Family Assessment and Care Plan - Case Study Example

Running Head: FAMILY ASSSESMENT Family Assessment Family Assessment The following assessment of Mr. and Mrs. W. was preformed over a period of several days during the month of September 2007. The information was gathered through the use of the family assessment and care plan tool adopted from the Manual of Nursing Diagnosis (Gordon, 1987). The process was conducted by way of personal interviews with both parties together as well as separately. Assessments were also made by personal observation of the conditions present in the home and the surrounding neighborhood. GENERAL FAMILY BACKGROUND: The Ws have resided in the same quiet suburban neighborhood for fifty-four years. Their house is an older a brick two-story with 3 bedrooms and 1 bath. Externally it presents in a slightly run down condition needing paint and some minor to possibly major structural repairs, but seems to be in otherwise sound shape and resistant to the elements. The neighborhood has a mixture of families of various age ranges and different sizes and makeup. There were some older couples observed walking the streets as well as young children playing. The couple states that the neighborhood was quieter when they first moved in but now has become a little noisier and more crowded. However, they still enjoy the area, it is close to all of their friends and much of their family and they have excellent relationships with their neighbors. This couple has been married for over sixty years. Mr. W is eighty-three and Mrs. W recently celebrated her seventy-eighth birthday. Mrs. W is a retired nurse who had volunteered some of her time to a local hospital. Mr. W had a long career as a crane operator and has an excellent pension and health benefit package form his former employer. They are currently in very stable financial condition, although Mr. W admits to have had some hard times while raising their children. They have three sons and four daughters. However, one son has an acute medical condition that causes them a certain amount of stress and concern. He was diagnosed several months ago with esophageal cancer. Currently he is undergoing treatment, but the doctor seems to be cautious about the prognosis. They are a very friendly couple and were quite genial with me and answered all my questions as candidly as they could. They also appear to have a very solid relationship and depend on each other for both physical and psychological support. It is rare that they are not in each others company. GENERAL HEALTH: Considering their age and some recent as well as long term physical issues, Mr. and Mrs. W are in relatively good physical health. They both get flu shots annually and medical check-ups every three months. Mr. W has had only one cold during the past year and Mrs. W reports having none. Recently Mr. W has undergone shoulder joint replacement surgery. He is recuperating well, but his refusal or forgetfulness at times to take his pain medication is of concern to both his wife and the doctor. He is also now experiencing some swelling in his wrist which may be due to poor circulation from the inflammation of his recent surgery. The pain medication that had been prescribed for him, Naproxen, also alleviates inflammation and his failure to adhere to this regime may slow his recuperation from the shoulder surgery. He also suffers from arthritis in both hands and joints and is currently taking medication that is helping with this. Mr. Ws Medications: Mrs. W. is in relatively stable health, although she is somewhat overweight. She has high cholesterol and has been prescribed Vytorin, which she takes in the evening before going to bed. She had been experiencing some knee joint pain most likely due to her weight and has recently undergone knee surgery to alleviate this. She is attempting to control her weight with diet and exercise, although her exercise regime is now limited due to her recent surgery. She was in moderate pain on the first interview, but on the next she seemed to be much more comfortable and was ambulatory. She also has moderate hypertension and is taking the combination drug Zestoretic. She is also taking Naproxen as well for her knee pain. Mrs. Ws Medications: Mrs. W adheres strictly to her medication regime, being a retired nurse she is aware of the benefits of doing so. However she has not transferred this ethic to her husband, who often does not. He either claims to forget or tries to avoid taking some of his medications, especially his pain prescription stating, "It makes me tired and groggy, Id rather have the pain." There has been some concern about forgetfulness regarding Mr. W. Mrs. W is not overly concerned about it but this has prompted them to make an appointment with a specialist in Alzheimers disease. Although there are multiple causes of dementia, Alzheimers disease is the most prevalent and common