Family

ASSESSING FAMILIES

"Family refers to two or more individuals who depend on one another for emotional, physical and economic support. The members of the family are self-defined". Based on this definition, it is relatively simple for the nurse to determine who constitutes a family: the family is whoever they say they are.

Family Functions 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

PROMOTING EFFECTIVE DISCIPLINE -Set clear, consistent, and developmentally appropriate expected behaviors; offer choices whenever possible. -Maintain consistency in responding to behaviors; provide encouragement and affection. -Role-model appropriate behaviors. -Provide an age-appropriate explanation of the consequence if the child demonstrates unacceptable behavior. -Always administer the consequence soon after the unacceptable behavior. -Keep the consequence appropriate to the age of the child and the situation. -Stay calm but firm without showing anger when administering the consequence.

-Always praise the child for displaying appropriate behavior (positive reinforcement). -Set the environment to assist the child in accomplishing the appropriate behavior; remove temptations that may lead to inappropriate behavior. -Reinforce that the child's behavior was "bad" but the child was not "bad." -Use extinction to reduce or eliminate reinforcement for an inappropriate behavior (e.g., ignore a temper tantrum). -When using time-out, use 1 minute per year of the child's age. Do not exceed 5 minutes. -Maintaining a positive, supportive, nurturing caregiver-child relationship. Using positive reinforcement to increase desirable behaviors. Using extinction or punishment to reduce or eliminate undesirable behaviors

The Relationship Between Families and Illness Among the many reasons for nurses to understand the concepts of family assessment, three stand out as important to a nursing assessment text:

-An ill person's family is an essential part of the context in which the illness occurs. -The family members, the ill person, and even the illness itself interact in such a way that no one component can be separated from the rest. -The statistics on family caregiving show that families are very much involved in providing care for an ill family member.

Risk Factors for Altered Family Health: Biologic Risks

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

RULES FOR DIVORCING PARENTS -Tell your children about the divorce and the reasons for the divorce in terms that they can understand. Be sure that you and your spouse are present together when telling the children; tell all the children at the same time. -Reassure your children that the divorce is not their fault. Repeat this as often as possible and as necessary. -Inform the children well in advance of anyone moving out of the house (except when abuse is present or there are concerns for immediate safety). -Clearly inform the children about the family structure after the divorce, such as who will live with whom and where; also discuss visitation clearly and honestly.

-Do not make your children be or act like adults. Seek support from other adults in your life. -Do not discuss money or finances with your children. Minimize unpredictable schedules and maintain routines, rules, and discipline, and be consistent in this area. -Never force or allow your children to take sides. -Avoid belittling your former spouse when the children can hear. However, do not lie to cover up for irresponsible behavior by the other parent. -Never put your children in the middle between you and your ex-spouse. -Keep each parent involved in the child's life. Write letters, emails, phone calls, and text messages to continue communication. This shows the child they remain important to you even when they are with the other parent. -Communicate directly with the other parent. Avoid making the child your messenger.

Risk Factors for Altered Family Health: Developmental Risk Factors

-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

Risk Factors for Altered Family Health: Psychosocial Risk Factors

-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

Risk Factors for Altered Family Health: Lifestyle Risk Factors

-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

Risk Factors for Altered Family Health: Environmental Risk Factors

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

Friedman and associates 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. -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.

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.

-Calgary Family Assessment Model -Friedman's Family Assessment Model Regardless of which model or framework you use to assess the family, there are three essential components of family assessment especially prominent in all family assessment models:

-structure -development -function Environmental components, cultural-ethnic variations, and areas of family coping, family stress, and family communication are usually incorporated into these three essential components. However, some models of family assessment may address them separately.

6. Safety measures: Instruct all patients to keep drugs out of the reach of children. Remind all patients to inform any healthcare provider they see about the drugs they are taking; this can prevent drug-drug interactions and misdiagnoses based on drug effects. Also alert patients to possible safety issues that could arise as a result of drug therapy. For example, teach patients to avoid driving or performing hazardous tasks if they are taking drugs that can make them dizzy or alter their thinking or response time. 7. Specific points about drug toxicity: Give patients a list of warning signs of drug toxicity. Advise patients to notify their healthcare provider if any of these effects occur.

