Alteration in Family Processes

Alteration
in Family Processes

(_)Actual (_)
Potential

Related
To:
[Check
those that apply]
(_)
Illness of a family member:_____________________
(_) Loss/gain of family member due to:______________
____________________________________________

(_) Change in family roles:_______________________
(_) Conflict:___________________________________
(_) Financial crisis:_____________________________
(_) Other:____________________________________
____________________________________________
____________________________________________

 

As
evidenced by:
[Check
those that apply]
Major:

(Must be
present
)

(_)
Family system cannot or does not adapt constructively to
crisis or family system cannot or does not communicate
openly and effectively between family members.
Minor:

(May be
present
)

(_)
Family system cannot or does not:
  • meet physical
    needs of all its members
  • meet emotional
    needs of all its members
  • meet spiritual
    needs of all its members
  • express or accept
    a wide range of feelings
  • seek or accept
    help appropriately

 

Date &
Sign.
Plan and Outcome
[Check
those that apply]
Target

Date:

Nursing Interventions
[Check
those that apply]
Date
Achieved:
  The
family member or patient will:

(_) Frequently verbalize feelings to
professional nurse and each other.

(_) Maintain
functional system of mutual support for each member.

(_) Seek appropriate
external resources when needed.

(_) Other:

  (_)
Assess causative and contributing factors.

(_) Meet with patient/family to
identify:

  • strengths/weaknesses
  • resources
    available
  • needs
  • priorities
  • alternative
    arrangements
  • Other:

(_) Encourage
verbalization of guilt, anger, hostility, etc. and
subsequent recognition of these feelings to:

  • nursing staff
  • family members

(_)Direct family to
hospital/community agencies:

  • home health care
  • nurse discharge
    planners
  • social workers
  • other:

 

(_)
Other:________________
________________________
________________________
________________________

 

 

__________________________
Patient/Significant other signature

 

__________________________
RN signature