clinical picture… Dementia is composed of a group of symptoms that result in a slow, global loss of cognitive functions without a change or clouding of consciousness. Early in the disorder, people with Alzheimers disease are able to perceive their cognitive loss, which adds to the emotional devastation of this disorder. To support a diagnosis of Alzheimers disease, cognitive impairments must be severe enough to impair self-maintenance, employment, and social functioning. Personality and social behaviors may be maintained well into the disease, and overlearned habits may also remain intact for some time. (Keough & Huebner, 2000, p. 375) At the time of these interviews no final decision has been made as to whether or not Mr. W is at the early onset of Alzheimers disease. Both family members voiced concerns about having to become caregivers at this stage in their lives. As the authors of "Treating Dementia: The Complementing Team Approach of Occupational Therapy and Psychology" state: There are physical and psychological burdens that simultaneously affect the family member and the caregiver. Primary and secondary burdens or stressors also affect the caregiver. Primary burdens are stressors caused directly by the limits of the patient; secondary burdens are stressors caused by the caregiver role. (Keough & Huebner, 2000, p. 375) This is true of Alzheimers as well as other debilitating conditions. Mrs. W has been a caregiver all her life and as a retired nurse it seems that she is worried she will now have to take up that role again. "When the environment affords opportunities for control that exceed the abilities or skills of the individual to take advantage of them, negative effects can occur" (Evans & Shapiro, 1993, p. 255). This is when it may be necessary to seek outside assistance from either at home nursing services or other sources of help. Eventually the consideration of a long-term care facility may be required. SLEEP-REST PATTERN: Both husband and wife claim to sleep for only about five or six hours a night. Mr. W. says that his wifes snoring occasionally wakes him up but he asks her to turn on her side and this resolves the problem. However, their sleep patterns are occasionally intermittent and easily disturbed. For instance when the sanitation truck comes through at about two am they are startled awake and stay so sometimes for the rest of the morning. They usually retire about nine or ten at night, sometimes as early as eight and awaken around four or five a.m. but Mrs. W states that it "depends how much sun is coming through the window at the time." Both claim not to take any sleep medication and appear well rested. Neither states that they are awakened or kept awake by anxiety very often. Although once in a while when they are kept awake by worries, they seem to be coping with them at this time. They were at first concerned by their lack of sleep, but were assured by their physician that it was a natural occurrence in this age group: Aging is associated with several well-described changes in patterns of sleep. Typically, there is a phase advance in the normal circadian sleep cycle: older people tend to go to sleep earlier in the evening but also to wake earlier. They may also wake more frequently during the night and experience fragmented sleep. The prevalence of many sleep disorders increases with age. Insomnia, whether primary or secondary to coexistant illness or medication use, is very common among elderly people. (Wolkove, Elkholy, Baltzan & Palayew, 2007, p. 1299) There is also some cautionary diagnosis as concerns the possible onset of Alzheimers disease: Sleep disturbance or disruption is common among patients experiencing dementia, particularly those with Alzheimer’s disease. Such patients often have difficulty not only falling asleep but also with repeated nighttime awakenings. In general, as the dementia progresses, these symptoms become increasingly severe and patients become noticeably and progressively sleepier during the daytime. (Wolkove, Elkholy, Baltzan & Palayew, 2007, p 1299) The authors also note that Delta sleep, the deepest and most restful form of sleep, diminishes greatly with age. Although in observing their alertness and activity, they seem to be having no ill effects from lack of sleep and said they only feel tired after more strenuous activity like shopping or walking distances. NUTRITIONAL -METABOLIC PATTERN: The couple generally eats three meals a day starting with breakfast at five or six a.m. and usually takes a multiple vitamin at that time. This is followed by lunch around eleven-thirty a.m. and then dinner sometimes as early as three p.m. but usually no later than five. They often take advantage of the early bird specials at a local chain restaurant. They almost always snack between meals with potato chips, nuts or cookies and often have a late evening snack, which is sometimes