B.

FAMILY NURSING CARE PLAN DEFINITION A Family Nursing Care Plan is the set of actions the nurse decides to implementt o be able to resolve identified family health and nursing problems. CHARACTERISTICS 1. The nursing care plan focuses on actions which are designed to solve orallevi ate an existing problem. The plan is a blueprint for action; the meats of the plan are theapproaches, str ategies, activities, methods, and materials by which thenurse hopes to change th e problem situation. 1. The nursing are plan is a product of deliberate systematic process. It is not based on impulsive or spur of the moment decisions. Theplanning proces s is characterized by logical thinking wherebyrelationships are put together to arrive at rational decisions. Theactions the nurse decides to implement are chos en from amongalternatives after careful analysis and weighing options open to he r. 1. The nursing are plan, as with all other plans, relates to the future. It utilized events in the past and what is happening in the present todetermine trends. It also envisions the future if the problem situation isnot corrected. 1. The nursing care plan revolves around identified health and nursingproblems. The problems are the starting points for the plan, and the bases for theobjectiv es of care and subsequent intervention measures. 1. The nursing care is a means to an end, not an end in itself. The goal in planning is to deliver the most appropriate care to client. Ifit doe s not serve the purpose for which it is initiated it becomesuseless and an expen sive undertaking. 1. Nursing care planning is continuous process, not a one-shot deal. The results of the evaluation of the plan s effectiveness pave the wayfor another cycle of planning until the problems are resolved. DESIRABLE QUALITIES OF A NURSING CARE PLAN 1. It should be based on a clear definition of the problems. A nursing care plan takes time and effort to make. It will be a sheerwaste of re sources if it does not produce the intended results becauseof a vague or erroneo us definition of a problem. A good plan is basedon a comprehensive analysis of t he problem situation. The main aswell as the contributory causes in the perpetua tion of the problemshould be identified. 1. A good plan is realistic.

It can be implemented with reasonable chance of success. This realismof a plan i s related to the quantity and quality of resources required inits execution. 1. The nursing care plan should be consistent with the goals and philosophy ofth e health agency. If the health agency for instances, promotes self reliance of the clientas one o f the philosophies, then the nurse must bear this in mind whenplanning her appro ach and intervention measures. 1. The nursing care plan is drawn with the family. This is consistent with the principle that the nurse works with and NOTfor the f amily. She involves the family in determining health needs andproblems, in estab lishing priorities, in selecting appropriate course ofaction, implementing them and evaluating outcomes. Throughparticipatory planning, the nurse also gives the family the feeling thatits dignity and integrity are preserved because of the r ealization that isnot totally helpless and can still do something about the prob lemsituation. 1. The nursing care plan is best kept in a written form. It is a means of communication not only among the nurse but alsobetween nurses a nd other members of the health team. Moreover, it is impossible for a nurse to keep many family care plan in her mind andremember the salient point of care. The development of standardforms can help motivate nurse s to write their nursing care plans. Written plans also serve as useful administrative device for evaluatingstaff per formance and the quality of care provided to clients. IMPORTANCE OF PLANNING CARE 1. They individualized care to clients The recipient of care whether individual of family or the entirecommunity are di fferent from each other. Nursing care, to beappropriate should suit and be uniqu e to a particular client. Planningfacilities the delivery of the most appropriat e care by considering theindividuality of each client 1. The nursing care plan helps in setting priorities By providing information about the client as well as the nature of hisproblems, the nurse set her priorities for care. 1. Nursing care plan promote systematic communication among the health care team Nursing care plan define the problems and details of nursinginterventions done t o resolve them. 1. Continuity of care is facilitated Gaps and duplication in services provided are minimized. Gaps andduplications of services are bound to occur in setting where there isfrequent turnover of staff or when several health workers are providingcare to the same family. 1. It facilitates the coordination of care By making known to other members of the health team what nursingcare is rendered . Coordination of care prevents fragmentation of

