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__**CRITICAL THINKING EXERCICES WEEK 10 - FAMILY NURSING**__

Please edit the questions below to contribute to the collective answer for the CTQ you received as a handout in class. Be sure to SAVE YOUR WORK!

1. Kathy is a palliative care nurse working with a family of four: Wai-Ling, a 45-year-old single mother; her adolescent sons, Chun and Wang; and Heng, her 76-year-old mother, who is in the last stages of terminal breast cancer. The family has lived together for 10 years, ever since they immigrated to Canada from Hong Kong. Heng helped Wai-Ling parent Chun and Wang and supported Wai-Ling when her husband died five years ago. Wai-Ling has decided to care for her mother in the family's home until Heng dies. Kathy will assist this family in achieving their goal. Kathy has just had in-service training in using CFAM.

a. What parts of the CFAM should Kathy use when assessing the family's needs? Structural - Internal - maybe drawing a genogram to get full picture of family make up, who is connected who (where the stronger bonds are), who is responsible for which roles/household expectations, how does the family communicate, etc. Structural - External - family health history, how has illness been managed by others, is cancer in the family. Structural - Context - Special cultural considerations for end of life, religious or spiritual beliefs and practices that need to be observed, Functional - Expressive - any communication barriers Assess family dyamics (assessing the role of each person), observe any changes that can be made in order to increase efficacy. For example, assigning more responsibility to Wai-Ling's adolescent sons can decrease her work load, and therefore decrease the likelihood of her having a break-down as caregiver.

She should also assess Wai-Ling’s, Chun’s, and Wang’s feelings and fears about Heng’s impending death.

b. How can Kathy help the family achieve their goal of caring for their aging family member at home? Find out what resources they already have and what they need to make that care possible; they may need meals, finances, assistance with the kids and then explore what services and supports can be provided by friends, family and the community. Educate them on resources available to them, that they may not be aware of.

c. How can Kathy determine this family's strengths, suffering, and resources? Through active listening and going through the CFAM, asking questions. In order to obtain this data, Kathy would find it beneficial to conduct a thorough interview with each family member individually first (they may express concerns they would not be comfortable sharing in group setting) as well as a group meeting that addresses their strengths, suffering, and resources.

Kathy should ask the family what they view as strengths and weaknesses. She should observe the family and share what she views as strengths and weakness and how to improve on the weaknesses. The determination of needed resources should be an ongoing assessment. These needs will change over time, and Kathy must collaborate with the family to (1) determine need, (2) obtain new resources, and (3) identify friends, family, and others who can assist.

d. What cultural aspects are important to consider for a family who has immigrated to Canada and is now facing the death of a loved one? Their spirituality/religion, the views of death in this culture, their distance from family and friends overseas, their expectations of the health care system (what sort of pain managment for example), power of attorney, division of assets, wills, etc that they might not be familiar with being new to the country. They might not know where and how to seek social support due to language barrier.

2. Dan and Kim divorced seven years ago, and neither has remarried. They have three daughters, aged 10, 12, and 14. At the time of the divorce, Dan was HIV-positive, and has remained so for five years. Kim has had repeated tests and remains HIV-negative. Dan is responding to therapy slowly. Kim and Dan share parenting responsibilities and have a friendly relationship. They have decided it would be easier for the family to live together again so that Dan can actively participate in his children's lives without placing caregiver demands on Kim when the extended family visits overnight. Kim also wants to care for her former husband.

a. What family development tasks are important to assess for this family as the members attempt to reunite?

It is important to find out what Dan and Kim are doing to include their children in the decision making process with in the family. How much time is allocate to the care of the children, are they given enough attention in term of their development, or is all the concentration of the Husband and providing financial support of the family. What are they doing as a family to cope with this situation? Are they talking about Dad's illness, and talking how it impacts each of their lives? How are they helping each other in this situation? What are the strengths of each individual in this family? How are these strengths being used? do they have help from outside the family?

