Family Dynamics

Promoting Physical Safety

A safe home and hospital environment allow the patient to move about as freely as possible and relieves the family of constant worry about safety. For the patient residing at home, in order to prevent falls and other injuries, all obvious hazards are removed and hand rails are installed. A hazard-free environment allows the patient maximum independence and a sense of autonomy. Adequate lighting, especially in halls, stairs, and bathrooms, is necessary. Nightlights are helpful, particularly if the patient has increased confusion at night, sometimes referred to as sundowning. Driving is prohibited, and smoking is allowed only with supervision. The patient may have a short attention span and be forgetful; therefore, the nurse and the family must be patient, repeat instructions as needed, and use reminders (i.e., post-it notes, electronic reminders) for daily activities. Doors leading from the house must be secured. Outside the home, all activities must be supervised to protect the patient, and the patient should wear some type of identification in case of separation from the caregiver. If the patient is hospitalized, additional precautionary measures should be taken. Wandering behavior, which may be worse in the hospital due to unfamiliar surroundings, can often be reduced by gentle persuasion, distraction, or by placing the patient close to the nursing station. Restraints should be avoided because they can increase agitation and lead to injury.

Moral Development middle age

According to Kohlberg (1969), a middle-aged adult may either remain at the conventional level or move to the postconventional level of moral development. The person who has had sustained responsibility for the welfare of others and has consistently applied ethical principles developed in adolescence is more likely to move to the postconventional level. At this level, the adult believes that the rights of others take precedence, and takes steps to support those rights.

Confusion Assessment Method (CAM)

Acute Onset 1.Is there evidence of an acute change in mental status from the patient's baseline? Inattentiona 2.A. Did the patient have difficulty focusing attention, for example, being easily distractible, or having difficulty keeping track of: What was being said? Not present at any time during interview. Present at some time during interview but in mild form. Present at some time during interview, in marked form. Uncertain. B.(If present or abnormal) Did this behavior fluctuate during the interview, that is, tend to come and go or increase and decrease in severity? Yes. No. Uncertain. Not applicable. C.(If present or abnormal) Please describe this behavior: Disorganized Thinking 3.Was the patient's thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject? Altered Level of Consciousness 4.Overall, how would you rate this patient's level of consciousness? Alert (normal). Vigilant (hyperalert, overly sensitive to environmental stimuli, startled very easily). Lethargic (drowsy, easily aroused). Stupor (difficult to arouse). Coma (unarousable). Uncertain. Disorientation 5.Was the patient disoriented at any time during the interview, such as thinking that they were somewhere other than the hospital, using the wrong bed, or misjudging the time of day? Memory Impairment 6.Did the patient demonstrate any memory problems during the interview, such as inability to remember events in the hospital or difficulty remembering instructions? Perceptual Disturbances 7.Did the patient have any evidence of perceptual disturbances, for example, hallucinations, illusions, or misinterpretations (such as thinking something was moving when it was not)? Psychomotor Agitation 8.Part 1. At any time during the interview, did the patient have an unusually increased level of motor activity, such as restlessness, picking at bedclothes, tapping fingers, or making frequent sudden changes of position? Psychomotor Retardation 8.Part 2. At any time during the interview, did the patient have an unusually decreased level of motor activity, such as sluggishness, staring into space, staying in one position for a long time, or moving very slowly? Altered Sleep-Wake Cycle 9.Did the patient have evidence of disturbance of the sleep-wake cycle, such as excessive daytime sleepiness with insomnia at night? aThe questions listed under this topic were repeated for each topic where applicable.

Stage V—Families with Teenagers (13-20 years) Tasks

Balancing of freedom with responsibility as teenagers mature and become increasingly autonomous Refocusing the marital relationship Communicating openly between parents and children

Geriatric Depression Scale

1. Are you basically satisfied with your life? YESNO 2. Have you dropped many of your activities and interests? YESNO 3. Do you feel that your life is empty? YESNO 4. Do you often get bored? YESNO a5. Are you hopeful about the future? YESNO 6. Are you bothered by thoughts you can't get out of your head? YESNO a7. Are you in good spirits most of the time? YESNO 8. Are you afraid that something bad is going to happen to you? YESNO a9. Do you feel happy most of the time? YESNO 10. Do you often feel helpless? YESNO 11. Do you often get restless and fidgety? YESNO 12. Do you prefer to stay at home, rather than going out and doing new things? YESNO 13. Do you frequently worry about the future? YESNO 14. Do you feel you have more problems with memory than most? YESNO a15. Do you think it is wonderful to be alive now? YESNO 16. Do you often feel downhearted and blue? YESNO 17. Do you feel pretty worthless the way you are now? YESNO 18. Do you worry a lot about the past? YESNO a19. Do you find life very exciting? YESNO 20. Is it hard for you to get started on new projects? YESNO a21. Do you feel full of energy? YESNO 22. Do you feel that your situation is hopeless? YESNO 23. Do you think that most people are better off than you are? YESNO 24. Do you frequently get upset over little things? YESNO 25. Do you frequently feel like crying? YESNO 26. Do you have trouble concentrating? YESNO a27. Do you enjoy getting up in the morning? YESNO 28. Do you prefer to avoid social gatherings? YESNO a29. Is it easy for you to make decisions? YESNO a30. Is your mind as clear as it used to be? YESNO Score: _____ (Number of "depressed" answers) Norms Normal: 5 ± 4 Mildly depressed: 15 ± 6 Very depressed: 23 ± 5

Family Structures

A family may consist of two or more people who may be related or unrelated either biologically or legally; members may be of the same biological sex or different biological sex, and members may be of the same or various generations. A family may include unmarried people with a meaningful commitment to each other (Pender et al., 2015). Nurses must remember that there are no absolute "rights" or "wrongs" about what makes a family, and one person's values must not be imposed on another person. Respect for all kinds of family members and relationships is essential to person-centered, individualized patient care.

CHOOSING AN OCCUPATION OR CAREER

A major psychosocial developmental requirement for the young adult is choosing a vocation. The young person's decision to enter the world of work is strongly influenced initially by the need to become independent of his or her family and to be self-sufficient. The choice of an occupation or a career is also guided by factors such as the desire to get married, raise a family, and become part of the community (Fig. 22-10). Occupational and career choices are largely tied to educational choices. Many careers require a college education. Adults learn from both informal and formal experiences and are largely goal-directed learners. If the person's identified goals are to increase career opportunities, maintain financial stability, and pursue upward mobility, the adult will be motivated to learn and change. The major factor in achieving satisfaction with a vocational choice is a person's belief that he or she is functioning to capacity and making a contribution to society.

The community

A person, as an individual and as a member of a family, is also a member of a community. The most basic definition of a community is a specific population or group of people living in the same geographic area under similar regulations and having common values, interests, and needs. A community may be a small neighborhood within a city or a large rural area, including a small town. Communities are based on shared characteristics of people, the area, social interaction, and familial, cultural, or ethnic heritage and ties. Within a community, people interact and share resources. The community environment affects the ability of the person to meet basic human needs. This section discusses the relationship of the community to basic human needs, including influences on health and illness. Be sure to check out the content on social determinants of health in Chapter 3. The physical and social environments of communities have been implicated by the Institute of Medicine and the National Research Council as possible contributing factors to health disadvantages in the United States as compared to other high-income countries (Woolf & Aron, 2013). Americans die younger and have a consistent pattern of poor health and death and suffering from illness and injuries compared to the other wealthiest nations in the world. Designing healthier community environments is one of the recommended strategies to promote more favorable health outcomes in the United States. See Chapter 3 for additional explanations of and implications for this U.S. health disadvantage. Many community factors affect the health of residents. A healthy community enables people to maintain a high quality of life and productivity. For example, a healthy community: offers access to health care services for all members of the community, which provide both treatment for illnesses and activities to promote health. has roads, schools, playgrounds, and other services to meet needs of the people in the community. maintains a safe and healthy environment. The Robert Wood Johnson Foundation (2016) has identified healthy communities as one of its four focus areas. See the foundation's website (http://www.rwjf.org/en/our-focus-areas/focus-areas/healthy-communities.html) for examples of programs to build healthy communities. Similarly, the Division of Community Health (DCH) and Partnerships to Improve Community Health (PICH) support the implementation of evidence-based strategies to improve the health of communities and reduce the prevalence of chronic disease. The DCH focus areas are tobacco use and exposure, poor nutrition, physical inactivity and lack of access to opportunities for chronic disease prevention, risk reduction, and disease management. The health of a community's residents is affected by the social support systems, the community health structure, environmental factors, and facilities providing assistance for those in need of shelter, housing, and food. Examples of community factors affecting health are listed in Box 4-2 and are discussed further in the following sections.

Family with older adults

Adjust to retirement Adjust to loss of spouse May move from family home Increasing age with loss of physical function Chronic illness Depression Death of spouse Screening for chronic illness Home safety information Retirement information Pharmacology information

Spiritual Development

Adolescents and young adults can think in the abstract and may question beliefs and practices that no longer serve to stabilize their identity or purpose. The individuating-reflective period in the young adult (defined by Fowler, 1981) brings discovery of the meaning of values as they relate to the achievement of social purposes and the acceptance of the value systems of others. Often, adolescents or young adults temporarily abandon traditional religious practices.

Assessment

Assess family compostion. Determine gender roles in the family. Evaluate rank order. Assess subsystems and boundaries. Evaluate the family power structure. Assess the extended family. Assess external systems. Assess context. Ask the family questions about the family's life-cycle stage(s) Assess instrumental function. Note affective and socialization function. Evaluate expressive function. Assess verbal communication. Assess nonverbal communication. Assess circular communication. Assess the family's health care function. Assess for multigenerational patterns.