services and increases the efficiency of the health service delivery system. ESTABLISHING PRIORITIES After the date analysis, the nurse may realize that the family is facedwith a nu mber of health nursing problems, which cannot be taken upall the same time consi dering the available resources for both thefamily and the nurse. Considering this situation, she can rank the identified problems intopriorities. There are four criteria for determining priorities amonghealth problems. These includes: 1. NATURE OF PROBLEM PRESENTED-categorized into health threat, health deficit, and foreseeable crisis. 2. MODIFIABILITY OF THE PROBLEM-refers to the probability ofsuccess in minimizin g, alleviation or totally eradicating the problemthrough nursing intervention. 3. PREVENTIVE POTENTIAL-refers to the nature and magnitude offuture problems tha t can be minimized or totally prevented ifintervention is done on the problem un der consideration. 4. SALIENCE-refers to the family s perception and evaluation of theproblem in term s of seriousness an urgency attention needed. FACTORS AFFECTING PRIORITY-SETTING 1. Current knowledge, technology, and interventions to manage the problem 2. Resources of the family-physical, financial, manpower 3. Resources of the nurse-skills, knowledge, and time 4. Resources of the community-facilities and community organization or support. SCALE FOR RANKING FAMILY HEALTH PROBLEMS ACCORDING TO PRIORITIES CRITERIA SCORE WEIGHT 1. NATURE OF THE PROBLEM PRESENTED SCALE: Health Deficit 3 Health Threat 2 1 Foreseeable Crisis 1 1. MODIFIABILITY OF THE PROBLEM SCALE:

Easily Modifiable Partially Modifiable Not Modifiable 1. PREVENTIVE POTENTIAL SCALE: High Moderate Low 1. SALIENCE SCALE: A serious problem, immediateaction needed A problem but not needingimmediate attention Not a felt need/problem TOTAL/HIGHEST SCORE Scoring: 2 1 0 3 2 1 2 1 0 2 1 1 5 1. Decide on a score for each of the criteria. 2. Divide the score by the highest possible score and multiply by the weight. SCORE/HIGHEST SCORE X WEIGHT 3. Sum up the scores for all the criteria. The highest score is 5, is equivalent tothe total weight. A. SCABIES AS A HEALTH DEFICIT TO THREE PRE-SCHOOL MEMBERS OF THE FAMILY CRITERIA NATURE OF THE PROBLEM HEALTH DEFICIT COMPUTATI

ON 3/3 X1 ACTUAL SCORE 1 JUSTIFICATION A health deficit that requiresimmediate attention and adequate management toreduce likelihood of transfer of the disease to the rest of the family members.

MODIFIABILTY X 2 1 The family does not have PARTIALLY MODIFIABLE adequate resources to solve theproblem. Inadequacy of livin gspace and water supply arebarriers to achievement of goodpersonal hygiene, whic h isimportant in the managementand prevention of scabies. PREVENTIVE POTENTIAL 3/3 X 1 1 Transfer of scabies to other HIGH family members is reduced oreliminated if the problem ismanaged adequately as soon aspossible. SALIENCE 1/1 X 1 1 The family recognized it as a A PROBLEM BUT NOT problem. It consulted the healthNEEDING IMMEDIATE personnel a month ago, ATTENTION however, it does not see the problem as needing immediateaction. TOTAL SCORE 4 A. IMPROPER REFUSE DISPOSAL CRITERIA NATURE OF THE PROBLEM MODIFIABILITY PREVENTIVE POTENTIAL SALIENCE TOTAL SCORE COMPUTATI ON 2/3 X1 2/2 X2 3/3 X1 0/2 X1 ACTUAL SCORE 0.67 2 1 0 3.67 JUSTIFICATION

It is a health threat Resources are available and interventions are feasible Communicable disease transferred by insects androdents can be prevented The family does not perceivethis as a health problem B. MALNUTRITION CRITERIA COMPUTATI ACTUAL JUSTIFICATION

