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]
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.
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 &
Plan and Outcome
[Check those that apply]
Nursing Interventions
[Check those that apply]
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