Health of the Adolescent and Young Adult

Although adolescence and young adulthood are times of maximum physiologic development and health, a wide variety of health problems can occur. Health promotion focuses on nutrition, relationships with self and others, and safety. The Advisory Committee on Immunization Practices now recommends routine vaccination with a quadrivalent meningococcal conjugate for children 11 to 12 years old, with a booster of a serogroup B meningococcal vaccine provided at age 16 (up to age 23, but preferably before age 18) when the risk for contracting meningococcal disease is highest (CDC, 2017d). College freshmen living in dormitories and young adults living in military barracks are at risk for meningococcal disease and require the vaccine for protection from it. Young adults who received the Tdap vaccine at ages 11 to 12 should have a tetanus and diphtheria (Td) booster every 10 years. Since 2000, there has been a recurrence of pertussis (whooping cough). Tdap vaccine may be given as one of these boosters if the Tdap was not previously received (CDC, 2017e). The CDC also recommends the vaccination of girls and women of ages 13 through 26 who did not receive the three doses of the HPV vaccine when they were younger. The HPV vaccine prevents the types of HPV that most commonly cause cervical cancer and genital warts (CDC, 2018b). See the accompanying box, Examples of NANDA-I Nursing Diagnoses: Adolescence, for health issues in adolescents.

The simple acts of good manners that invite a trusting relationship are:

Always call the client(s) by name. Introduce yourself by name. Examine your attitude and adjust responses to convey interest and acceptance. Explain your role for the time you will spend with the client/family. Explain any procedure before entering the room with equipment to perform the procedure. Keep appointments and promises to return. Be honest.

Family and Role Reversal

An older adult's spouse and other family members are natural support systems that help the person maintain functional health and independence and meet the developmental tasks of old age. Supportive assistance may include providing transportation, food, shelter, social interactions, and even complex medical and nursing treatments. Significant others, such as close friends and neighbors, may also take on tasks formerly assumed to be the responsibilities of the traditional family. Not all families can assist an aged member satisfactorily because of geographic distance, low income, poor health, strained marital relationships, or infringement on career or lifestyle. Adult children may feel "sandwiched" between responsibilities for their own children and careers and the needs of older parents. It can be a guilt-ridden and emotionally draining time for all involved when an older adult's physical or emotional illness causes a reversal of roles. The adult child may take on a parenting-type role, while the parent assumes a more dependent, child-like role. This situation can strain family resources. The nurse must view the whole family as the recipient of care and assess the family for capabilities and limitations for assisting the aged member. The nurse can help ease the strain by listening to the patient's and family's concerns and by validating the importance of family needs. The nurse assists the patient and family to find workable solutions and may refer the family to community support services.

ESTABLISHING A FAMILY

As discussed in Chapter 4, there are many different types and configurations of families. Families provide a safe zone and a buffer between the needs of people and the expectations of society. Each family has the potential to provide a caring, supportive environment. Establishing a family involves both parents, even though the physiologic changes of pregnancy take place in the woman. Pregnancy is a period of adjustment requiring family members to be flexible enough to adapt to the changes that pregnancy and a new family member will bring. The cognitive, psychosocial, cultural, and educational dimensions of the prospective parents influence completion of the tasks. The verification of pregnancy may raise conflicting emotions in the woman, influenced by such factors as whether the pregnancy was planned or unplanned and how the baby may affect career goals. As body changes occur and fetal movement is felt, the woman begins to visualize herself as a mother and normally assumes responsibility for the health of the growing baby. As the time for delivery becomes closer, the woman centers on maternal tasks (such as preparing the baby's room and having clothing ready) and prepares herself for labor and delivery. During the pregnancy, the expectant father needs to learn the normal physiologic and psychological changes of pregnancy, accept his supportive role in meeting maternal needs, and explore his feelings about the developing infant and the birth.

Health of the Older Adult

As the number of older adults increases, nurses will spend more time providing care for this population. Older adults who require care are in all types of health care settings, including hospitals, long-term care facilities, emergency departments, outpatient surgeries, and homes. Nursing care for older adults should be based on two principles: Most older people are not impaired. They are functional members of the community who benefit from health-oriented interventions. Older people are more vulnerable to physical, emotional, and socioeconomic problems than people in other age groups. They may require special attention to health promotion and maintenance. This section provides a broad introduction to the health care needs of the older adult in terms of chronic illness, accidental injuries, and acute illness.

Relating to age group

As the population ages, social organizations for older adults are becoming more numerous. For example, most communities have senior citizens' centers that offer meals, social and informational programs, and other activities for a nominal fee. Other organizations offer opportunities for travel, cultural events, and political involvement. Affiliation with people of the same age allows older adults to share common interests and concerns, and to find status among their peers. Some adults reside in retirement communities that provide a multitude of opportunities for social engagement. It should not be assumed, however, that older adults want to associate only with others their age; intergenerational friendships can be both mutually beneficial and extremely rewarding

Spiritual Development middle age

As with moral development, not all adults progress to Fowler's (1981) paradoxical-consolidative state of spiritual development. Fowler believed that only some people reach this stage, and only after 30 years of age. Most middle adults are less rigid in their beliefs, and many have increased faith in a supreme being as well as trust in spiritual strength.

Home, Community-Based, and Transitional Care

Because chronic conditions are so costly to people, families, and society, two of the major goals of nursing are the prevention of chronic conditions and the care of people with them. This requires promoting healthy lifestyles and encouraging the use of safety and disease prevention measures, such as wearing seat belts and obtaining immunizations. Prevention should also begin early in life and continue throughout life. Education on self-care may need to address interactions among the patient's chronic conditions as well as skills necessary to manage the individual diseases and their interactive effects. Patient and family education is an important nursing role that may make the difference in the ability of the patient and the family to adapt to chronic conditions. Well-informed, educated patients are more likely than uninformed patients to be concerned about their health and do what is necessary to maintain it. They are also more likely to manage symptoms, recognize the onset of complications, and seek health care early. Knowledge is the key to making informed choices and decisions during all phases of the chronic illness trajectory. Despite the importance of educating the patient and the family, the nurse must recognize that patients recently diagnosed with serious chronic conditions and their families may need time to understand the significance of their condition and its effect on their lives. Education must be planned carefully so that it is not acute. Furthermore, it is important to assess the impact of a new diagnosis of chronic illness on a patient's life and the meaning of self-management to the patient. The nurse who cares for patients with chronic conditions in the hospital, clinic, home, or any other setting should assess patient's knowledge about their illness and its management; the nurse cannot assume that patients with a long-standing chronic condition have the knowledge necessary to manage the condition. Patients' learning needs change as the chronic condition changes and their personal situations change. The nurse must also recognize that patients may know how their body responds under certain conditions and how best to manage their symptoms. Contact with patients in any setting offers nurses the ideal opportunity to reassess patients' learning needs and provide additional education about a chronic condition and its management. Educational strategies and materials should be adapted to the individual patient so that the patient and the family can understand and follow recommendations from health care providers. For instance, educational materials should be tailored for people with low literacy levels and available in several languages and in various alternative formats (e.g., Braille, large print, audiotapes). It may be necessary to provide sign language interpreters.

Supporting Cognitive Function

Because dementia of any type is degenerative and progressive, patients display a decline in cognitive function over time. In the early phase of dementia, minimal cuing and guidance may be all that are needed for the patient to function fairly independently for a number of years. However, as the patient's cognitive ability declines, family members must provide more and more assistance and supervision. A calm, predictable environment helps people with dementia interpret their surroundings and activities. Environmental stimuli are limited, and a regular routine is established. A quiet, pleasant manner of speaking, clear and simple explanations, and the use of memory aids and cues help minimize confusion and disorientation and give patients a sense of security. Prominently displayed clocks and calendars may enhance orientation to time. Color-coding the doorway may help patients who have difficulty locating their room. Active participation may help patients maintain cognitive, functional, and social interaction abilities for a longer period. Physical activity and communication have also been demonstrated to slow some of the cognitive decline of AD.

BIOLOGIC Risk Factors for Altered Family Health

Birth defects Intellectual disability Genetic predisposition to certain diseases, including cardiovascular diseases and cancer

examples of Physical Dimension-Physiologic needs

Breathing Circulation Temperature Intake of food and fluids Elimination of wastes Movement

Continuing and Transitional Care

Chronic illness management is a collaborative process between the patient, family, nurse, and other health care providers. Collaboration extends to all settings and throughout the illness trajectory. Keeping an illness stable over time requires careful monitoring of symptoms and attention to management regimens. Detecting problems early and helping patients develop appropriate management strategies can make a significant difference in outcomes. Most chronic conditions are managed in the home. Therefore, care and education during hospitalization should focus on essential information about the condition so that management can continue once the patient is discharged home. Nurses in all settings should be aware of the resources and services available in a community and should make the arrangements (before hospital discharge, if the patient is hospitalized) to secure those resources and services. When appropriate, home care services are contacted directly. The home health nurse reassesses how the patient and the family are adapting to the chronic condition and its treatment and continues or revises the plan of care accordingly. Because chronic conditions occur worldwide and the world is increasingly interconnected, nurses should think beyond the personal level to the community and global levels. In terms of illness prevention and health promotion, this entails wide-ranging efforts to assess people for risks of chronic illness (e.g., blood pressure and diabetes screening, stroke risk assessments) and group education related to illness prevention and management. In addition, nurses should remind patients with chronic illnesses or disabilities and their families about the need for ongoing health promotion and preventive health screening recommended for all people, because chronic illness and disability are often considered the main concern while other health-related issues are ignored (see Chart 7-6). Telehealth or telehomecare (use of electronic data and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health, and health administration) has been used effectively to provide care for patients with chronic illness. It is particularly useful in monitoring patients with chronic conditions living in rural areas (Health Resources & Services Administration, 2013). It has also been used to deliver select medical and nursing interventions (e.g., counseling) and provide ongoing education and support. Transitional care, if available, should be considered and implemented when the patient has MCC, has impaired cognitive status as well as physical limitations, has complex therapies, or is frail or unstable prior to discharge from the hospital to home. Transitional care nurses serve as the primary coordinator of care. These nurses conduct assessments of the patient as well as the family caregivers' ability to assist in management of the patient in the home. Nurses in this role help the patient and the family set goals during hospitalization, identify the reasons for the patient's current health status, design a plan of care that addresses them, make home visits, provide telephone support, and coordinate various care providers and services (Naylor et al., 2017) (see Chapter 2).