ON SCORE NATURE OF THE PROBLEM MODIFIABILTY PREVENTIVE POTENTIAL SALIENCE TOTAL SCORE 3/3 X1 2/2 X2 3/3 X1 2/2 X1 1 2 1 1 5 It is a health deficit that requiresimmediate management toeliminate untoward consequences. The problem is easily modifiablesince the nurse s resources are available, she can help thefamily on effective budgeting ofmoney and scheduling of time. she can develop skills of othermembers to achieve goodnutrition proper food sele ctionand preparation, and feedingpractices. The nurse can alsoeducate the family to utilize thebackyard by planting nutritiousvegetables. Susceptibility to other diseasesand infections can be preventedif malnutrition i s eliminated; normal growth and developmentcan thus be achieved. A serious problem needingimmediate action and attention The list of health problems ranked according to priorities is presented: 1. MALNUTRITION 5 2. SCABIES 4 3. IMPROPER REFUSE DISPOSAL3.67 3. FORMULATION OF GOALS AND OBJECTIVES OF NURSING CARE ESTABLISHMENT OF GOALS GOALS Is a general statement of purpose. It is the end towards which all efforts aredi

rected. It i the condition or state to be brought about by specific courses ofac tion. Example: after nursing intervention, the family will be able to take care of the premature infant competently. Goals established by the nurse with the family usually relate to health mater, specifically the alleviation of disease conditions. Health problems are

however, intertwined with other problems like socio-economic ones. It iscommon t herefore, for a community health nurse to find herself setting in non-health goals like: Example 1: at the end of nursing intervention, the family will be able to starta piggery business. Example 2: at the end of nursing intervention, the family will be able to startl itigation proceedings against landlord. A cardinal principle in goal setting states that goals must be set mutuallywith the family. This ensures their acceptance and realization. Unless thefamily unde rstands and accepts the goals of nursing care it cannot beexpected to participat e actively in the implementation of needed actions. Basic to the establishment of mutually acceptable goals in the family srecognition and acceptance of existing health needs and problems. Thenurse must as certain the family s knowledge and acceptance of theproblem as well as the desire to take actions to resolve them. This is donein the assessment phase. Goals set by the nurse and the family should be realistic or attainable. They should therefore be set in reasonable levels. Too high goals and theirsubse quent failure frustrate the nurse and the family. Goals are best stated in terms of client s outcomes, whether at the individual, family, or community levels. Perpetuate BARRIERS TO JOINT GOAL SETTING BETWEEN THE NURSE AND THE FAMILY: 1. Failure on the part of the family to perceive the existence of the problem. 2. The family ay realize the existence of a health problem but is too busy atthe moment with other concerns and preoccupations. 3. Sometimes the family perceives the existence of the problem but does notsee i t as serious enough to warrant attention. 4. A big barrier to collaborative goal setting between the nurse and thefamily f ailure to develop a working relationship. 5. The family may perceive the presence of a problem and the need to takeaction. It may, however, refuse to face and do something about thesituation, freeman of fers the following reasons for this kind behaviour: FEAR OF CONSEQUENCES OF TAKING ACTION-diagnosis of adisease condition may mean e xpenses or social stigma for thefamily. RESPECT FOR TRADITION-in the Philippine culture, elders plays apart in decision making. Behaviours which are not sanctioned bythe old folks in the family are no t likely to be adopted. A couple forinstance, may not accept the goal of limitin g family size to justthree children if their parents do not approve of contracep tivepractice. FAILURE TO PERCEIVE THE BENEFITS OF ACTION PROPOSED-this could be a function of a client s previous experience with the healthworkers and t heir services. Going to the health center, for example, is an advice frequently given by the nurse. When this does notyields beneficial results from the point of view of the family, it willbe ignored the next time it is offered. FAILURE TO RELATE THE PROPOSED ACTION TO THE FAMILY S GOALS-families differ in their prioritizing of their goals. Economic