8. Specific warnings about drug discontinuation: Remember that some drugs with a small margin of safety and drugs with particular systemic effects cannot be stopped abruptly without dangerous effects. Alert patients who are taking these types of drugs to this problem and encourage them to call their healthcare provider immediately if they cannot take their medication for any reason (e.g., illness, financial constraints).

Boundaries keep subsystems separate and distinct from other subsystems. They are maintained by rules that differentiate the particular subsystem's tasks from those of other subsystems. The most functional families have subsystems with clear boundaries; however, some connection between subsystems is maintained along with the boundaries. Disengaged families have rigid boundaries, which leads to low levels of effective communication and support among family members. Enmeshed families have diffuse boundaries, which make it difficult for individuals to achieve individuation from the family.

Power structure relates to the influences each member has on the family processes and function. Some distribution of power is necessary to maintain order so that the family can function. There is usually a power hierarchy, with the parents having more authority than the children. In the most functional families, parents have a sense of shared power and children gain increasing power as they mature and become more responsible. A tool to help the nurse and family examine family relationships based on structure is the Family Attachment Diagram. This is a diagram of the family members' interactions. It represents the reciprocal nature and quality of interactions.

Context The context of a family refers to the interrelated conditions in which the family exists: it is the family's setting. Four elements make up the context of the family structure: -race or ethnicity -social class -religion -environment

Race or ethnicity may influence family structure and interactions. Assessment should include how much the family identifies with and adheres to traditional practices of a particular culture, whether the family's practices are similar to those of the neighborhood of residence, and whether the family has more than one ethnic or racial makeup. Effects of social class and religion provide context for the family structure and lifestyle. A couple from different social classes or different religions may bring different expectations into the family system. Environmental characteristics of the residence, neighborhood, and family and neighborhood interactions clarify the context for the family structure and interactions.

PARENTING STYLES Maccoby and Martin were the basis of the development of four major parenting styles seen in our society: -authoritarian -authoritative -permissive -uninvolved or rejecting-neglecting

The styles are defined by the amount of support and control exerted over the child during parenting. Many parents may use more than one parenting style and may fall somewhere in between styles instead of adhering strictly to one style. Also some parents may change parenting styles as the child ages and matures. Whatever the style, sensitive and responsive caregiving is needed to promote appropriate physical, neurophysiologic, and psychological development. Nurses need to recognize different parenting styles and provide support to parents by discussing the effects of different parenting models and teaching parenting skills.

EXTINCTION Another form of discipline is extinction, which focuses on reducing or eliminating the positive reinforcement for inappropriate behavior. Examples are ignoring the temper tantrums of a toddler, withholding or removing privileges, and requiring "time-out." Withholding or removing privileges such as TV, music device, computer, or cell phone use is most effective for older children and adolescents. The adolescent may be grounded for a short time or not allowed to drive the car. To be effective, the privilege being withheld or removed must be something that the child values.

Time-out is an extinction discipline method that is most effective with toddlers, preschoolers, and early school-age children. It involves removing the child from the problem area and placing him or her in a neutral, nonthreatening, safe area where no interaction occurs between the child and parents or others for a specifically determined period.

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: -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?

PERMISSIVE Permissive or laissez-faire parents have little control over the behavior of their children. Rules or standards may be inconsistent, unclear, or nonexistent. Permissive parents allow their children to determine their own standards and rules for behavior. Discipline can be lax, inconsistent, or absent. Parents can be warm, cool, or uninvolved. There are more negative than positive effects associated with this style of parenting. Negative effects include children being impulsive, low happiness, poor school performance, problems with authority, lacking responsibility and independence.

UNINVOLVED OR REJECTING-NEGLECTING Uninvolved parents are indifferent. They do not provide rules or standards. The child's basic needs are often met but the parent is disconnected from the child's life. In some cases the parents may neglect or reject the child. They can be cold and uninterested in meeting the child's needs. They minimize their interactions and time with the children. This type of parenting is associated with negative effects such as the child lacking interest in school, lacking interest in the future, and lacking emotional and self-control. This type of parenting may also lead to lack of trust, low self-esteem, and anger toward others.