(1) providing shelter, food, clothing, health care, and other essentials needed by its members, (2) establishing ways of interacting, communicating, and expressing affection, (3) maintaining morale and motivation, (4) rewarding achievement, (5) meeting personal and family crises, (6) setting attainable goals for family members, and (7) developing family loyalties and values.

As Dan's disease progresses Kim will be required to provide more care and this could lead to caregiver burden. Knowing this, the family should plan in advance what strategies will be used to prevent this as time goes on. Also, the family may want to consider how this decision will impact the children. Family hardiness needs to be assessed: identify the strengths and durability of the family. Does this family possess the resiliency needed to cope with the upcoming role changes, and challenges. What resources will the family use to adapt to this change as well as changes in the future. Family should try to maintain open lines of communication so that the children are able to express themselves.

As this family begins to live in the same household, challenges regarding division of work, decision making, and co-parenting will occur. In addition, the family will confront the issue of dealing with the death of a parent from an illness that may have some social stigma for some people. The girls are approaching adolescence or are adolescents. At a developmental time when adolescents tend to move away from family influence toward more peer influence, this family is reuniting. How the parents can foster the girls’ autonomy and yet promote family cohesion is a challenge. A common task at this developmental stage is for the parents to refocus on marital and career issues. In view of the father’s illness and the circumstances involved in the couple’s reuniting, it would be important for the parents to clarify for the girls the nature of the couple’s relationship. For example, is the couple reuniting as a married couple? As a caregiving relationship? As parenting partners?

b. How should the nurse determine what support services the family needs?

By noticing and asking (CFAM) about their needs. Ie: Do you need any help with cooking or cleaning around the house? Noticing non-verbal, verbal cues. Asking and noticing roles in regards to daily chores, financial situations, and if there is role strain or caregiver burden happening. Creating a genogram and paying close attention to areas where stressful or strained relationships may be affecting their lives and may need support from psychologists, social services, tutors for the children etc.

Assess the family’s perceived needs. Assess family needs, and point out nonperceived needs. Determine strengths and weaknesses. Ask each family member about how he or she believes the family is coping with the new living arrangements and situation. If any members feel their family could use some support, what types of support do they need?

c. What assessment questions would be useful to ask in order to assess how the illness is affecting this family? Do family members have any signs of emotional, physical, or spiritual suffering?
 * 1) How is each member of the family dealing with the structure of the family living together after the divorce?
 * 2) How does your health affect one another?
 * 3) We could find out about the client's education on the matter related to HIV
 * 4) Find out if the parent's are sexually active?
 * 5) When did you find out about your chronic health problem?
 * 6) How do each of you feel about the diagnosis?
 * 7) What is your biggest fear each?
 * 8) Any changes occur after being diagnosed?
 * 9) How has this impacted your social life, friends and family?
 * 10) What has been a positive change, what has been a negative change in your life since this health condition?
 * 11) What are you most worried about?
 * 12) What support do you have from those around you?
 * 13) How would you describe your quality of life?
 * 14) What would you like nurses to know about your experience?
 * 15) What impact has Dan’s illness had on the family?
 * 16) Who do you think is coping best and worst with the illness?
 * 17) What do you notice about how family members cope?
 * 18) What do they say or do?
 * 19) If you were to offer family members ideas about how to cope with emotional, physical, or spiritual suffering, who do you think might be most amenable to your suggestions?

3. Mr. and Mrs. Baillargeron, both in their early 50s, are the youngest members of large families. They work full-time and have two teenage children. Both sets of their parents are in their 80s and have chronic health problems. All of their siblings live farther away.

A. How can the nurse help Mr. and Mrs. Baillargeron access resources to aid in caring for their parents and maintain the responsibilities of their own family unit?