Stress and Coping in the Older Adult

Coping patterns and the ability to adapt to stress develop over the course of a lifetime and remain consistent later in life. Experiencing success in younger adulthood helps a person develop a positive self-image that remains solid through old age. A person's abilities to adapt to change, make decisions, and respond predictably are also determined by past experiences. A flexible, well-functioning person will probably continue as such. However, losses may accumulate within a short period of time and become acute. The older person often has fewer choices and diminished resources to deal with stressful events. Common stressors of old age include normal aging changes that impair physical function, activities, and appearance; disability from injury or chronic illness; social and environmental losses related to loss of income and decreased ability to perform previous roles and activities; and the deaths of significant others. Many older adults rely strongly on their families and spiritual beliefs for comfort during stressful times. An additional aspect of coping that nurse researchers have examined is self-efficacy, which is the confidence to perform well at a particular task or life domain (Hladek, Gill, Bandeen-Roche, et al., 2019). Chart 8-2 is a Nursing Research Profile about the associations between coping self-efficacy and frailty in a group of community-dwelling older adults.

Developmental Tasks of Families

Duvall (1984) identified critical family developmental tasks and stages in a family life cycle. Duvall's theory, based on Erikson's theory of psychosocial development (described in Chapter 22), states that all families have certain basic tasks for survival and continuity, as well as specific tasks related to developmental stages throughout the life of the family. These stages and developmental tasks are outlined in Table 4-2. If the family does not meet certain developmental tasks, societal disapproval may lead to intervention by children's services, social services, police departments, welfare facilities, or health departments (Edelman & Mandle, 2014). The successful mastery of each developmental stage is important to the family's adaptation and growth through successive stages.

Eriksons theory for older adults

Erikson (1963) identified ego integrity versus despair and disgust as the last stage of human development, which begins at about 60 years of age. Older adults continue to look forward, but now also look back and begin to reflect on their lives. It is a time for realization of a wholeness perspective, with an inner search for meaning and order in the life cycle. Older adults search for emotional integration and acceptance of the past and present, as well as acceptance of physiologic decline without fear of death. Older adults often like to tell stories of past events. This phenomenon, called life review or reminiscence, has been identified worldwide. Reminiscence is a way for older adults to relive and restructure life experiences, often in relation to their current situation, and with the added benefit of the perspective provided by life experience and wisdom. Although reminiscence therapy is often used in patients with mild to moderate dementia, reminiscence has value for older adults who do not have cognitive or memory impairments (Fig. 23-4). Nurses use reminiscence therapy to encourage reflection and facilitate adaptation to present circumstances. Ego integrity is facilitated when an older adult has successfully accomplished tasks earlier in life. Older adulthood can be a time for the person to look backward with pride and without regrets, and to look forward with optimism and enthusiasm. A person who regrets the past and sees current problems as insurmountable, however, may despair. This person may view life as a series of unresolved problems and missed opportunities, and feel worthless or hopeless. A despairing person may want to do things over but fears the lack of time before death. The tasks of midlife continue or may resurface. Older adults still strive to guide the coming generations and to leave something behind (generativity vs. stagnation). Their need for love and closeness continues (intimacy vs. isolation), as does a strong sense of who one is in relation to family and community (identity vs. role diffusion). Because of physical and social changes associated with aging, older adults are repeatedly faced with the need to adapt and to again face already completed tasks.

Couple and family with young children

Establish a mutually satisfying marriage Plan to have or not to have children Have and adjust to infant Support needs of all family members Adjust to cost of family life Adapt to needs and activity of children Cope with loss of energy and privacy Encourage and support growth and development and educational achievements Inadequate knowledge of contraception and family Inadequate knowledge of sexual and marital roles Lack of knowledge about child safety and health Child abuse and neglect First pregnancy before age 16 Family planning clinics Prenatal classes Well-child clinics Vision and hearing screenings Dental health information Parent support groups Safety in the home, daycare, school, neighborhood, and community

Stage I—Beginning Families (stage of marriage) Tasks

Establishing a mutually satisfying marriage Relating harmoniously to the kin network Planning a family (decisions about parenthood)

Stage VI—Launching Young Adults (from first to last child leaving home) Tasks

Expanding the family circle to include new family members acquired by marriage of children Continuing to renew and readjust in the marital relationship Assisting aging and ill parents of the husband or wife

Family Functions

Families have important functions that affect how individual family members meet their basic human needs and maintain their health. The family provides the individual with an environment for development and social interactions. Families also are important to society as a whole because they provide new and socialized members for society. Family functions occur in five major areas. Physically, the family provides a safe, comfortable environment necessary for growth, development, and rest or recuperation. Economically, the family provides financial aid to family members and also helps meet society's needs. The reproductive function of many families is to have and raise children. The affective and coping functions of the family provide emotional comfort to family members and help members establish their identity and maintain it in times of stress. Finally, through socialization, the family teaches; transmits beliefs, values, attitudes, and coping mechanisms; provides feedback; and guides problem solving

DEVELOPMENTAL Risk Factors for Altered Family Health

Families who have new babies, especially if support systems are unavailable Older adults, especially those living alone or on a fixed income Unmarried adolescent mothers who lack personal, economic, and educational resources

Commendations

Offer at least one or two commendations during each meeting with the family. The individual or family can be commended on strengths, resources, or competencies observed or reported to the nurse. Commendations are observations of behavior. Look for patterns, not one-time occurrences to commend. Examples include "Your family shows much courage in living with your wife's cancer for 5 years"; "Your son is so gentle despite feeling so ill" (Wright & Leahey, 2000, p. 282). The commendations offer family members a new view of themselves. Wright and Leahey propose that many families experiencing illness, disability, or trauma have a "commendation-deficit disorder" (p. 282). Changing the view of themselves helps the family members to look differently at the health problem and more toward solutions.

General Routine Screening versus Focused Specialty Assessment of the Family

Family assessment varies with the nurse's level of education in family nursing and with the type of family nursing care to be provided. The usual approach to family assessment taken by nurses who are not specialists in family nursing is to focus on the individual as client and the family as context for the client's illness and care. This type of family assessment focuses on determining strengths and problem areas within the family's structure and function that influence development of the illness and the family's ability to support the client. A more advanced knowledge of family nursing is required to care for the family as client. Using this approach, the nurse views the family unit as a system and does not focus on any one family member. Instead, the nurse works at all times simultaneously with a mental picture of the family system and the individuals in the system. The nurse caring for the family system can still provide care to the individual when necessary, but the primary assessment and interventions are directed toward the family as a dynamic system. The information provided in this chapter is relevant to either approach, but omits expert family systems nursing concepts.

Family Risk Factors

Family patterns of behavior, the environment in which the family lives, and genetic factors can all place family members at risk for health problems. Nurses should assess these factors before developing nursing care plans. Typical questions in a family assessment include the following (Pender, Murdaugh, & Parsons, 2014): What is the family's structure? What is the family's socioeconomic status? What are family members' cultural background and religious affiliation? Who cares for children if both parents work? What are the family's health practices (e.g., types of foods eaten, meal times, immunizations, bedtime, exercise)? How does the family define health? What habits are present in the family (e.g., do any family members smoke, drink to excess, or use drugs)? How does the family cope with stress? Is any family member the primary caregiver for another family member? Do close friends or family members live nearby and can they help if necessary?

examples of Emotional Dimension-Self-esteem needs

Fear Sadness Loneliness Happiness Accepting self

Housing Options for Older Adults

Home modification: By making changes, older adults may be able to stay in their own homes. Examples of modifications are replacing doorknobs with handles, replacing faucet handles with levers, and installing grab bars in bathtubs. Home sharing: Two or more people may share an apartment or house. Each person usually has a private bedroom and shares the other living spaces. These homes may be sponsored by faith-based groups or community facilities. Accessory apartment: A separate apartment is constructed in part of an existing house, such as a basement, attic, or converted garage, or as a home addition. This allows older adults to live independently and privately while not being alone. Elderly cottage housing opportunities (ECHO): ECHO homes are small portable cottages that are placed (most often) in the yard of an adult child's home. These units typically cost $28,000 or more, but do allow living independently, but close to support. Senior retirement communities: A grouping of rental apartments, condominiums, townhomes, or houses for residents who can take care of themselves and are mobile. Meals may be available in a central dining room, and housekeeping services may be offered (at additional cost). Social and recreational activities are usually offered. Continuing care retirement community (CCRC): This type of housing community offers several options and services, depending on the needs of the resident. Residents usually begin by living independently in apartments, and then move to an assisted-living facility on the same grounds. A skilled nursing center is also part of the community and available when needed. Sometimes called "aging-in-place" models, this type of housing tends to be expensive. Assisted-living facility: These facilities generally provide housing, group meals, personal care, support services, and social activities in a social setting. Some health care may be provided. Costs vary from around $29,000 to $66,000 annually depending on location. Some states pay for personal care services for those with limited incomes. Board and care homes, adult family homes, and adult group homes: Smaller in scale than assisted-living facilities, these services provide a room, meals, and help with daily activities. They may be licensed or unlicensed. Costs average $33,000 per year for a private room; Supplemental Security Income (SSI) will help pay for those with very limited incomes. Long-term care facilities: These facilities provide skilled nursing care or long-term care, including meals, personal care, and medical care. Bedrooms and bathrooms may be shared. Costs average $66,000 per year, but many are more expensive. Medicare provides only short-term coverage following a hospitalization. Medicaid provides coverage for low-income, low-asset people.

examples of Environmental Dimension-Safety and security needs

Housing Community/neighborhood Climate

Suicide (Self-harm)

In 2016, suicide surpassed homicide and became the second-leading cause of death among teenagers (ages 15 to 19) in the United States. The suicide rate increased from 8 deaths per 100,000 in 1999 to 8.7 deaths per 100,000 in 2014, with female suicide rates rising almost 56% (VanOrman & Jarosz, 2016). These rates are highest in rural areas and are attributed to an increase in the number of attempts that result in death. For example, reports of death attributed to suffocation, a lethal form of suicide that includes hanging, have nearly doubled in the past 15 years (VanOrman & Jarosz, 2016). A history of previous suicide attempts and depression are possible risk factors. Verbal or nonverbal indicators of suicide should not be ignored; rather, an immediate referral should be made to a professional trained in suicide intervention.

