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

Minor: (_) Family system cannot or does not:

(May be meet physical needs of all its members
present) 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 Target Nursing Interventions Date

Sign. [Check those that apply] Date: [Check those that apply] Achieved:
The family member or patient (_) Assess causative and
will: contributing factors.

(_) Frequently verbalize feelings (_) Meet with patient/family to

to professional nurse and each identify:
other.
strengths/weaknesses

(_) Maintain functional system of
mutual support for each member.
(_) Seek appropriate external
resources when needed.
(_) Other:
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