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.

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.

THE FAMILY Every person is a member of a number of groups: -such as family -friends -professional colleagues -a church congregation -school class. However, 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.

family- 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.

Family Structure INTERNAL FAMILY STRUCTURE

ASSESSMENT PROCEDURE Assess family composition. Use a genogram and fill in as much information as possible. Ask the following questions: -What is the family type (nuclear, three-generation, single-parent)? -Who does the family consider to be family? -Has anyone recently moved in or out? Has anyone recently died? NORMAL FINDINGS Family identifies family type and members of the family. A new baby born into family or young adult moving out reflects normal life-cycle tasks. Death is also a normal part of life, but it is not often viewed as a family strength. ABNORMAL FINDINGS A new baby or a young adult moving out may cause excessive stress for family. Death of a family member often causes a variety of different reactions including denial, extreme grief, depression, guilt, and even relief. Serious family problems may result when family members react to, and deal with, the death differently.

Family Structure INTERNAL FAMILY STRUCTURE

ASSESSMENT PROCEDURE Determine gender roles in the family. Gender often determines an expected family role. Ask each family member the following question: -What are the expected behaviors for men in your family? For women? Clinical Tip: It is important to ask both the men and women what they perceive to be the roles of men and women in the family because they may perceive the roles differently. NORMAL FINDINGS Family members understand and agree on expected gender-related behaviors; expected behaviors are flexible. ABNORMAL FINDINGS Rigid, traditional gender-related behaviors reduce the family's flexibility for meeting family needs. One or more family members have different beliefs about expected behaviors for men and women, which can lead to family conflict.

AUTHORITARIAN The authoritarian parent expects obedience from the child and discourages the child from questioning the family's rules. The parent provides low support and high control over the child. The rules and standards set forth by the parents are strictly enforced and firm. The parents expect the child to accept the family's beliefs and values and demand respect for these beliefs. The parents are the ultimate authority and allow little, if any, participation by the child in making decisions. Behavior that does not adhere to the family's rules and standards is punished. This parenting style is associated with negative effects on self-esteem, happiness and social skills, increased aggression, and defiance.

AUTHORITATIVE The authoritative or democratic parent shows some respect for the child's opinions. Although parents still have the ultimate authority and expect the child to adhere to the rules, authoritative parents allow children to be different and believe that each child is an individual. They exhibit warmth and consistently, fairly, and firmly enforce the family's rules and standards without emphasizing punishment. This type of parenting is associated with increased independence, happiness, self-confidence, and socially responsible individuals.

Family Structure INTERNAL FAMILY STRUCTURE

Assess subsystems and boundaries. See "Family Function" for questions. Family subgroups are present and appear healthy. Permeable boundaries are present. Family subgroups are absent or appear excessively strong, excluding other family members. Rigid or diffuse boundaries are present.

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.

The Human Dimensions and Basic Human Needs: Sociocultural dimension

BASIC HUMAN NEED Love and belonging needs - EXAMPLES Relationships with others Communications with others Support systems Being part of a community Feeling loved by others

The Human Dimensions and Basic Human Needs: Physical dimension

BASIC HUMAN NEED Physiologic needs - EXAMPLES Breathing Circulation Temperature Intake of food and fluids Elimination of wastes Movement

The Human Dimensions and Basic Human Needs: Environmental dimension

BASIC HUMAN NEED Safety and security needs - EXAMPLES Housing Community/neighborhood Climate

The Human Dimensions and Basic Human Needs: Intellectual and spiritual dimensions

BASIC HUMAN NEED Self-actualization needs - EXAMPLES Thinking Learning Decision making Values Beliefs Fulfillment Helping others

The Human Dimensions and Basic Human Needs: Emotional dimension

BASIC HUMAN NEED Self-esteem needs - EXAMPLES Fear Sadness Loneliness Happiness Accepting self

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. 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

Family Structures: Extended family- aunts, uncles, and grandparents. Couples without children and couples with grown children who no longer live at home are considered nuclear families as well.