Stage VII—Middle-Aged Parents (empty nest through retirement) Tasks

Providing a health-promoting environment Sustaining satisfying and meaningful relationships with aging parents and adult children Strengthening the marital relationship

Promoting Family Health

In addition to individual concepts of homeostasis, stress, adaptation, and health problems associated with maladaptation, the concept of family is also important. Nurses can intervene with both individuals and families to reduce stress and its health-related effects. The family (group whose members are related by reciprocal caring, mutual responsibilities, and loyalties) plays a central role in the life of the patient and is a major part of the context of the patient's life. It is within families that people grow, are nurtured, acquire a sense of self, develop beliefs and values about life, and progress through life's developmental stages (Fig. 5-7). Families are also the first source for socialization and education about health and illness. Ideally, the health care team conducts a careful and comprehensive family assessment (including coping style), develops interventions tailored to handle the stressors, implements the specified treatment protocols, and facilitates the construction of social support systems. The use of existing family strengths, resources, and education is augmented by therapeutic family interventions. The nurse's primary goals are to maintain and improve the patient's present level of health and to prevent physical and emotional deterioration. Next, the nurse intervenes in the cycle that the illness creates: patient illness, stress for other family members, new illness in other family members, and additional patient stress. Figure 5-7 • Within families, individuals progress through life's developmental stages. Helping the family members manage the myriad stressors that bombard them daily involves working with family members to develop coping skills. Seven traits that enhance coping of family members under stress have been identified (Burr, Klein, Burr, et al., 1994). Communication skills and spirituality were frequently useful traits. Cognitive abilities, emotional strengths, relationship capabilities, willingness to use community resources, and individual strengths and talents were also associated with effective coping. As nurses work with families, they must not underestimate the impact of their therapeutic interactions, educational information, positive role modeling, provision of direct care, and education on promoting health. Maladaptive coping may result if health care team members are not perceived as actively supporting family members. Often, denial and blaming of others occur. Sometimes, physiologic illness, emotional withdrawal, and physical distancing are the results of severe family conflict, violent behavior, or addiction to drugs and alcohol. Substance abuse may develop in family members who feel unable to cope or solve problems. People may engage in these dysfunctional behaviors when faced with difficult or problematic situations.

PSYCHOSOCIAL Risk Factors for Altered Family Health

Inadequate childcare resources, when both parents work, for preschool and school-aged children Inadequate income to provide safe housing, food, clothing, and health care Conflict between family members

TIPS FOR CONDUCTING THE 15-MINUTE FAMILY INTERVIEW

Introduce yourself and use good manners in interactions. Seek opportunities to involve family in care delivery and decision making. Use active listening, create family genograms (ecomaps), and ask key therapeutic questions to help family members (and the nurse) better understand the family's needs and beliefs about themselves and the illness. Seek opportunities to commend individuals and the family.

LIFESTYLE Risk Factors for Altered Family Health

Lack of knowledge about sexual and marital roles, leading to teenage marriage and pregnancy; divorce; sexually transmitted infections; child, spouse, or elder abuse; and lack of prenatal or child care Alterations in nutrition—either more or less than body requirements at any age Chemical dependency, including the use of alcohol, drugs, and nicotine Inadequate dental care and hygiene Unsafe or unstimulating home environment

ENVIRONMENTAL Risk Factors for Altered Family Health

Lack of knowledge or finances to provide safe and clean living conditions Work or social pressures that cause stress Air, water, or food pollution

Family with adolescents and young adults

Maintain open communications Support moral and ethical family values Balance teenagers' freedom with responsibility Maintain supportive home base Strengthen marital relationships Family of origin Family value of aggressiveness Inadequate problem-solving abilities Conflict between family members Physical or sexual abuse Sexually transmitted diseases Accident prevention programs Sex education Mental health programs Screening for chronic illness

Family with middle-aged adults

Maintain ties with younger and older generations Prepare for retirement Depression Exposure to environmental or work-related health risks, such as sunlight, asbestos, radiation, coal dust, and air or water pollution Blood pressure screenings Screening for chronic illness

Stage VIII—Family in Retirement and Old Age (retirement to death of both spouses) Tasks

Maintaining a satisfying living arrangement Adjusting to a reduced income Maintaining marital relationships Adjusting to loss of spouse Maintaining intergenerational family ties Continuing to make sense out of one's existence (life review and integration)

Living Arrangements

Many older adults have more than adequate financial resources and good health even until very late in life; therefore, they have many housing options. In 2017, 93% of older adults lived in the community, with a relatively small percentage (2.3%) residing in nursing homes and a comparable percentage living in some type of senior housing. Seventy-six percent of those older than 65 years own their homes. In 2018, 28% of noninstitutionalized older people lived alone, and widowed women predominated. In 2018, 70% of men older than 65 years were married compared with 40% of women in the same age group. This difference in marital status increases with age and is a result of several factors: Women have a longer life expectancy than men; women tend to marry older men; and women tend to remain widowed, whereas men often remarry (AoA, 2020). Many older adults relocate in response to changes in their lives such as retirement or widowhood, a significant deterioration in health, or disability. The type of housing they choose depends on their reason for moving. With increasing disability and illness, older adults may move to retirement facilities or assisted living communities that provide some support such as meals, transportation, and housekeeping but otherwise allow them to live somewhat independently. If they develop a serious illness or disability and can no longer live independently or semi-independently, they may need to move to a setting where additional support is available, such as a relative's home or a long-term care or assisted living facility. Often they will seek a location near an adult child's home.

Long-Term Care Facilities

Many types of nursing homes, nursing facilities, or long-term care facilities offer continuous nursing care. Contrary to the myth of family abandonment and the fear of "ending up in a nursing home," the actual percentage of older adults residing in long-term care facilities has declined, from 5.4% in 1985 to 2.3% in 2018 (AoA, 2020). However, the actual number of older people who reside in long-term care facilities has risen owing to the large increase in the population of older adults and the use of nursing homes for short-term rehabilitation. Short-term nursing facility care is often reimbursed by Medicare if the patient is recovering from an acute illness such as a stroke, myocardial infarction (MI), or cancer and requires skilled nursing care or therapy for recuperation. Usually, if an older adult suffers a major health event and is hospitalized and then goes to a nursing facility, Medicare covers the cost of the first 30 to 90 days in a skilled nursing facility as long as ongoing therapy is needed. The requirement for continued Medicare coverage during this time is documentation of persistent improvement in the condition that requires therapy, most often physical therapy, occupational therapy, respiratory therapy, or cognitive therapy. Some adults choose to have long-term care insurance as a means of paying, at least in part, for the cost of these services should they become necessary. Costs of long-term care for older adults who are living in nursing homes and are medically stable, despite having multiple chronic and debilitating health issues, are primarily paid out-of-pocket by the patient. When a person's financial resources become exhausted as a result of prolonged nursing home care, the patient, the institution, or both may apply for Medicare and Medicaid reimbursement depending on the situation. Family members are not responsible for nursing home costs. An increasing number of skilled nursing facilities offer subacute care. This area of the facility offers a high level of nursing care that may either avoid the need for a resident to be transferred to a hospital from the nursing home or allow a hospitalized patient to be transferred back to the nursing facility sooner.

Stage III—Families with Preschool Children (2.5-6 years) Tasks

Meeting family members' needs for adequate housing, space, privacy, and safety Socializing the children Integrating new child members while still meeting the needs of other children Maintaining healthy relationships within the family (marital and parent-child) and outside the family (extended family and community)

Health of the Middle Adult

Middle-aged adults are subject to physical and emotional health problems associated with lifestyle behaviors, developmental or situational crises, family history, and the environment. Both acute and chronic illnesses are more likely to occur, and recovery takes longer. This is a result of slower and more prolonged responses to stressors, more pronounced reactions to an illness, and the possibility of more than one illness being present at a time. The leading causes of death in the middle adult years (ages 45 to 64), according to 2015 statistics, are malignant neoplasms; cardiovascular disease; unintentional injury, including poisoning, motor vehicle accidents, and falls; liver disease; diabetes mellitus; suicide; chronic lower respiratory disease; cerebrovascular causes; septicemia (infection); and nephritis (kidney disease) (Centers for Disease Control and Prevention [CDC], 2017b). Other major health problems include rheumatoid arthritis, obesity, alcoholism, and depression. The risk for these common health problems often depends on a combination of lifestyle factors and aging. As one gets older, energy requirements decrease. Middle-aged adults tend to maintain previous eating patterns and caloric intake while being less physically active. This trend can result in obesity and atherosclerosis, with an increased risk for high blood pressure, coronary artery disease, renal failure, and diabetes. Additionally, smoking and alcohol consumption put the person at greater risk for cancer, chronic respiratory diseases, and liver disease. Chronic illness in middle-aged adults has a major effect on self-concept and may precipitate changes in life structure. For example, after a serious heart attack, a man may face changes in his family role, his earning capacity, and his social relationships. Such changes usually cause great stress. Middle age does not automatically result in physical or emotional health problems. Many men and women remain healthy throughout their lives, but knowing preventive health care practices and their special needs at this age can help middle-aged adults have improved quality and quantity of life. In fact, many adults cultivate new eating and exercise habits when they personally experience the metabolic and functional changes associated with aging.