popcorn, but most of the time it is ice cream. Lately they have been using a dietetic variety for this as well as for several other snacks. They enjoy a wide variety of foods and seem to have no diet restrictions other than Mrs. Ws weight concern. Their daily fluid intake is sporadic and not monitored. Mrs. W states that she tries to drink the standard eight cups of water but Mr. W. is unconcerned. When not drinking water they prefer to drink diet soft drinks, regular soda, some juices and coffee or tea. As mentioned before they do not consume alcohol. APPEARANCE OF HOME AND FAMILY MEMBERS: As mentioned earlier the exterior of the home is in need of some attention and needs painting as well as shingle replacement and roof repair. Currently there are no leaks and it appeared that there is little draft inside the home. However, the interior of the home is kept clean, well lighted and very organized by both parties. The overall appearance of the kitchen is clean and free of grease and dirt. There were a few dishes piled in the sink on one occasion but that does not appear to be the norm. The bathroom sanitary facilities are old, but seem to be very clean and in good working order as well. There was noted some dirt in corners that has been accumulating, but not to the point of uncleanness. The home did retain some cooking odors, but on the whole is being kept up well. They appear to take great pride in the appearance of their surroundings. The couple has always been observed to be clean and well dressed and in appropriate attire. Occasionally Mr. W will be walking barefoot but usually puts on shoes after I have arrived. On quick glance he does not seem to be suffering from any foot-related skin or diabetic problems, but Mr. W has many age spots appearing on his hand and forearms. Mr. W did have skin cancer approximately two and a half years ago. Since the topical surgery there has been no recurrence and he has had no trouble healing. Mrs. W has a full set of dentures but I observed her not wearing them occasionally during our interviews. When asked she said that it is a loose fit and sometimes falls out when she talks despite the use of adhesive creams. She does not seem too concerned and says she will get a new set "eventually." Mr. W has some minor dental problems and will be receiving a cap on a tooth that has recently undergone a root canal. ELIMINATION PATTERN: Mrs. W claims to have a bowel movement every other day while Mr. W states he has them every two to three days. Mr. W says that he does take an over-the-counter laxative occasionally when he feels uncomfortable or it has just been too long since his last BM, however his wife states that she never uses them. The infrequency of their bowel movements does not at this time appear to be a concern for them or their physicians, "Constipation is a common complaint in older adults. Although constipation is not a physiologic consequence of normal aging, decreased mobility and other comorbid medical conditions may contribute to its increased prevalence in older adults" (Hsieh, 2005, p 2227) ACTIVITY & EXERCISE PATTERN: Prior to their recent surgeries and joint problems both had walked religiously for one hour a day most days of the week. Currently Mrs. Ws knee surgery has kept her from walking at all and she simply does a short stretching routine, as she is able. According to Mrs. W. the most important thing for her health is to maintain a good attitude. As mentioned earlier Mrs. W also volunteered some time at a local hospital, but has been restricted in doing that. Mr. W has kept up with his one hour a day walks and also likes to putter around the house to keep busy, fixing or breaking things depending on who you are talking to at the time. They both enjoying reading and love to travel when they can, usually to visit their family. They both actively maintain the interior of the house, vacuuming, doing laundry, dusting, etc. At this point they seem to be able to keep up this activity, albeit limited with respect to their current surgeries. They do rely on some neighbors to help out occasionally and their immediate neighbor mows their lawn for them. Mrs. W has always maintained the checkbook and continues to do so without incident. There is apparently not that many bills and they are all paid on time. There was no mention of not having enough money to keep up with their financial situation. COGNITIVE PERCEPTUAL PATTERN: The couple was very adept at answering all of my questions. Mr. W occasionally asked me to repeat myself which might indicate some hearing loss although neither admitted to this nor does either of them use hearing aids. Mrs. W has recently undergone cataract surgery and has recovered nicely and her vision is clear. Both are actively engaged in the decision-making process regarding their lives, although I feel that Mrs. W is the final word in a disagreement. Both are native