Blended family is another form of a nuclear family, formed when parents bring unrelated children from previous relationships together to form a new family. Single-Parent Family 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. Other Family Structures In addition to traditional and single-parent families, cohabiting adults and single adults are other family structures. Cohabiting families are 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).

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. The commendations offer family members a new view of themselves.

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 and Leahey propose that many families experiencing illness, disability, or trauma have a "commendation-deficit disorder" Changing the view of themselves helps the family members to look differently at the health problem and more toward solutions.

A family member's gender often determines his or her role and behavior in the family. Rank order refers to the sibling rank of each family member. Example: Families often treat the oldest child differently from the way they treat the youngest child. The rank order and gender of each family member in relation to other siblings' rank order and gender make a difference in how the person will eventually relate to a spouse and children. For example, an older sister of a younger brother may bring certain expectations of how women relate to men into a marriage. If the older sister marries a man who is an older brother to a younger sister, there may be conflict or competition because each may expect to be the responsible leader.

Each member of a family may belong to several subsystems. Subsystems may be related to gender, generational position (parents, grandparents, children), shared interests or activities (e.g., music, sports, hobbies), or to function (work at home, work away from home). Examples of subsystems are parent-child, spousal, sibling, grandmother-granddaughter, mother-daughter, and father-son. Subsystems in a family relate to one another according to rules and patterns, which are often not perceived by the family until pointed out by an outsider.

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 illnesses, and disabilities. 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.

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.

Family Structure INTERNAL FAMILY STRUCTURE

Evaluate rank order. Spousal rank order often plays a significant role in family harmony. Ask spouses: What rank order did you have in your childhood family (e.g., older sister, youngest brother)? Using the family's answers and information you know concerning birth order, ask yourself: -Are spouses' birth rank orders likely to be complementary or competitive? Complementary birth order of spouses can support each spouse's interaction with the other based on past experiences with siblings (e.g., older brother marries younger sister). Competitive birth order of spouses may result in problems. For example, if an older brother marries an older sister, both may be used to being the responsible leader.

Family Structure INTERNAL FAMILY STRUCTURE

Evaluate the family power structure. Ask the family to rate the structure of the family on a scale with chaos (no leader) at one end, equality in the middle, and domination by one individual at the other end. If the family is dominated by one individual, ask the clients who that person is. A power hierarchy with parents equally in control, but tending toward egalitarian and flexible power shifts, is considered normal. This type of structure demonstrates respect for all family members and encourages family development and effective functioning. Chaotic or authoritarian power structures tend to prevent effective family functioning and individual development.

The nurse has a significant role and responsibility in identifying the health patterns of patients receiving care as well as those of their families.

If those patterns are not achieving physiologic, psychological, and social balance, the nurse is obligated, with the assistance and agreement of the patient, to seek ways to promote individual and family balance.

Family Genograms and Ecomaps The genogram acts as a continuous visual reminder to caregivers to "think family."

In addition, the ecomap illustrates the family's interactions with outside systems.

Family structure has three elements: internal structure external structure context

Internal Structure refers to the ordering of relationships within the confines of that family. It consists of all the details in the family that define the structure of the family. Elements of internal structure include family composition, gender (and gender roles), rank order, subsystems, boundaries, and power structure. Family composition can be illustrated by recording the family tree graphically as a genogram. A genogram helps the nurse to view the whole family as a unit. It shows names, relationships, and other information such as ages, marriages, divorces, adoptions, and health data. Behavior and health-illness patterns can be examined using the genogram because both of these patterns tend to repeat through the generations.

Nursing interventions for a family in a health crisis: includes 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.

It is important to involve family members in planning and implementing care.

FAMILY ASSESSMENT Family knowledge can be obtained and applied even in very brief meetings with a family. Technique 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.

Manners 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 Structures: 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

Nuclear Family- called the traditional family, is composed of two parents and their children. a nuclear family as "two or more persons who depend on one another for emotional, physical, or financial support." -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.