Relationships With Children and Aging Family Members

Middle-aged adults may be caught in a "generation sandwich." Their children may be independent and married, with children of their own, or may be recent college graduates who have returned home to live. Difficulty finding employment coupled with the burden of student loans often necessitates the postponement of independent living. Providing ongoing support for adult children while simultaneously caring for aging parents presents a unique set of financial, logistical, resource, and emotional stressors for middle-aged adults. Although much has been written about the "empty-nest syndrome" that occurs when the last child leaves home, most middle-aged parents welcome the increased space, time, and independence they have when active parenting ceases. However, as their involvement with and responsibility for children decrease, middle adults may be called upon to help care for aging parents and other family members. The physical aging or death of a parent makes the middle adult's own aging and inevitable death a reality.

Employment

Middle-aged adults may experience changes in employment. They may opt for a career change and return to school to obtain new knowledge and skills. These changes often result from a need for increased job satisfaction, satisfying a life-long goal, or economic conditions. Some employees in this age group have lost their jobs because of company downsizing during the recent economic turmoil and have had to acquire new skills and additional education to find employment in other areas. Women who have been immersed in a career may decide to have children and either become stay-at-home moms or reduce their workload. Increasing numbers of middle-aged adults are self-employed, often working from home. As the 50s approach, questions about retirement and economic security become more prevalent, with an increased interest in the benefits of financial and retirement plans. These concerns can be heightened by overall economic conditions. For example, many people who had planned on an early retirement may decide to continue their active employment status, whereas others who had planned to work longer are laid off and forced into an unplanned early retirement. The security of retirement investments and income is critical to ensure that people remain financially stable and that workers receive the pensions they are working toward or have already achieved.

OA Physical Strength and Health

Most older adults gradually modify their lifestyle to accommodate for declining strength and health. They rest more frequently, although continued activity and exercise are important for maintaining all physiologic functions. Diet modifications and prescribed medications may be necessary. The potential with this age group for sleep disorders, that may result in daytime sleepiness, contributes to slower response time, impaired memory, and behavior that may be mistaken for some form of cognitive impairment. Confusion and cognitive impairment in an older adult are not a normal consequences of aging. An alteration in cognition or mental status that is new should be considered an acute problem and considered in relation to infection, polypharmacy, or other factors (Fitzgerald et al., 2017). An older adult is at high risk for accidents and falls and may need to curtail driving or use a cane or other aid to remain mobile. Because of chronic illness, an older adult may need to adjust to living with some pain. Pain should not be assumed to be a normal consequence of aging, but it is often experienced by older adults and frequently is undertreated. Attitudes toward treating pain in this population may interfere with optimum pain relief. Providers and patients need to collaborate to differentiate mild chronic pain that may be related to the normal processes of aging, and acute or chronic pain that interferes with a functional lifestyle and requires intervention. Additional information about pain management for older adults can be found in Chapter 35. Delirium, sleep disturbances, cognitive changes, and diminished functional abilities may occur when pain is not managed adequately. With severe illness, loss of independence can occur. The loss of health is difficult to adjust to because it affects every aspect of life.

Living at Home or With Family

Most older adults want to remain in their own homes; in fact, they function best in their own environment. The family home and familiar community may have strong emotional significance for them, and this should not be ignored. However, with advanced age and increasing disability, adjustments to the environment may be required to allow older adults to remain in their own homes or apartments. Additional family support or more formal support may be necessary to compensate for declining function and mobility. Many services and organizations can assist older adults to successfully "age in place" in their own homes or in assisted living facilities (see Resources at the end of this chapter). Sometimes older adults or couples move in with adult children. This can be a rewarding experience as the children, their parents, and the grandchildren interact and share household responsibilities (see Fig. 8-3). It can also be stressful, depending on family dynamics. Adult children and their older parents may choose to pool their financial resources by moving into a house that has an attached "in-law suite." This arrangement provides security for the older adult and privacy for both families. Many older adults and their adult children make housing decisions in times of crisis, such as during a serious illness or after the death of a spouse. Caring for an older adult may also be stressful; older adults and their families often are unaware of the emotional and physical demands of shared housing and assuming care for an increasingly dependent person, especially given the uncertain and extended length of time that may be associated with caring for a person with a chronic illness. Families can be helped by anticipatory guidance and long-term planning before a crisis occurs. Older adults should participate in decisions that affect them as much as possible.

Nursing Care of Patients with Chronic Conditions

Nursing care of patients with chronic conditions is varied and occurs in a variety of settings. Care may be direct or supportive. Direct care may be provided in the clinic or primary care provider's office, a nurse-managed center or clinic, a hospital, long-term care facility, or the patient's home. Direct care includes assessing the patient's physical status, providing wound care, managing and overseeing medication regimens, providing education to the patient and family, and performing technical tasks. The availability of this type of nursing care may allow the patient to remain at home and return to a more normal life after an acute episode of illness. Because much of the day-to-day responsibility for managing chronic conditions rests with the patient and the family, nurses often provide supportive care at home. Supportive care may include ongoing monitoring, education, counseling, serving as an advocate for the patient, making referrals, and case management. Giving supportive care is just as important as giving direct physical care. For example, through ongoing monitoring either in the home or in a clinic, a nurse might detect early signs of impending complications and make a referral (e.g., contact the primary health care clinician or consult the medical protocol in a clinic) for medical evaluation, thereby preventing a lengthy and costly hospitalization. Keeping in mind the many facets and implications of chronic health conditions and their potential impact on patients and families will enable the nurse to provide direct physical care to the patient when warranted, to address the emotional and psychological needs of the patient and family, and to prepare and assist patients and family caregivers to assume management of the condition. By doing so, the nurse can help patients and families maintain as normal a life as possible and as they desire. Working with people with chronic illness requires not only dealing with the medical aspects of their disorder but also working with the whole person—physically, emotionally, and socially. This holistic approach to care requires nurses to draw on their knowledge and skills, including knowledge from the social sciences and psychology, in particular. People often respond to illness, health education, and regimens in ways that differ from the expectations of health care providers. Although quality of life is usually affected by chronic illness, especially if the illness is severe, patients' perceptions of what constitutes quality of life often drive their management behaviors or affect how they view advice about health care. Nurses and other health care professionals need to recognize this, even though it may be difficult to see patients make unwise choices and decisions about lifestyles and disease management. People have the right to receive care without fearing ridicule or refusal of treatment, even if their behaviors (e.g., smoking, substance abuse, overeating, failure to follow health care providers' recommendations) may have contributed to their chronic disorder.

Moral and Spiritual Development

Older adults, according to Kohlberg (1969), have completed their moral development. Most are at the conventional level, following society's rules in response to others' expectations. Spiritually, an older adult may remain at an earlier level, often at the individuative-reflective level. Many older adults, however, demonstrate conjunctive faith, where they integrate faith and truth to see the reality of their own beliefs, or universalizing faith, where they trust a greater power and believe in the future. Another perspective on moral and spiritual development in older adults is the theory of gerotranscendence, which describes the transformation of a person's view of reality from a rational, social, individually focused, materialistic perspective to a more transcendent vision. This new vision is manifest by maturity, wisdom, spirituality, changes in perceptions of time and space (disappearance of distance), a decreased emphasis on superficial relationships, and, ultimately, life satisfaction (Tornstam, 1994). As a person ages, spirituality and transcendence are a resource and a source of strength when faced with inevitable change and loss.

Circular Communication

One example of a feedback system in communications is circular communication which is a reciprocal communication between two people. Wright and Leahey (2013, p. 128) note that most relationship issues have a pattern of circular communication. One person speaks and the other person interprets what is heard, then reacts and speaks on the basis of the interpretation, creating a circular feedback loop based on the individuals' perceptions and reactions. Circular communication can be positive or negative. An example of negative circular communication is as follows: An angry wife criticizes her husband; the husband feels angry and withdraws; the wife becomes even angrier and criticizes more; the husband becomes angrier and withdraws further. Each person sees the problem as the other's, and each person's communication influences the other person's behavior.

Promoting Independence in Self-Care Activities

Pathophysiologic changes in the brain make it difficult for people with AD to maintain physical independence. Patients should be assisted to remain functionally independent for as long as possible. One way to do this is to simplify daily activities by organizing them into short, achievable steps so that the patient experiences a sense of accomplishment. Frequently, occupational therapists can suggest ways to simplify tasks or recommend adaptive equipment. Direct patient supervision is sometimes necessary; however, maintaining personal dignity and autonomy is important for people with AD, who should be encouraged to make choices when appropriate and to participate in self-care activities as much as possible.