English speakers only. Considering the possible onset of Alzheimers or other stressors that could bring on mental and emotional fatigue, it might be suggested that a psychological examination be conducted. The psychologist uses standard guidelines, conducts brief mental status exams, or administers brief screening instruments, such as a Mini-Mental State Examination that is often preformed in these situations to determine general cognitive function. The psychologist refers for formal neuropsychological evaluation as appropriate. The psychologist uses the results to address specific concerns of the patient or caregivers regarding older adults ability to perform activities of daily or instrumental activities of daily living. The psychologist communicates the results of these assessments clearly and sensitively to the older adult, family, and other relevant care providers. (Molinari, Karel, Jones, Zeiss, Cooley, Wray, Brown & Gallagher-Thompson, 2003). SELF-PERCEPTION -- SELF-CONCEPT PATTERN/ROLE RELATIONSHIP PATTERN: In general the mood of the couple is positive, they both seem happy and very upbeat when discussing their family and themselves. Although Mrs. W is more actively engaged in the community, Mr. W seems quite happy spending time with his wife as well as an occasional trip to the VFW hall. The couples concern over some of the forgetfulness that Mr. W is experiencing as well as their concern over their sons medical condition and several other factors have the couple showing some signs of stress. Mr. Ws recent shoulder surgery has been a bit of a burden, as well as Mrs. Ws knee surgery. But both seem to be coping with these life changes quite adequately for now. Mrs. W has one sister and five brothers while Mr. W has only one brother. Both say they have excellent relationships with these family members and speak with them often. They state that there are no family problems now that are too hard to handle and both feel very positive about their lives in general. In quantifying their mood states on a range from five, very nervous to one, very relaxed, both couple would rate a one during our interviews. There was some slight tension when talking about each others problems but that was quickly brushed aside. In rating them on assertiveness on a scale from five, very assertive to one, passive, Mr. W. would come in at between two or three and Mrs. W would certainly be a five. When the couple was being interviewed together, Mrs. W answered most of the questions, as Mr. W would most often defer to her. She would certainly qualify as the leader of this family. SEXUALITY PATTERN: The couple continues to share the same bed but when asked if they still maintain a sexual relationship, they laugh and say, "theres no need to for that now." I did not want to press the issue, as it is often a difficult subject to broach at any age. However the author of "Perimenopausal Issues in Sexuality" states: Perimenopausal women are more vulnerable to sexual problems because of the various physiological, psychosocial and disease processes occurring at this time in their lives. As these women may be reluctant to complain about sexual difficulties it is helpful for health professionals working in this field to ask them about their sex lives. Hopefully, as a result, sexual problems will be identified at an early stage when they are easier to treat (Myskow, 2002, p 253). Sometimes it is worth a little discomfort to get at the truth of a situation for the well being of the all the family members concerned. COPING-STRESS-TOLERANCE PATTERN/VALUE-BELIEF PATTERN: The biggest changes in the family over the past few years seem to be very positive ones. Several great-grand children were born all healthy and happy. They are visited often by all of their children, grand- and great-grand children. This seems to give them a sense of fulfillment and contentment when thinking about their lives. In an article on "Life Review Therapy" the authors state that this process: ...involves emotional processing of events from the individuals past. Autobiographical retrieval practice focused on bringing up specific events that these older adults might not have spontaneously reviewed. The results showed that older adults who received autobiographical memory practice improved their mood state, with decreased depressive symptoms and feelings of hopelessness, and improved their life satisfaction, compared with a control group, who did not show changes in their mood state (Serrano, Latorre, Gatz & Montanes, 2004, p. 276). The onsets of Mr. Ws shoulder problem and concerns about his mental state as well as Mrs. Ws knee surgery have caused some stress in the relationship. Although not high at the moment there is a possibility that this tension may increase. Even though they are actively seeking medical interventions in this regard, psychological interventions as previously mentioned may be