and social goal generally occupy a higher position than health goalsin ranking o f concerns and priorities. FORMULATION OBJECTIVES OF NURSING CARE OBJECTIVES In contrast o goals, objectives refer to more specific statements of thedesired results or outcomes of care. They specify the criteria by which thedegrees of ef fectiveness of care are to be measured. Goals tell where thefamily is going; obj ectives are the milestones to reach the destination. Objectives can be stated in various ways depending upon the focus, levelof gener ality and time required for their realization. It can either be nurseoriented (based on activities of the nurse) or client-oriented (stated interms o f outcomes). NURSE-ORIENTED Example 1: during the home visit, the nurse will discuss the importance ofimmuni zation. Example 2: during the second nurse-family contact, the nurse will showthe differ ent types of fertility-regulating methods. CLIENT-ORIENTED Example 3: after the nursing intervention, the malnourished pre-schoolmember of the family will increase their weights by at least one pound permonth. Example 4: after the nursing intervention, there will be improvedrelationship am ong family members. Example 5: after the nurse s visit, the family will bring the pre-schoolmembers to the well-baby clinic the following day. Stating objectives in terms of client outcomes will indicate during theevaluatio n phase whether the desired changes in the problem situationresulted from the nu rse s action. Nurse-oriented objectives will not tell ifthe nurse s activities produ ced some beneficial results; they only indicatewhat the nurse did and in qualita tive evaluation, how well she performedthem. Objectives can also be stated in general sense or specific terms. GENERAL: after the nursing intervention, the family will utilize community resources for health care. SPECIFIC: after the nursing intervention, a. The family will bring the pregnant member to the health center regularly for check ups; b. The family will also consult the health center on every episode ofillness among members. GENERAL: after the nursing intervention, the family will be able to takecare of the mentally challenged child competently. SPECIFIC: After the nursing intervention, a. The family will be able to feed the mentally challenged prescribedquantity and q uality of food.

b. They will be able to teach the child simple skills related to activities ofdaily living and c. The family will be able to apply measures taught to prevent infection inthe ment ally challenged child. The more specific the objective, the easier is the evaluation of theirattainment . Specifically stated objectives define already the criteria forevaluation. Objectives may vary according to the time span required for their realization. 1. SHORT-TERM OR IMMEDIATE OBJECTIVES are formulated for problem situations which require immediate attention, and resultscan be observed in a relatively short period of time. They areaccomplished with few nurse-famil y contacts and relatively less resources. 2. LONG-TERM OR ULTIMATE OBJECTIVES require several nurse-familyencounters and i nvestment of more resources. The nature of the outcomes sought requires time to demonstrate. Such is the natureof behaviour cha nge which is often the object of nursingintervention. 3. MEDIUM-TERM OR INTERMMEDIATE OBJECTIVES are those which are not immediately achieved and are required to attain the long term ones. Example: NURSING GOAL-the family will cope effectively with thethreat of pulmona ry tuberculosis. SHORT-TERM: the infant and preschool members of the family will beimmunized with BCG. MEDIUM-TERM: all members of the family will have a complete physicalcheck-up to rule out pulmonary tuberculosis. LONG-TERM: all members of the family will participate in the care ofthe sick mem bers and apply preventive measures against the spreadof infection. As with goals, objectives should be realistic and attainable consideringthe reso urces of the nurse, the family, and community. In addition, they should be measurable. Specific statements of objectives facilitatethe evalu ation of their attainment. Objectives and evaluation aredirectly related. When o bjectives are stated in terms of observablefacts and/or behaviour, then the crit eria for evaluation becomeinherent and evidence. 4. SELECTING APPROPRIATE NURSING ACTIONS With the nursing assessment reflecting what the family is experiencing andwhy, t he intervention phase commences. Nursing actions are implemented which hopefully will help the familyovercome the obstacles to health functioning. These nursing interventionshave been determine d by the goals and objectives previously set.

The choice of nursing intervention is highly dependent on two majorvariables-the nature of the problem and the resources available to solve theproblem In family nursing practice, problems resolve around the family s assumptionof the health tasks. Nursing interventions are aimed at minimizing oreliminating the po ssible reasons for or causes of the family s inability to dothese tasks. To illustrate, the nurse can utilize the following nursing actions to stimulater ecognition and acceptance of health needs and problems: Broaden the base of the family s information Help the family to see the implications of the situations, or the consequences of the conditions. Relate heath needs to the goals of the family-both health related andnon-health related goals. Encourage wholesome emotional attitudes towards the problem. The nurse can work on the family s failure to decide on taking appropriatehealth a ctions through: Discussing the consequences of inaction. Identifying the courses of action open to the family and resources neededfor eac h. Discussing the consequences of each courses of action available. The nurse can increase the family s confidence in providing nursing care toits sic k, disabled and dependent member through demonstrations on nursingprocedures uti lizing supplies and equipments available in the home. The nurse should involve the patient and family in order to motivate them toassu me responsibility for their own care. The nurse also explains and clarifies doubts thus the role of the nurse shiftsdi rect care giver to that of a teacher. She can explore the ways to minimize or prevent threats to the maintenanceof hea lth and personal development among family members She can utilize intervention measures involving environmental manipulationsthrou gh improvements on the physical facilities in the home either byconstruction of needed ones or modifying existing ones. To minimize or eliminate psychological threats in the home environment, thenurse can work closely with the family to improve its communicationpatterns, role ass umptions and relationships and interaction patterns. The nurse can eliminate barriers or blocks to an effective referral system. The nurse utilizes her own resources, those of the family and the resourcesavail able in the community, such as: Family resources-physical and psycho-social strengths and assets ofindividual me mbers, financial capabilities, physical facilities and thepresence of support sy