The nurse should educate the client on social support services, health care services and government assistance programs that are available. -Referral to Social Worker -Respite Care -Support groups for family members with their chronic illnesses

From the text: Mr. and Mrs. Baillargeron are “sandwiched” between elder parents and teenaged children while trying to meet the demands and expectations of their full-time jobs and other outside commitments. If the family is interested in obtaining additional assistance, the nurse can aid this family in finding outside resources for their elder parents. Ideas include the following: Have the teenagers post and maintain a Web page regarding the parents’ and grandparents’ needs, concerns, and information for the distant family members. Ask the extended family to send money to help support inexpensive, community-based, gerontological day care with activities, meals, games, health lectures, and socialization or to pay for nursing care at night as their health demands increase. Have the family sign up for rotating weekends to stay with the grandparents (e.g., one weekend per month). The family members who live farther away may send more money or cards, letters, pictures, or e-mails. Additional support may be available through their religious affiliation and community centre. Any of these efforts would help relieve the responsibilities of total caretaking by any one person, which creates caregiver role strain and decreases ability to function. These efforts also remind the care recipients that they are still part of their community and decrease the potential for depression and elder abuse (which is all too common when older adults have been isolated from their peers).

B. What developmental tasks does this family have? 1. Shifting of parent-child relationships to permit adolescent to move in and out of system 2. Refocus on midlife marital and career issues 3. Beginning shift toward joint caring for older generation

C. What kinds of questions can you ask to assess the family's emotional and verbal communication (found in CFAM's functional assessment category)?

A family's verbal and emotional communication are a part of the functional assessment within CFAM. The branch regarding emotional and verbal communication is related to expressive functioning. When assessing a family's emotional communication you are addressing the range and type of emotions or feelings expressed. Questions regarding this might look like: When assessing a family's verbal communication you are addressing: the use of direct versus indirect language and clear versus masked language. Questions surrounding this may look like: In this family's scenario some of the following questions may be useful:
 * Would you consider yourself an emotional person? What about the other members in your family?
 * Are there any emotions that come to mind when you think of certain family members?
 * When something wonderful happens who do you think to share that news with first? When something horrible happens who do you think to share that with first?
 * <span style="font-family: arial,sans-serif; line-height: 24px;">How does your family express love? What about anger or disappointment?
 * <span style="font-family: arial,sans-serif; line-height: 24px;">is there anyone you go to for support within this family?
 * <span style="font-family: arial,sans-serif; line-height: 24px;">How do you address your family members?
 * <span style="font-family: arial,sans-serif; line-height: 24px;">When you have something important to share, how do you approach saying it?
 * <span style="font-family: arial,sans-serif; line-height: 24px;">Tell me about how your family verbally communicates with one another.
 * <span style="font-family: arial,sans-serif; line-height: 24px;">When you have a suggestion or criticism are you direct with your information?
 * <span style="font-family: Arial,sans-serif; font-size: 10pt;">how are household tasks divided in the family
 * <span style="font-family: Arial,sans-serif; font-size: 10pt;">on a scale of 1-10 describe the level of communication in your family. why do you rate it as such?
 * <span style="font-family: arial,sans-serif; line-height: 24px;">How often do you talk to your siblings? When you talk to them what is the typical focus of your conversations?
 * <span style="font-family: arial,sans-serif; line-height: 24px;">How has your parents' health emotionally impacted you?
 * <span style="font-family: arial,sans-serif; line-height: 24px;">Has this effect taken a toll on any relationships within your family?
 * <span style="font-family: arial,sans-serif; line-height: 24px;">As busy parents, how often do you communicate with your children? Are these instances meaningful conversations? How often are you able to have these types of conversations?
 * <span style="font-family: arial,sans-serif; line-height: 24px;">When you think of your parents, what are some of the emotions surrounding them?

From the text: <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">How do your parents feel about caring for your grandparents? Who in the family tends to start conversations about feelings? How can you tell when your mom is happy or sad? How about your dad? If your teenagers were sad, with whom might they talk about their feelings? Would they be more likely to speak about feelings directly or indirectly? Who among your family members is the most clear and direct when communicating verbally?