appropriate as well. However, in general most problems are handled in a forthright manner, although mostly by medical personnel and not psychological or neuropsychological practitioners. Up to this point this practice seems to be working well in helping them to cope with these life situations. Both stated that Religion is also a helpful practice and is beneficial for their well being when difficulties arise. However, neither has sought out the advice of a priest to counsel them for any of their family situations or personal problems. Mr. W seemed to feel more strongly about the benefits of religion and to find great comfort in it. There was a bible present on the coffee table during all of my visits. On the whole they both are relaxed in their attitude towards life. When Mrs. W becomes tense or nervous about something she likes to talk about her problems. She usually calls her sister or talks to one of the kids, mostly her daughters. Mr. W prefers to start moving around to break the tension, either by walking or finding something to fix. When asked about their personal fulfillment, Mrs. W seems to be content that she is getting what she wants to out of life. However, Mr. W, on the other hand, did not seem so sure about that. It may be that he is a little more than slightly concerned about his conditions considering his age or his medications may be having some impact on his mood. But as the authors of "Impact of Screening Older People with Physical Illness for Depression," point out: The stigma of mental illness is perhaps the most fundamental reason why elderly people are not treated. Another reason is the ageist assumption that depression is an inevitable consequence of old age--an assumption that is clearly unjustified in view of evidence that at least 85% of elderly people do not have depression. A third reason is that recognition of depression late in life may be difficult because of the likelihood of its presenting with somatic and anxiety symptoms rather than with overt sadness.[9] Conversely, when there is concurrent physical illness, depressive symptoms may be regarded as unimportant (Katona & Livingston, 2000, p 91). It is important not to make the mistake of dismissing possible signs of depression as simple reactions to the current physical situation. Further questions about medical side effects should be asked as well as a psychological assessment by a qualified professional. Concerning their home they both have some rules: No smoking in the house, no one does any illegal drugs and you have to treat others well. OTHER CONCERNS: Although the couple seems to be coping quite adequately with their current situations, they both expressed concerns for their future ability to do so both physically and mentally. They do not wish to move or sell their home, but there may come a time when they will have to do so. Mrs. Ws sister has tried to get them to move to a senior community, but Mrs. W has resisted this notion. Mr. W is keen on the idea but they are not sure that the sale of their home will be enough to afford a condo in her sisters retirement village. In a private moment with me Mrs. W voiced concerns that she might die first leaving her husband to fend for himself and this caused her great consternation. The tears welled up in her eyes as she spoke about it. I mentioned that to help alleviate her concern perhaps she should look into alternatives for him should that circumstance occur. She agreed. References Evans, G. W. and Shapiro, D. H. (May 1993). Specifying dysfunctional mismatches between different control dimensions. British Journal of Psychology; 84, (2), p255. Gordon, M. (1987). Manual of nursing diagnosis (2nd ed.). New York: McGraw-Hill Hsieh, C. (2005) Treatment of constipation in older adults. American Family Physician, 72 (11), p2277-2284. Katona, C. & Livingston, G. (2000) Impact of screening older people with physical illness for depression? Lancet. 356, (9224), p91 Keough, J. and Huber, R.A (July 2000). Treating dementia: the complementing team approach of occupational therapy and psychology. Journal of Psychology. 134, (4), p375 Molinari, V., Karel, M. Jones, S., Zeiss A., Cooley, S. G., Wray, L., Brown, E. and Gallagher-Thompson, D. 2003. Recommendations about the knowledge and skills required of psychologists working with older adults. Professional Psychology: Research and Practice. 34 (4), pp. 435-443. Myskow, L. (2002) Perimenopausal issues in sexuality. Sexual & Relationship Therapy. 17 (3), p 253. Serrano, J.P., Latorre J.M., Gatz M., Montanes, M.J. (2004) Life review therapy using autobiographical retrieval practice for older adults with depressive symptomatology. Psychology and Aging. 19 (2), pp. 272-277. Wolkove, N., Elkholy, O., Baltzan, M., and Palayew, M. (2007). Sleep and aging: Sleep disorders commonly found in older people CMAJ: Canadian Medical Association Journal. 176 (9). P 1299-1304, Read More