Therapeutic Conversation is purposeful and time limited; however nurse-family communications are therapeutic even though the nurse may not think of them as such.

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

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.

People learn health care activities, health beliefs, and health values in the family.

Focus on Patient and Family Teaching INCLUDE THE FOLLOWING KEY ELEMENTS IN ANY DRUG EDUCATION PROGRAM 1. Name, dose, and action of drug: Ensure that patients know this information. Many patients see more than one healthcare provider; this knowledge is crucial to ensuring safe and effective drug therapy and avoiding drug-drug interactions. Urge patients to keep a written and/or electronic list of the drugs that they are taking to show to any healthcare provider taking care of them and in case of an emergency when they are not able to report their drug history. 2. Timing of administration: Teach patients when to take the drug with respect to frequency, other drugs, and meals.

3. Special storage and preparation instructions: Inform patients about any special handling or storing required. Some drugs may require refrigeration; others may need to be mixed with a specific liquid such as water or fruit juice. Be sure that patients know how to carry out these requirements. 4. Specific OTC drugs or alternative therapies to avoid: Prevent possible interactions between prescribed drugs and other drugs or remedies the patient may be using or taking. Many patients do not consider OTC drugs or herbal or alternative therapies to be actual drugs and may inadvertently take them along with their prescribed medications, causing unwanted or even dangerous drug-drug interactions. Prevent these situations by explaining which drugs or therapies should be avoided. Encourage patients to always report all of the drugs or therapies that they are using to healthcare providers to reduce the risk of possible inadvertent adverse effects. 5. Special comfort measures: Teach patients how to cope with anticipated adverse effects to ease anxiety and avoid noncompliance with drug therapy. If a patient knows that a diuretic is going to lead to increased urination, the day can be scheduled so that bathrooms are nearby when they might be needed. Also educate patients about the importance of follow-up tests or evaluation.

TYPES OF FAMILY STRUCTURES Nuclear family (Husband, wife, and children living in same household) -May include natural or adopted children -Once considered the traditional family structure; now decreased due to trends in divorce rates or other social situations such as nonmarital childbearing Binuclear family (Child who is member of two families due to joint custody; parenting is considered a joint venture) Always works better when the interests of the child are put above the parents' needs and desires Single-parent family (One parent responsible for care of children) -May result from death, divorce, desertion, birth outside marriage, or adoption -Likely to encounter several challenges because of economic, social, and personal restraints; one person as homemaker, caregiver, and financial provider

Commuter family (Adults in the family living and working apart for professional or financial reasons, often leaving the daily care of children to one parent) Similar to single-parent family, but without as much economic challenge Step or blended family (Adults with children from previous marriages or from the new marriage) -May lead to family conflict due to different expectations for the child and adults; may have different views and practices related to child care and health Extended family (Nuclear family and grandparents, cousins, aunts, and uncles) Need to determine decision maker as well as primary caretaker of the children May be encouraged and supported by some cultures, such as Hispanic and Asian cultures

External Structure refers to those outside groups or things to which the family is connected. External structures may influence aspects of the internal structure of the family. Two elements of external structure include extended family and external systems. Extended family may consist of family members not residing in the home but with whom the family interacts frequently such as grandparents or an aunt and uncle who live a short distance away. It also may include family members with whom the family interacts infrequently such as a first cousin who lives across the country and with whom the family communicates only through Christmas cards and a visit once every few years. However, the family feels confident that this cousin would be supportive in time of need. Another type of extended family is the "cut-off" family member. An example would be a brother who left home many years ago and with whom there is no contact at all. This brother may still be considered extended family.

External systems are those systems that are larger than the family and with which the family interacts. These systems include institutions, agencies, and significant people outside the family. Some specific examples of external systems include a family's health center, school, jobs, volunteer agency, church, recreational organizations, friends, neighbors, coworkers, and extended family (only those with whom interaction is frequent). An ecomap can be used to assess the family members' interactions with the systems outside the family.

