Formulating a Family Care Plan

Formulating a Family Care Plan

I Identifying Data

· Name: __________________________________________________________________________________________________

· Address: __________________________________________________________________________________________________

· Phone number(s):_____________________________________________________________________________________________

· Household members (relationship, gender, age, occupation, education):____________________________________________________

· Financial data (sources of income, financial assistance, medical care; expenditures):___________________________________________

· Ethnicity: __________________________________________________________________________________________________

· Religion: __________________________________________________________________________________________________

· Identified client(s):______________________________________________________________________________________________

· Source of referral and reason: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

II Genogram

· Include household members, extended family, and significant others

· Age or date of birth, occupation, geographical location, illnesses, health problems, major events

· Triangles and characteristics of relationships

III Individual Health Needs (for each household family member)

· Identified health problems or concerns: ________________________________________________________________________________

· Medical diagnoses: _____________________________________________________________________________________________

· Recent surgery or hospitalizations: _________________________________________________________________________________

· Medications and immunizations: _________________________________________________________________________________

· Physical assessment data: ______________________________________________________________________________________

· Emotional and cognitive functioning: _______________________________________________________________________________

· Coping: _____________________________________________________________________________________________________

· Sources of medical and dental care: ____________________________________________________________________________

· Health screening practices: ____________________________________________________________________________________

IV Interpersonal Needs

· Identified subsystems and dyads:________________________________________________________________________________

· Prenatal care needed: _________________________________________________________________________________________

· Parent–child interactions:_______________________________________________________________________________________

· Spousal relationships:_________________________________________________________________________________________

· Sibling relationships:_________________________________________________________________________________________

· Concerns about older members:___________________________________________________________________________________

· Caring for other dependent members:________________________________________________________________________________

· Significant others:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

V Family Needs

· A. Developmental

· Children and ages:____________________________________________________________________________________________

· Responsibilities for other members: _____________________________________________________________________________

· Recent additions or loss of members:_____________________________________________________________________________

· Other major normative transitions occurring now:____________________________________________________________________

· Transitions that are out of sequence or delayed:_____________________________________________________________________

· Tasks that need to be accomplished:_______________________________________________________________________________

· Daily health-promotion practices for nutrition, sleep, leisure, child care, hygiene, socialization, transmission of norms and values: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________

· Family planning used:_______________________________________________________________________________________

· B. Loss or Illness

· Nonnormative events or illnesses:______________________________________________________________________________

· Reactions and perceptions of ability to cope:________________________________________________________________________

· Coping behaviors used by individuals and family unit:_________________________________________________________________

· Meaning to the family:_________________________________________________________________________________________

· Adjustments family has made:________________________________________________________________________________

· Roles and tasks being assumed by members:_________________________________________________________________________

· Any one individual bearing most of responsibility:_____________________________________________________________________

· Family idea of alternative coping behaviors available:____________________________________________________________________

· Level of anxiety now and usually:_________________________________________________________________________________

· C. Resources and Support

· General level of resources and economic exchange with community:_________________________________________________________

· External sources of instrumental support (money, home aides, transportation, medicines, etc.):____________________________________

· Internal sources of instrumental support (available from family members):___________________________________________________

· External sources of affective support (emotional and social support, help with problem solving):_____________________________________

· Internal sources of affective support (who in family is most helpful to whom?): _________________________________________________

· Family more open or closed to outside?______________________________________________________________________________

· Family willing to use external sources of support?_______________________________________________________________________

· D. Environment

· Type of dwelling:________________________________________________________________________________________________

· Number of rooms, bathrooms, stairs; refrigeration, cooking:_______________________________________________________________

· Water and sewage:______________________________________________________________________________________________

· Sleeping arrangements:_____________________________________________________________________________________________

· Types of jobs held by members:_______________________________________________________________________________________

· Exposure to hazardous conditions at job:___________________________________________________________________________

· Level of safety in the neighborhood:____________________________________________________________________________________

· Level of safety in household:________________________________________________________________________________________

· Attitudes toward involvement in community:___________________________________________________________________________

· Compliance with rules and laws of society:____________________________________________________________________

· How are values similar to and different from those of the immediate social environment?_____________________________________

· E. Internal Dynamics

· Roles of family members clearly defined?______________________________________________________________________

· Where do authority and decision making rest?_____________________________________________________________________

· Subsystems and members:__________________________________________________________________________________

· Hierarchies, coalitions, and boundaries:________________________________________________________________________

· Typical patterns of interaction:_______________________________________________________________________________

· Communication, including verbal and nonverbal:__________________________________________________________________

· Expression of affection, anger, anxiety, support, etc.:________________________________________________________________

· Problem-solving style:________________________________________________________________________________________

· Degree of cohesiveness and loyalty to family members:___________________________________________________________________________________________________________________________________________________________________________

· Conflict management:________________________________________________________________________________________

__________________________________________________________________________________________________________

VI Analysis

· Identification of family style:__________________________________________________________________________________

· Identification of family strengths:_____________________________________________________________________________

· Identification of family functioning:____________________________________________________________________________

· What are needs identified by family? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

· What are needs identified by community/public health nurse?________________________________________________________________