The Family in Health and Illness

People learn health care activities, health beliefs, and health values in the family. When patients enter the health care system, they bring their own personal behaviors and needs, but they also bring (in a sense) their family too. Friedman and associates (2003) identified the importance of family-centered nursing care in four ways. First, the family is composed of interdependent members who affect one another. If some form of illness occurs in one member, all other members become involved in the illness. Second, because there is a strong relationship between the family and the health status of its members, the role of the family is essential in every level of nursing care. Third, the level of health of the family and in turn each of its members can be significantly improved through health promotion activities. Finally, illness of one family member may suggest the possibility of the same problem in other members. Through assessment and intervention, the nurse can assist in improving the health status of all family members. Illness may precipitate a health crisis in a family. If an illness is relatively minor, such as a viral infection in a child, changes in family tasks may be minor and brief. But if a family member's injury or illness is serious, the roles and responsibilities, as well as functions, of other family members change. This is especially true if the illness is chronic and long term, results in disability, or decreases the person's time to live. Some families find it difficult to adapt to the stress of changes in financial, social, and caregiving resources, whereas other families experience renewed family closeness and stability. Regardless of how the family adapts, members of the family must constantly adjust roles and responsibilities to manage the needs of the ill family member and the family. Nursing interventions for a family in a health crisis include providing teaching that is honest, open, and respectful; using therapeutic communication skills; applying knowledge of family dynamics; and making referrals to community health care and financial resources to support realistic hope. In addition, it is important to involve family members in planning and implementing care.

The human dimensions and basic human needs

Physical Dimension-Physiologic needs Environmental Dimension-Safety and security needs Sociocultural Dimension-Love and belonging needs Emotional Dimension-Self-esteem needs Intellectual and Spritual Dimension-Self-actualization needs

The Role of the Family

Planning for care and understanding the psychosocial issues confronting older adults must be accomplished within the context of the family. If dependency needs occur, the spouse often assumes the role of primary caregiver. In the absence of a surviving spouse, an adult child may assume caregiver responsibilities and need help in providing or arranging for care and support. Two common myths in American society are that adult children and their aged parents are socially alienated, and that adult children abandon their parents when health and other dependency problems arise. In reality, the family has been and continues to be an important source of support for older adults; similarly, older family members provide a great deal of support to younger family members. Although adult children are not financially responsible for their older parents, social attitudes and cultural values often dictate that adult children should provide services and assume the burden of care if their aged parents cannot care for themselves. It is estimated that in 2018, informal caregivers provided 18.5 billion hours of unpaid care (Alzheimer's Association, 2019). Caregiving, which may continue for many years, can become a source of family stress and is a well-known risk for psychiatric and physical morbidity. Evidence-based interventions to reduce distress and enhance well-being in caregivers have been identified. Three broad types of effective programs include psychoeducational skill building, cognitive behavioral therapy, and using a combination of at least two approaches such as education, family meetings, and skill building sessions (Bakas, McCarthy, & Miller, 2018). Researchers have reported that web-based interventions are effective, efficient, and a better fit for the hectic lives of families and caregivers

Family Genograms and Ecomaps

The genogram (see Fig. 33-2) acts as a continuous visual reminder to caregivers to "think family." In addition, the ecomap (see Fig. 33-4) illustrates the family's interactions with outside systems.

Spousal Relationships

Relationships with a spouse or partner may change. Although for many this is a time of greater security and stability with stronger emotional commitment and sharing, for some it is a time of disenchantment. Either partner may develop negative or critical feelings and attitudes as a result of changes in physical appearance, energy levels, or sexual needs and abilities. Dissatisfaction with not achieving career or family goals contributes to the stresses placed on the marriage. Extramarital affairs and divorce may result. Loss of a spouse or partner is more likely in the middle adult years. The loss is a major crisis and a threat to a person's self-concept, and may result in a major role change. Many changes may occur, including a reduced income, changes in lifestyle and social relationships, and the need for help to work through the loss and grief

examples of Sociocultural Dimension-Love and belonging needs

Relationships with others Communications with others Support systems Being part of a community Feeling loved by others

Retirement and Reduced Income

Retirement brings a change in a person's concept of time. Many older adults must learn to occupy their leisure time in ways that maintain their self-esteem while being personally satisfying. Satisfaction with retirement is closely tied to income and the relationships one has outside of work. While many older adults have adequate retirement income, for others a lack of adequate income can affect their ability to meet their needs, such as for medical care and housing or social and creative interests. Spouse or Partner Health When a person's spouse or partner becomes ill, numerous and difficult adjustments must be made. An older adult may face new roles for the first time, such as cooking meals or handling family finances. These role changes come at a time when stress is already high. Providing physical care can be an overwhelming task if the caregiver is also frail or in poor health. Adaptations may be needed in living conditions and lifestyle, and one spouse may need to plan social and recreational events alone. The need for love and belonging does not diminish with age, and may become acute with the loss of the spouse or partner through illness or institutionalization. Humans are sexual beings, and sexual behavior does not necessarily stop in old age. Sexuality is part of who we are, and older adults are no exception. Like younger adults, older adults need to express their intimacy physically by touching and sexual activity, and emotionally by sharing joys, sorrows, ideas, and values

Stage II—Childbearing Families (oldest child is infant through 30 months) Tasks

Setting up the young family as a stable unit (integrating new baby into family) Reconciling conflicting developmental tasks and needs of various family members Maintaining a satisfying marital relationship Expanding relationships with extended family by adding parenting and grandparenting roles

Stage IV—Families with Schoolchildren (6-13 years) Tasks

Socializing the children, including promoting school achievement and fostering of healthy peer relations of children Maintaining a satisfying marital relationship Meeting the physical health needs of family members

Psychosocial Aspects of Aging

Successful psychological aging is reflected in the ability of older adults to adapt to physical, social, and emotional losses and to achieve life satisfaction. Because changes in life patterns are inevitable over a lifetime, older adults need resiliency and coping skills when confronting stresses and change. A positive self-image enhances risk taking and participation in new, untested roles. Although attitudes toward older adults differ in ethnic subcultures, a subtle theme of ageism—prejudice or discrimination against older adults—predominates in society, and many myths surround aging. Ageism is based on stereotypes—simplified and often untrue beliefs that reinforce society's negative image of older adults. Although older adults make up an extremely heterogeneous and increasingly a racially and ethnically diverse group, these negative stereotypes are sometimes attributed to all older adults. Fear of aging and the inability of many to confront their own aging process may trigger ageist beliefs. Retirement and perceived nonproductivity are also responsible for negative feelings, because a younger working person may falsely see older people as not contributing to society, as draining economic resources, and may actually feel that they are in competition with children for resources. Concern about the large numbers of older people leaving the workforce (baby boomers began to turn 65 years of age in 2010) is fueling this debate. Negative images are so common in society that older adults themselves often believe and perpetuate them. An understanding of the aging process and respect for each person as an individual can dispel the myths of aging. Nurses can facilitate successful aging by recommending health promotion strategies such as anticipatory planning for retirement, including ensuring adequate income, developing routines not associated with work, replacing work-related friends with new acquaintances, and relying on other people and groups in addition to spouse to fill leisure time

Recommending Support and Therapy Groups

Support groups exist especially for people in similar stressful situations. Groups have been formed by people with ostomies; women who have had mastectomies; and people with cancer or other serious diseases, chronic illness and disability. There are groups for single parents, substance abusers and their family members, homicide bereavement, and victims of child abuse. Professional, civic, and religious support groups are active in many communities (Mavandadi, Wray, & Toseland, 2019; Supiano & Overfelt, 2018). Encounter groups, assertiveness training programs, and consciousness-raising groups help people modify their usual behaviors in their transactions with their environment. Many find that being a member of a group with similar problems or goals has a releasing effect that promotes freedom of expression and exchange of ideas.

Moral Development

The child enters adolescence with a law-and-order orientation and may never progress beyond that point. Young adults who have mastered previous levels of moral development reach the conventional level and are concerned with maintaining expectations. They also value conformity, loyalty, and social order. Some people may enter the postconventional stage, in which they make moral judgments on the basis of universal beliefs.

Enhancing Social Support

The nature of social support and its influence on coping have been studied extensively. Social support has been demonstrated to be an effective moderator of life stress. Such support has been found to provide people with several different types of emotional information (Nicks, Wray, Peavler, et al., 2019; Warner, Roberts, Jeanblanc, et al., 2017). The first type of information leads people to believe that they are cared for and loved. This emotional support appears most often in a relationship between two people in which mutual trust and attachment are expressed by helping each other to meet their emotional needs. The second type of information leads people to believe that they are esteemed and valued. This is most effective when others in a group recognize a person's favorable position within that group, demonstrating the person's value. Known as esteem support, this elevates the person's sense of self-worth. The third type of information leads people to feel that they belong to a network of communication and mutual obligation. Members of this network share information and make goods and services available to the members as needed. Social support also facilitates a person's coping behaviors; however, this depends on the nature of the social support. People can have extensive relationships and interact frequently; however, the necessary support comes only when people feel a deep level of involvement and concern, not when they merely touch the surface of each other's lives. The critical qualities within a social network are the exchange of intimate communications and the presence of solidarity and trust. Emotional support from family and significant others provides love and a sense of sharing the burden. The emotions that accompany stress are unpleasant and often increase in a spiraling fashion if relief is not provided. Being able to talk with someone and express feelings openly may help a person gain mastery of the situation. Nurses can provide this support but also must identify the person's social support system and encourage its use. People who are "loners," who are isolated, or who withdraw in times of stress have a high risk of coping failure. Because anxiety can also distort a person's ability to process information, it helps to seek information and advice from others who can assist with analyzing the threat and developing a strategy to manage it. Again, this use of others helps people maintain mastery of a situation and self-esteem. Thus, social networks assist with management of stress by providing people with: A positive social identity Emotional support Material aid and tangible services Access to information Access to new social contacts and new social roles

Nursing Interventions to Promote Family Health

The nurse can help reduce risk factors with activities that promote health for all family members at any level of development. Recall that each person has his or her own definition of health, based in part on family beliefs and values about health and illness. The nurse assists both the person and the family to meet basic human needs. Examples of stage-specific risk factors and nursing interventions to promote health in the family are shown in Table 4-2. Nurses may carry out such activities themselves or may refer the individual or family to other health care providers. Health promotion activities and nursing actions can reduce the risk for illness and facilitate healthy behaviors at any age within the family life cycle.