Family Stages, Tasks, Health Risk Factors, and Nursing Interventions to Promote Health: Family with adolescents and young adults

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

Family Stages, Tasks, Health Risk Factors, and Nursing Interventions to Promote Health: Family with middle-aged adults

FAMILY STAGE Family with middle-aged adults TASKS -Maintain ties with younger and older generations -Prepare for retirement STAGE-SPECIFIC RISK FACTORS -Depression -Exposure to environmental or work-related health risks, such as sunlight, asbestos, radiation, coal dust, and air or water pollution STAGE-SPECIFIC NURSING INTERVENTIONS/REFERRALS -Blood pressure screenings -Screening for chronic illness

Family Stages, Tasks, Health Risk Factors, and Nursing Interventions to Promote Health: Family with older adults

FAMILY STAGE Family with older adults TASKS -Adjust to retirement -Adjust to loss of spouse -May move from family home STAGE-SPECIFIC RISK FACTORS -Increasing age with loss of physical function -Chronic illness -Depression -Death of spouse STAGE-SPECIFIC NURSING INTERVENTIONS/REFERRALS -Screening for chronic illness -Home safety information -Retirement information -Pharmacology information

Family Stages, Tasks, Health Risk Factors, and Nursing Interventions to Promote Health Couple and family with young children

FAMILY STAGE Couple and family with young children TASKS -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 STAGE-SPECIFIC RISK FACTORS -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 STAGE-SPECIFIC NURSING INTERVENTIONS/REFERRALS -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

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

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 one another meet their emotional needs. 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 individual's value. Known as esteem support, this elevates the person's sense of self-worth. 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.

Same-sex family (also called homosexual or gay/lesbian family) (Adults of the same sex living together with or without children) May face prejudice against those with different lifestyles Communal family (Group of people living together to raise children and manage household; unrelated by blood or marriage) -May face prejudice against those with different lifestyles -Need to determine the decision maker and caretaker of children Adolescent families (Young parents still mastering the developmental tasks of their own childhood) Teenage girls have greater risk for health problems during pregnancy and delivery of premature infants, leading to risk of subsequent health and developmental problems Probably still need support from their family related to financial, emotional, and school issues

Foster family (A temporary family for children who are placed away from their parents to ensure their emotional and physical well-being) -May include foster family's children and other foster children in the home -Foster children are more likely to have unmet health needs and chronic health problems because they may have been living in a variety of settings (AAP, 2000) Grandparents-as-parents families (Grandparents raising their grandchildren if parents are unable to do so) -May increase the risk for physical, financial, and emotional stress on older adults -May lead to confusion and emotional stress for child if biologic parents are in and out of the child's life

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. Families are also the first source for socialization and teaching about health and illness.

Seven traits that enhance coping of family members under stress: -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.

Applying Maslow's Theory Nurses can apply Maslow's hierarchy of basic needs in the assessment, planning, implementation, and evaluation of patient care.

The hierarchy can be used with patients at any age, in all settings where care is provided, and in both health and illness. It helps the nurse identify unmet needs as they become health care needs. The hierarchy of basic needs allows the nurse to locate the patient on the health-illness continuum and to incorporate the human dimensions and health models into meeting needs

In a closed adoption there is no contact between the adoptive parents, the adopted child, and the birth mother. In an open adoption there is as much contact among the individuals as desired. Regardless of the method used to adopt a child, adoptive families may be faced with unique issues. Some adopted children have complex medical, developmental, behavioral, educational, and psychological issues

The nurse needs to be sensitive, understanding, and supportive when interacting with adopted children and their families. "Positive" adoption language should be used. This includes saying "birth parent" when referring to biologic parents instead of "natural" or "real parent" and just parents when talking about adoptive parents. Also, do not refer to the child as their "adopted child" or other children as "natural child". When discussing adoption using terms such as "make an adoption plan" instead of "give away" or "give up for adoption" are preferred. The nurse also needs to provide reassurance and understanding regarding missing health information and provide appropriate resources and referrals to resources that are knowledgeable about adoption and sensitive to the issues that may arise.