is effective for weight loss in the morbidly obese patient and can result in improvement of obesity related co-morbidities …" (p. 130). Martha says she is doing this because she wants her life back. She misses doing things with the family and with her friends. Martha's family is being prepared for her changes. She will continue to change for the next year. She is planning how she will acquire new clothes and what she will do for exercise. She is aware that she may see changes in her family and in her friends as she begins to lose weight and change herself. She is already attending support groups which is a part of the system of wellness that bariatric patients' use as a resource. She has also connected with a therapist in her community that she may use if there is a need. Goals and Concerns The family has done an excellent job of gathering information about the various types of bariatric surgery. They have talked to the surgeon and to me about the process and what to expect. One of the areas we talked about extensively was the after effects of the surgery. I had the family meet with a small group of people who had the surgery one to three years ago so that they would understand that the first year is often the most difficult. Because there are a variety of vitamin supplements and other nutritional supplements that must be taken, and most must be chewable or liquid, one of my duties was to help them find these items. I found a resource called Bariatric Advantage that provides vitamins and protein supplements prepared specifically for bariatric patients. The supplements are a very important part of post surgery planning and they must be affordable and easy to obtain. We also went over techniques to avoid dumping syndrome. First Visit In the first visit with the family I spent time getting to know them and understanding their needs. Martha was a wealth of information about the surgery and she admitted that she had some reservations, especially about the pain. As Allen and Warner (2002) state, I focused on the health aspects that the client showed. In this situation, it was more important to emphasize the health aspects to lead the family through the entire process. Talking about how healthy Martha would become helped the family focus on the positive effects of the surgery. We also talked about the complications that can happen. Some of the complications that can happen with the Roux-en-Y procedure include leakage of the pouch that is created, poor healing in some areas or wound dehiscence (Clutts, 2009, p. 337). Martha was aware of these possibilities, but she is confident that she will come through the surgery with no complications. Second Visit The second visit was just after Martha had her surgery, within the first week of her being home. This was a chance to talk to the entire family about the surgery and Martha's changes. The family realized that they must help cook now because Martha has to take care of her own needs. For the first 14 days she is on a liquid diet that consists of clear soups, broth, gelatin, sugar free popsicles and lots of water. For the next 14 days, she will be on a pureed diet which allows tea, crystal light, cream soups, pureed vegetables and meats (Martha has a list of what she can have through each phase). In the following 14 days, she will have a soft food diet consisting of soft cooked pasta, vegetables, unsweetened fruits, fish, poultry and other nutritional foods (Grindel and Grindel, p. 139-140). I went over this food plan with the family so that everyone would understand what Martha was doing and why. I also made suggestions as to ways they could help Martha. We brainstormed additional foods that fit into each category so that Martha could have a variety. WE went over the nutritional needs and made sure that Martha had all she needed to continue her progress. Third Visit This next visit was during her soft diet week because I wanted to see how Martha was doing several weeks out. She had been to her surgeon again for her first weigh in and had lost 38 pounds! This is normal in the first month because a lot of the weight that is lost is water retention. I also wanted to discuss her fitness plan. For people undergoing bariatric surgery, exercise can be difficult, especially when they have been sedentary for many years. Most doctors tell their patients to walk, but this is not always easy for someone who has been morbidly or super obese. Martha has trouble walking because she has edema in her legs and she has flat feet. She was fitted for orthotics that help some but she is out of breath easily; her doctor has suggested using oxygen when she is walking or working out and she has started on a small amount when she is out and about. Her doctor says that as she loses more weight, she will be able to stop the oxygen. The issue of exercise is particularly important for the post bariatric surgery patient because it helps them become active and help with the weight loss. Hunt and Gross (2009) recognized that exercise was difficult for this group and studied it according to tow theories. They wanted to understand the best way to encourage someone to exercise and to discover the predictors of those who would follow through with it. What they found was that the Theory of Planned Behavior was the best predictor of whether someone would stick to exercise. This basically meant that those patients who were able to identify an exercise plan were more likely to exercise than those who did not have a plan. In Martha's case we developed a plan that would help her stay focused on exercise and