stem provided by relatives and significant others. Nurse resources-knowledge about family health and her skills in helpingfamily ma nage them. These skills may range from simple nursingprocedure to complicated be havioural problems such as maritaldisharmony. Availability of time and logistica l support are also part ofresources of the nurse. Community Resources-include existing agencies, programs or activitiesfor health and related needs/problems and community organization forhealth actions.

The choice of appropriate nursing interventions and the method of nursefamily contact (home-visit, clinic conference, and group approach) aredependent upon the nature of the family health problems presented and themix or combinatio n of available resources. 1. EVALUATING FAMILY HEALTH CARE DEFINITION AND CONCEPTS Evaluation is interwoven in every nursing activity and every step of thehealth n urse. Concerned with the determination of whether the objectives setwere attaine d or to what degree they were attained. Evaluation is always related to objectives. Evaluation when address to the result or outcome of care answers the question did the intended results occur? There is always an element of subjectivity in evaluation; the process involvesva lue judgement which is subjective Evaluation also involves decision-making. did nursing make a difference? or what res ults came out of the nursing activity? decisions have to be madeon whether the ob jectives have to be formulated, approaches and strategiesmodified, resources inc reased and the like. If evaluation shows that the objectives was not achieved, the nurse has tofind o ut the reason why; the objectives may be unrealistic, nursing actionsmay be inap propriate or uncontrollable environment factors may beoperative in this situatio n. DIMENSIONS OF EVALUATION EFFECTIVENESS-focus is attainment of the objectives EFFICIENCY-relates to cost whether in terms of money, time, effort, ormaterials APPROPRIATENESS-ability to solve or correct existing problem situation, aquestio n that involves professional judgement. ADEQUACY-pertains to its comprehensiveness whether all necessaryactivities were performed in order to realize the intended results. Criteria and Standard CRITERIA-refer to the signs or indicators that tell us if the objective has been achieved. They are names and description of variables that are relevantindicator s of having attained the objectives. They are free from any valuejudgement and a re independent to time frame. STANDARD-once a value judgement is applied to a criterion; it acquires thestatus of a standard. It refers to the desired level of performancecorresponding with a criterion against which actual performance iscompared. It tells us what the ac ceptable level of performance or state ofaffairs should be for us to say that th e intervention was successful. ACTIVITY AND OUTCOME ACTIVITIES-are actions performed to accomplish an objective. They are thethings the nurse does in order to achieved a desired result or outcome. Activities consume time and resources. Examples are health teachings, demonstration and referrals.

OUTCOME-is the results produced by activities. Where activity is the cause, outcome is the effect. They can also be immediate, immediate or ultimateoutcomes . Patient care outcomes can be measured along three broad lines: PHYSICAL CONDITION-decreased temperature or weight and change inclinical manifes tations PSYCHOLOGICAL OR ATTITUDINAL STATUS-decreased anxiety andfavourable attitude tow ards health care personnel. KNOWLEDGE ON LEARNING BEHAVIOR-compliance of the patient withinstructions given by the nurse. IMPORTANCE OF EVALUATION Evaluation, whether of single activity or an entire program, is an expensiveand time-consuming process. The temptation to forego it in favour of moreactivities is therefore understandably appealing. There are foremost reasons why nurses should evaluate their activitiesand/or int ervention: To eliminate or stop the continued performance of useless activities andinterven tions. To increase the efficiency of nursing interventions To provide documentations of the results of nursing efforts and justification of the cost of nursing services. To promote growth of the profession and refinement of nursing practice.