Taste and Smell

The senses of taste and smell are reduced in older adults. Of the four basic tastes (sweet, sour, salty, and bitter), sweet tastes are particularly dulled in older adults. Blunted taste may contribute to the preference for salty, highly seasoned foods, but herbs, onions, garlic, and lemon can be used as substitutes for salt to flavor food. Changes in the sense of smell, generally greater than the loss of taste, are related to cell loss in the nasal passages and in the olfactory bulb in the brain (Norris, 2019). Environmental factors such as long-term exposure to toxins (e.g., dust, pollen, smoke) contribute to the cellular damage.

examples of Intellectual and Spritual Dimension-Self-actualization needs

Thinking Learning Decision making Values Beliefs Fulfillment Helping others

Adjusting to the Changes of Middle Adulthood

Various changes can take place during the middle years. These include changes in employment, relationships with a spouse or partner, relationships with children who are becoming adults, and relationships with aging parents. Midlife transition may occur in both men and women in their 40s. Although one does not feel that one is aging, realizing that others consider you "old" or "older" can be stressful.

OA Living Arrangements

Various types of housing options for older adults are outlined in Box 23-4 on page 578. The ability to function safely and independently at home depends a great deal on a person's functional health, transportation, income, and family. An older adult, for example, may need assistance with home repairs, housecleaning, or grocery shopping. Architectural barriers, such as steps, may need to be modified. Easy access to medical and recreational facilities and churches may become more important. Many older adults in poor health can continue living at home with some assistance from visiting nurses or with the aid of other services, such as home-delivered meals and senior transportation. Assisted-living housing is becoming more common, providing such requirements as meals, health care services, and housekeeping services. Most older adults prefer to live in their own home and find it difficult to move. Over half of this population lives with a spouse or partner, but this number decreases with increasing age and the death of the significant other. Moving in with adult children creates changes in roles and authority. In 2010, approximately 1.94 million grandparents over the age of 65 lived in a home with a grandchild (Administration on Aging, Administration for Community Living, & U.S. Department of Health and Human Service, 2016). If the older adult is chronically ill or cognitively impaired, the family caregivers face a lack of freedom, emotional stress, and the physical challenges inherent in daily caregiving. Although the largest percentage of residents in long-term care facilities are older adults, many of whom have disabilities, only about 4% of older adults live in long-term care facilities (West, Cole, Goodkind, & He, 2014). When a person moves to a long-term care facility, the loss of home and possessions and the need to conform to the routines of institutional living can be traumatic for the person and family. Some people, however, choose to move for convenience, social relationships, or needed health care. Additional options for older adults include quality patient-centered programs with a focus on providing long-term care to older adults who want to remain in the community. Several examples are listed here: PACE, the Program of All-Inclusive Care for the Elderly, is a Medicare- and Medicaid-funded program where adults aged 55 years or older who meet specific criteria can receive comprehensive interdisciplinary care. They also receive support to live in the community as long as possible. Approximately 122 PACE programs are active around the country (National PACE Association, 2018). NORCs (Naturally Occurring Retirement Communities) are formal organizations structured around a model of support services that are geographically based rather than service based. NORC coordinator positions can be federally or locally funded (Siegler, Lama, Knight, Laureano, & Reid, 2015). NORCs have been recognized as viable options to assist older adults to age in place, and are referenced under Title IV of the Older Americans Act (Colello & Napili, 2016). REACH (Racial and Ethnic Approaches to Community Health) programs represent an effort by the CDC to establish community-based, culturally appropriate programs to reduce health disparities, improve health, and decrease complications from chronic diseases among African Americans, Hispanics/Latinos, Asian Americans, Alaska Natives, and Pacific Islanders. The CDC seeks to eliminate socially determined barriers to achieving health by supporting and funding community-based strategies, providing infrastructure, supporting national and international organizations, and increasing evidence-based strategies that address health disparities. In 2014, REACH committed $34.9 million and funded 49 facilities and organizations (CDC, 2017d). Retirement centers and senior citizens' housing have become common. For the family members of older adults who need health care, alternative methods of care have become available. Examples include respite care facilities, which allow the family a needed rest by temporarily housing and caring for an ailing older family member, and adult day services (ADS) centers, which provide a safe, stimulating environment during the day when family caregivers must work. Nurses should be knowledgeable about what health care and social services are available in the patient's community so that the patient and family can be referred. The old-old have special significance for nursing care because they are more likely to need help with mobility and basic activities of daily living. They may need increasing assistance to maintain a safe and comfortable living environment. The older the person, the more likely that the individual needs family and community support to maintain functional health. Additional resources for community support services that help older adults live independently are located in

Nursing Care for Special Populations with Chronic Illness

When providing care and education, the nurse must consider multiple factors (e.g., age; gender; culture and ethnicity; cognitive status; the presence of physical, sensory, and cognitive limitations; health literacy) that influence susceptibility to chronic illness and the ways patients respond to chronic disorders. Certain populations, for example, tend to be more susceptible to certain chronic conditions. Populations at high risk for specific conditions can be targeted for special education and monitoring programs; this includes those at risk because of their genetic profile (see Chapter 6 for further discussion of genomics and genetics). People of different cultures and genders may respond to illness differently, and being aware of these differences is essential. For cultures in which patients rely heavily on the support of their families, the families must be involved and made part of the nursing plan of care. As the United States becomes more multicultural and ethnically diverse, and as the general population ages, nurses need to be aware of how a person's culture and age affect chronic illness management and be prepared to adapt their care accordingly. It is important to consider the effect of a preexisting disability, or a disability associated with recurrence of a chronic condition, on the patient's ability to manage ADLs, self-care, and the therapeutic regimen. These issues were discussed earlier in this chapter.

As the nurse identifies and carries out interventions to help meet patients' needs, it is important to remember that Maslow's hierarchy is only

a framework or guideline, and that, in actuality, each person sets his or her own priorities for needs. Additionally, basic human needs are interrelated, and may require nursing actions at more than one level at a given time. For example, in caring for a person coming into the emergency department with a heart attack, the nurse's immediate concern is the patient's physiologic needs (e.g., oxygen and pain relief). At the same time, safety needs (e.g., for oxygen use precautions and for ensuring that the person does not fall off the examining table) and love and belonging needs (e.g., for having a family member nearby if possible) are still major considerations. You will learn how nurses meet basic human needs throughout the rest of this book.

only one group—the family—is typically concerned with

all parts of a person's life and with meeting the individual's basic human needs to promote health.

Nuclear Family

also called the traditional family, is composed of two parents and their children. Contemporary descriptions of a nuclear family vary. Pender et al. (2015) define a nuclear family as "two or more persons who depend on one another for emotional, physical, or financial support." There is great variability in nuclear family structure in today's "postmodern families." The parents may be heterosexual or homosexual, and are usually either married or in a committed relationship; family members live together until the children leave home as young adults. The nuclear family may be composed of biologic parents and children, adoptive parents and children, surrogate parents and children, or stepparents and children. Multiple research studies have concluded that family processes, such as the quality of parenting and harmony between parents, rather than family structures, contribute to a child's well-being (American Academy of Pediatrics, 2012). In the past, the traditional nuclear family typically consisted of a breadwinner husband and caregiver wife. In contemporary nuclear families, both parents may work for pay while sharing roles in providing physical and emotional safety and security. The two major causes of this change are increased education and career opportunities for women, and changes in our economy resulting in a need for additional income to maintain a desired standard of living. The contemporary nuclear family often lives in close geographic proximity to relatives, such as aunts, uncles, and grandparents, who are a part of the extended family. Couples without children and couples with grown children who no longer live at home are considered nuclear families as well. The blended family is another form of a nuclear family, formed when parents bring unrelated children from previous relationships together to form a new family.

Assisted Living Facilities

an option when an older person's physical or cognitive changes necessitate at least minimal supervision or assistance. Assisted living allows for a degree of independence while providing minimal nursing assistance with administration of medication, assistance with ADLs, or other chronic health care needs. Other services, such as laundry, cleaning, and meals, may also be included. Both assisted living and CCRCs are costly and primarily paid out-of-pocket.

Differentiation of Self

assessed in relation to the boundaries of the subsystems in the structure of the family. This concept is based on a balance of emotional and intellectual levels of function. The emotional level, associated with lower brain centers, relates to feelings. The intellectual level, associated with the cerebral cortex, relates to cognition. How connected these levels, or systems, are affects the person's social functioning. The greater the balance between thinking and feeling, the higher the differentiation of self and the better the person is at managing anxiety. The Bowen Center (n.d.) provides a summary of key elements of the concept of differentiation of self. The family with highly differentiated adult members is flexible in its interactions, seeks to support all members, understands each member as unique, and encourages members to develop differently from one another. Family roles are assigned on the basis of knowledge, skill, and interest. The family with low levels of differentiation has adult members who demonstrate impulsive actions, who have difficulty delaying gratification, who cannot analyze a situation before reacting, and who cannot maintain intimate interpersonal relationships (similar to the developmental level of a 2-year-old child). Intense, short-term relationships are the norm, and emotionally based reactions can escalate into violence. Family roles are assigned on the basis of family tradition. A moderately differentiated person is less dominated by emotions, but personal relationships are often emotion dominated. Life is rule bound, and thinking is usually dualistic (things and people are black and white, good or bad, smart or stupid). A situation cannot be perceived from any but a personal perspective. The person tends to "fuse" or become enmeshed with another in emotional relationships, losing the self in the efforts to please the other. Families with moderately differentiated members exhibit rigid patterns of interactions that are rule bound and have defined roles and acceptable behaviors.