keep her interested in doing more. Martha has joined a recreation center that has a variety of fitness programs. To start, she is taking an aqua program geared to people with arthritis or other joint problems. This is helping her to acclimate herself to exercise and it will build stamina and work on her core area. She can then progress into the water aerobics program at a later time. She has enough variety in the programs they offer that she can add other types of programs as she becomes stronger. As an example, they have sports teams for bowling, golf or tennis, and they have martial arts and other activities. Martha is happy with this variety. As she feels ready, she will also start taking walks with her children again. Post Operative Care and Follow-up Follow-up is a very important aspect of bariatric surgery. Some surgeons require a patient to follow-up once a month for the first year after surgery. Harrington (2006) states that post operative care can include: "oxygenation and hemodynamic monitoring, pain management, wound care, nutrition therapy, education and emotional support" (p. 359). Although each of these is provided in the hospital after surgery, the patient must be sure to follow-up with their post-operative care program to make sure that everything is going well. Martha and I talked about her follow-up and she goes once a month to the surgeon's office. She obtains her B-12 shots there and then has any new questions answered. One of the major issues for her and her family that appeared was that her eating habits had to change. This meant that she eats more protein during the day, drinks lots of liquid and includes fruits and vegetables. However, she cannot eat desserts any more and she cannot snack on some of her favorite junk foods. This also meant that as her family eats large meals, she is limited to two ounces of food. The family expressed concern that she was not getting enough to eat, but Martha assured them that she is getting enough food. Martha supplements her meals with approved protein drinks and protein bars (approved by her surgeon). The family had some anxiety about eating in front of Martha, so she took them to the support groups so they could talk to other people who were living with bariatric patients. Everyone has some of the same concerns if they are considered the "caregiver" in the situation. The family had to be reminded that this is Martha's journey and she must do what is best for her--their job is to support her efforts. In my follow-up, I was particularly interested in what I should do as a nurse to make sure Martha was getting what she needed. Doolen and Miller (2005) gave some answers to this concern. They suggest that one of the greatest concerns is to make sure that the patients receive their nutritional needs. They must make sure they are getting their vitamins and mineral supplements as well as enough protein. Bariatric patients need to take supplements for vitamins B-1, B-12, calcium with vitamin D, Foliate, Iron and Vitamin A (Doolen and Miler, p. 448). These supplements prevent malabsorption and prevent other physical challenges. Patients must be ready to take the initiative to take care of themselves for a life time. They will always need the supplements and they will eat in this way for the rest of their lives (Doolen and Miller, 2005). McGlinch et al. (2006) suggest that planning must happen before the patient goes into surgery. This was an important part of Martha's planning in the beginning and she did her research to make sure she was doing what was right for her. They suggest that once the patient is home from the hospital, the community nurse can assess any early signs that there are complications. By understanding bariatric surgery and the patient's description of any symptoms that may sound like something is wrong, the nurse can give a better understanding of what needs to be reported to the patient's doctor. I have discussed this with Martha during her follow-up visit and she seems to understand what challenges may need to be sent to the doctor. I was satisfied that she was doing well and would report any complications that may be present. In looking at Martha's overall view of health, it is clear that she grew up in a family that valued health and that she has passed this information on to her family. For reasons she did not disclose, she started gaining weight a few years ago and had made many efforts to reduce her weight but these efforts did not help her loose much. In reading Allen and Warner's article, they state that most people receive their first ideas of health from their families. Since "one family member's situation influences and in turn is influenced by all family members" (Allen and Warner, p. 103), it is clear that Martha's family was influenced by the fact that she had the surgery. The family seemed to be doing better at he follow-up tan they did in the first visit. The children were learning to cook for themselves and Martha's husband and children had made an adjustment to the changes in Martha's life. As the nurse practitioner in this situation, I saw the family evolve together and I believe it was because of the strong love and respect they had for each other. Another important issue that arose during the follow-up visit was the way that society treats obese people. This conversation began because Martha is experiencing some challenges with her friends and family. Some people were able to deal with her changes without problems while others were not. She had several people she knew who used to seem guarded around her, open up to her once they found out she was having the surgery. She equated this to how some people feel about obese people in our society. She talked at length about how she can see from different eyes now than she did before and she sees the influence that society has on people's perception of those who are obese. One of the challenges that I thought about in this conversation was that nurses are part of society and therefore may have their own biases against obese patients if they have no knowledge of bariatric surgery. Jeffrey and Kitto (2006) created a study to find out how nurses felt about weight loss surgery. They found conflicting perceptions of how patients were seen by nurses. Some saw them as they would any other patient, but others had challenges with the obese patient and the weight loss surgery because they felt as though it was the patient's responsibility to have lost the weight on their own. In some societies, the patient is always supposed to take control of their bodies and "regulate its functioning in concert with such state supported programmes as health promotion activities" (Jeffrey and Kitto, p. 79). With these kinds of attitudes, it can be difficult for some nurses to understand the situation that a morbidly obese person has as they embark into bariatric surgery. Nurses who felt that way in the study were reporting the typical comments that come as a reminder to the way that society does not understand the morbidly obese. Specifically, they had the attitude that these people could have done something sooner to help themselves or they were wondering why the individual could not keep the weight off prior to having surgery (Jeffrey and Kitto, p. 80). Clearly, it is important for nurses to understand bariatric surgery especially in situations where they work in a hospital or other facility that does not have a bariatric program set up. Conclusion Bariatric surgery has become a major surgery for people who have high BMI scores and certain co-morbidities. According to the American Society for Metabolic and Bariatric Surgery, the number of bariatric surgeries has increased from 16,000 in the early 1990's to an estimated 220,000 in 2008 in the United States. (National Institute of Diabetes and Digestive and Kidney Diseases, 2010). The options in the United states that are most popular are the Roux-en-Y and the Laparoscopic Adjustable Gastric Banding (also called Lap-Band) (Bariatric.us). The Roux-en-?Y tends to be the more drastic of the two surgeries because it causes a total lifestyle change for the individual; it has also been shown to be the most successful. There is a misconception about this surgery where many people believe that having the surgery will be a cure for their obesity. The fact is that it is a way for the individual to take more control over their lives. In fact, "eating well and exercising will remain an important aspect of patients' health regimens for the rest of their lives" (Harrigan, p. 363). Bariatric surgery should not be taken lightly by nursing staff or by patients. It is a very serious operation with many possible complications. Any patient who undergoes the surgery must do so with a qualified surgeon who has done the surgery many times. The individual should also be wiling to follow the strict guidelines that are a part of the post operative care. The patients with the most success are those who follow the directions from the surgeon, change their eating habits and commit to an exercise program. Martha is a stellar case because she has done all the things that were required and she is losing the weight she wants to lose. She is changing her life and she is feeling better than she has for many years. References Allen, F.M., and Warner. M. (2002). A developmental model of health and nursing. Journal of Family Nursing. 8 (4). doi: 10.1177/10748400223751 Bariatric.us (2010). Consumer guide to bariatric surgery. Retrieved April 28, 2010 from http://www.bariatric.us/ Clutts, B.J. (2009). Recognition and management of complications following Roux-en-Y gastric bypass: A guide for health care workers in non-bariatric hospitals. MEDSURG Nursing. 18 (6). 335-341. Retrieved April 28, 2010 from Academic Search Premier database (AN: 46837518) Doolen, J.L. and Miller, S.K. (2005). Primary care management of patients following bariatric surgery. Journal of the American Academy of Nurse Practitioners. 17 (11). 446-450. doi: 10.111/j.1745-7599.2005.00069.x Grindel, M. E. and Grindel, C.G. (2006). Nursing care of the person having bariatric surgery. MEDSERG Nursing. 15 (3). 120-146. Retrieved April 28, 2010 from Academic Search Premier database (AN: 21110332). Harrington, L. (2006). Postoperative care of patients undergoing bariatric surgery. MEDSURG Nursing. 15 (6). 357-363. Retrieved April 28, 2010 from Academic Search Premier database. (AN: 23659832). Jeffrey, C.A., Kitto, S. (2006). Struggling to care: Nurses' perceptions of caring for obese patients in an Australian bariatric ward. Health Sociology Review. 15 (1). 71-83. doi:10.5555/hesr.2006.15.1.71 McGlinch, B.P., Que, F.G., Nelson, J., Wrobleski, D.M., Grant, J.E., & Collazo, Clavell, M. (2006). Perioperative care of patients undergoing bariatric surgery. Mayo Clinic Proceedings Supplement. 81 (10). S25-S33. Retrieved April 29, 2010 from Academic Search Premier (AN: 23254802). National Institute of Diabetes and Digestive and Kidney Diseases. (2010). Longitudinal assessment of bariatric surgery. Weight Control Information Network. Retrieved April 22, 2010 from http://www.win.niddk.nih.gov/publications/ labs.htm#howmany Read More