Cognitive Aspects of Aging

can be affected by many variables, including sensory impairment, physiologic health, environment, sleep, and psychosocial influences. Older adults may experience temporary changes in cognitive function (i.e., delirium) when hospitalized or admitted to skilled nursing facilities, rehabilitation centers, or long-term care facilities. These changes are related to differences in the environment or in medical therapy or to alteration in role performance. A commonly used assessment tool is the Mini-Mental State Examination (MMSE) (see Chart 8-3). Good sleep hygiene can improve cognition, as can treatment of depression and anxiety. Several researchers are evaluating memory enhancement programs for older adults. In addition, researchers have found that eating a healthy balanced diet, being physically active for at least 30 minutes each day, and getting plenty of sleep can assist in preventing chronic illnesses as well as improving cognitive function (McDougall, 2017). When intelligence test scores from people of all ages are compared, test scores for older adults show a progressive decline beginning in midlife. However, research has shown that environment and health have a considerable influence on scores, and that certain types of intelligence (e.g., spatial perceptions and retention of nonintellectual information) decline, whereas others (e.g., problem-solving ability based on past experiences, verbal comprehension, mathematical ability) do not. Cardiovascular health, a stimulating environment, and high levels of education, occupational status, and income all appear to have a positive effect on intelligence scores in later life.

Social roles

change with the developmental tasks and adjustments of older adulthood, but the need to feel valued, useful, and productive continues. Older adults may develop new hobbies or increase their involvement in community, church, or family affairs (Fig. 23-7). They may do volunteer work or even begin a new career. If an older adult cannot adjust and form new relationships, social isolation can become a problem. Social isolation is a sense of being alone and lonely as a result of having fewer meaningful relationships. It may occur because of declining health or income, transportation problems, or ageism. Whatever the cause, prolonged social isolation has been associated with declining health and higher mortality rates.

Communication Theory

concerns the sending and receiving of both verbal and nonverbal messages. The focus is on how individuals interact with one another. According to Wright and Leahey (2013, pp. 34-36), the major concepts of communication theory applied to families are: All nonverbal communication is meaningful. All communication has two major channels for transmission (digital, or verbal, communication; and analog or analogic communication, which includes all types of nonverbal communication as well as music, poetry, and painting) A dyadic (two-person) relationship has varying degrees of symmetry and complementarity (both of which may be healthy depending on context). All communication consists of two levels: content (what is said) and relationship (of those interacting).

Triangles

discussed in relation to subsystems of family structure. Titelman (2008) describes Bowen's triangle as a relational pattern or emotional configuration that exists among one or two family members and another person, object, or issue. Triangles exist in all families; who makes up a triangle can change depending on the situation. However, when two people avoid dealing with emotional closeness or an issue that produces anxiety, the two people may use a third person to evade the stress. For instance, a wife may pull in a child as a third person in the couple's relationship; the husband may distance himself from the conflict by deeper involvement in work. As the intensity of the relationship changes, the amount of interaction is usually balanced, so that as two members move closer, the third withdraws.

FAMILY ASSESSMENT

family knowledge can be obtained and applied even in very brief meetings with a family.

With changes in family structure

have come other influences on the basic human needs of family members. Considerations for the family, and for nursing care, include support systems (in our mobile society, family members may live hundreds or thousands of miles away), availability of childcare, time for leisure and recreation, struggles to meet financial commitments, and changing role models.

Single-Parent Family

may be separated, divorced, widowed, or never married. Increasing numbers of never-married men and women are choosing to become parents. More than one fourth of all children in North America are now estimated to live in single-parent families (American Academy of Pediatrics, 2011). Many single-parent families are headed by women. Single parents often have special problems and needs, including financial concerns and role shifts (i.e., having the roles of both parents), and they may remarry or enter into new relationships. The situation and needs of the single-parent family are important considerations when planning and implementing nursing care.

Single adults

may not be living with others, but they are part of a family of origin, usually have a social network with significant others, or may even regard a pet as family. Most single adults living alone are either young adults who achieve independence and enter the workforce or older adults who never married or are left alone after the death of a spouse.

Delirium

occurs secondary to numerous causes, including physical illness, surgery, medication or alcohol toxicity, dehydration, fecal impaction, malnutrition, infection, head trauma, lack of environmental cues, and sensory deprivation or overload. Older adults are particularly vulnerable to acute confusion because of their decreased biologic reserve and the large number of medications they may take. Nurses must recognize the symptoms of delirium and report them immediately. The Confusion Assessment Method (CAM) is a commonly used screening tool (Inouye, van Dyck, Alessi, et al., 1990). (See Chart 8-7.) Because of the acute and unexpected onset of symptoms and the unknown underlying cause, delirium is a medical emergency. If the delirium goes unrecognized and the underlying cause is not treated, permanent, irreversible brain damage or death can follow.

Continuing Care Retirement Communities

offer three levels of living arrangements and care that provide for aging in place (Miller, 2019). CCRCs consist of independent single-dwelling houses or apartments for people who can manage their day-to-day needs, assisted living apartments for those who need limited assistance with their daily living needs, and skilled nursing services when continuous nursing assistance is required. CCRCs usually contract for a large down payment before the resident moves into the community. This payment gives a person or couple the option of residing in the same community from the time of total independence through the need for assisted or skilled nursing care. Decisions about living arrangements and health care can be made before any decline in health status occurs. CCRCs also provide continuity at a time in an older adult's life when many other factors, such as health status, income, and availability of friends and family members, may be changing.

Cohabiting families

people who choose to live together for a variety of reasons, including relationships, financial need, or changing values. Cohabiting families include unmarried adults living together (they may be of any age, including retired people who choose not to marry because it would impose financial hardship) and communal or group marriages. Other family structures include binuclear (where divorced parents assume joint custody of children) and dyadic nuclear (in which the couple chooses not to have children).

Technique

provide a guide to a 15-minute (or shorter) family interview (pp. 263-277). Key elements of the interview, which occurs only in the context of a therapeutic relationship, are manners, therapeutic conversation, family genogram (and ecomap as appropriate), therapeutic questions, and commendations. See Box 33-3 for a summary of the interview technique, which reflects successful interview techniques in any form of family nursing. Essential points follow. Manners

Therapeutic Conversation

purposeful and time limited; however nurse-family communications are therapeutic even though the nurse may not think of them as such (Wright & Leahey, 2013, p. 266). The art of listening is paramount. The nurse not only makes information giving and client involvement in decision making an integral part of the care delivery process but also seeks opportunities to engage in purposeful conversations with families. Nurse-family therapeutic conversations can include such basic ideas as: Invitations to accompany the client to the unit, clinic, or hospital Inclusion of family members in health care facility admission procedures Encouragement to ask questions during client orientation to a health care facility Acknowledgment of client and family's expertise in managing health problems by asking about routines at home Presentation of opportunities to practice how client will handle different interactions in the future such as telling family members and others that they cannot eat certain foods Consultation with families and clients about their ideas for treatment and discharge

A family can be defined

simply as any group of people who live together and depend on one another for physical, emotional, and financial support. Families are essential to the health and survival of the individual family members, as well as to society as a whole. The family is a buffer between the needs of the individual member and the demands and expectations of society. The role of the family is to help meet the basic human needs of its members while also meeting the needs of society

Injuries

the leading cause of death for adolescents and young adults. Motor vehicle crashes are the most common cause of mortality, often associated with the use of alcohol or other drugs. In 2015, a total of 2,715 teenagers of ages 13 to 19 died in a motor vehicle accident. Drivers 16 to 19 years of age are three times more likely to be involved in a fatal crash than drivers 20 and older (Insurance Institute for Highway Safety Highway Loss Data Institute, 2017). Sport injuries remain an issue for the active teenager and young adult. Among adolescents 10 to 17 years of age, more than one million serious sports-related injuries occur each year

Havighurst theory for older adults

the major tasks of old age are primarily concerned with the maintenance of social contacts and relationships. Successful aging depends on a person's ability to be flexible and adapt to new age-related roles. The person must find new and meaningful roles in old age while being reasonably comfortable with the social customs of the times.

Alzheimer's Disease

the sixth leading cause of death in the United States. For adults 65 years of age and older it is the fifth leading cause of death. AD is a progressive, irreversible, degenerative neurologic disease that begins insidiously and is characterized by gradual losses of cognitive function and disturbances in behavior and affect. AD can occur in people as young as 40 years of age but is less common before 65 years of age. Although the prevalence of AD increases dramatically with increasing age, affecting as many as half of those 85 years and older, AD is not a normal part of aging. Without a cure or any preventive measures, it is estimated that 13.8 million Americans will have this disease by 2050 (Alzheimer's Association, 2019). There are numerous theories about the cause of age-related cognitive decline. Although the greatest risk factor for AD is increasing age, many environmental, dietary, and inflammatory factors also may determine whether a person suffers from this cognitive disease. AD is a complex brain disorder caused by a combination of various factors that may include genetics, neurotransmitter changes, vascular abnormalities, stress hormones, circadian changes, head trauma, and the presence of seizure disorders. AD can be classified into two types: familial or early-onset AD and sporadic or late-onset AD (see Chapter 6, Table 6-5). Familial AD is rare, accounting for less than 2% of all cases, and is frequently associated with genetic mutations. It can occur in middle-aged adults. If family members have at least two other relatives with AD, then there is a familial component, which may include both environmental triggers and genetic determinants (NIH, 2017).