disabled family Coping
[Diagnostic Division: Social Interaction]
Submitted 1980; Revised 1996
Definition: Behavior of SO (family member or other primary person) that disables his/her capacities and the client’s capacity to effectively address tasks essential to either person’s adaptation to the health challenge.
Significant person with chronically unexpressed feelings of guilt, anxiety, hostility, despair, and so forth
SUBJECTIVE
[Expresses despair regarding family reactions/lack of involvement]
OBJECTIVE
Intolerance, rejection, abandonment, desertion
Psychosomaticism
Agitation, depression, aggression, hostility
Taking on illness signs of client
Neglectful relationships with other family members
Carrying on usual routines disregarding client’s needs
Neglectful care of the client in regard to basic human needs and/ or illness treatment
Distortion of reality regarding the client’s health problem, including extreme denial about its existence or severity
Decisions and actions by family that are detrimental to economic or social well-being
Impaired restructuring of a meaningful life for self, impaired individualization, prolonged overconcern for client
Client’s development of helpless, inactive dependence
Criteria—Family Will:
• Verbalize more realistic understanding and expectations of the client.
• Visit/contact client regularly.
• Participate positively in care of client, within limits of family’s abilities and client’s needs.
• Express feelings and expectations openly and honestly as appropriate.
NURSING PRIORITY NO. 1. To assess causative/contributing factors:
• Ascertain preillness behaviors/interactions of the family. Provides comparative baseline.
• Identify current behaviors of the family members (e.g., withdrawal—not visiting, brief visits, and/or ignoring client when visiting; anger and hostility toward client and others; ways of touching between family members, expressions of guilt).
• Note cultural factors related to family relationships that may be involved in problems of caring for member who is ill.
• Note other factors that may be stressful for the family (e.g., financial difficulties or lack of community support, as when illness occurs when out of town). Provides opportunity for appropriate referrals.
• Determine readiness of family members to be involved with care of the client.
• Establish rapport with family members who are available. Promotes therapeutic relationship and support for problemsolving solutions.
• Acknowledge difficulty of the situation for the family. Reduces blaming/guilt feelings.
• Active-listen concerns; note both overconcern/lack of concern, which may interfere with ability to resolve situation.
• Allow free expression of feelings, including frustration, anger, hostility, and hopelessness. Place limits on actingout/ inappropriate behaviors to minimize risk of violent behavior.
• Give accurate information to SO(s) from the beginning.
• Act as liaison between family and healthcare providers to provide explanations and clarification of treatment plan.
• Provide brief, simple explanations about use and alarms when equipment (such as a ventilator) is involved. Identify appropriate professional(s) for continued support/problemsolving.
• Provide time for private interaction between client/family.
• Include SO(s) in the plan of care; provide instruction to assist them to learn necessary skills to help client.
• Accompany family when they visit to be available for questions, concerns, and support.
• Assist SO(s) to initiate therapeutic communication with client.
• Refer client to protective services as necessitated by risk of physical harm. Removing client from home enhances individual safety and may reduce stress on family to allow opportunity for therapeutic intervention.
• Assist family to identify coping skills being used and how these skills are/are not helping them deal with situation.
• Reframe negative expressions into positive whenever possible. (A positive frame contributes to supportive interactions and can lead to better outcomes.)
• Respect family needs for withdrawal and intervene judiciously. Situation may be overwhelming and time away can be beneficial to continued participation.
• Encourage family to deal with the situation in small increments rather than the whole picture at one time.
• Assist the family to identify familiar things that would be helpful to the client (e.g., a family picture on the wall), especially when hospitalized for long period of time, to reinforce/ maintain orientation.
• Refer family to appropriate resources as needed (e.g., family therapy, financial counseling, spiritual advisor).
• Refer to ND anticipatory Grieving, as appropriate.
ASSESSMENT/REASSESSMENT
• Assessment findings, current/past behaviors, including family members who are directly involved and support systems available.
• Emotional response(s) to situation/stressors.
PLANNING
• Plan of care/interventions and who is involved in planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Responses of individuals to interventions/teaching and
actions performed.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Ongoing needs/resources/other follow-up recommendations and who is responsible for actions.
• Specific referrals made.
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defensive Coping
Taxonomy II: Coping/Stress Tolerance—Class 2 Coping Responses (00071)
[Diagnostic Division: Ego Integrity]
Submitted 1988
Definition: Repeated projection of falsely positive selfevaluation based on a self-protective pattern that defends against underlying perceived threats to positive self-regard
Related Factors
To be developed
[Refer to ND ineffective Coping]
Defining Characteristics
SUBJECTIVE
Denial of obvious problems/weaknesses
Projection of blame/responsibility
Hypersensitive to slight/criticism
Grandiosity
Rationalizes failures
[Refuses or rejects assistance]
OBJECTIVE
Superior attitude toward others
Difficulty establishing/maintaining relationships, [avoidance of intimacy]
Hostile laughter or ridicule of others, [aggressive behavior]
Difficulty in reality testing perceptions
Lack of follow-through or participation in treatment or therapy
[Attention-seeking behavior]
Desired Outcomes/Evaluation
Criteria—Client Will:
• Verbalize understanding of own problems/stressors.
• Identify areas of concern/problems.
• Demonstrate acceptance of responsibility for own actions, successes, and failures.
• Participate in treatment program/therapy.
• Maintain involvement in relationships.
Actions/Interventions
• Refer to ND ineffective Coping for additional interventions.
NURSING PRIORITY NO. 1. To determine degree of impairment:
• Assess ability to comprehend current situation, developmental level of functioning.
• Determine level of anxiety and effectiveness of current coping mechanisms.
• Determine coping mechanisms used (e.g., projection, avoidance, rationalization) and purpose of coping strategy (e.g., may mask low self-esteem) to note how these behaviors affect current situation.
• Assist client to identify/consider need to address problem differently.
• Describe all aspects of the problem using therapeutic communication skills, such as Active-listening.
• Observe interactions with others to note difficulties/ability to establish satisfactory relationships.
• Note expressions of grandiosity in the face of contrary evidence (e.g., “I’m going to buy a new car” when the individual has no job or available finances).
NURSING PRIORITY NO. 2. To assist client to deal with current situation:
• Provide explanation of the rules of the treatment program and consequences of lack of cooperation.
• Set limits on manipulative behavior; be consistent in enforcing consequences when rules are broken and limits tested.
• Develop therapeutic relationship to enable client to test new behaviors in a safe environment. Use positive, nonjudgmental approach and “I” language to promote sense of self-esteem.
• Encourage control in all situations possible, include client in decisions and planning to preserve autonomy.
• Acknowledge individual strengths and incorporate awareness of personal assets/strengths in plan.
• Convey attitude of acceptance and respect (unconditional positive regard) to avoid threatening client’s self-concept, preserve existing self-esteem.
• Encourage identification and expression of feelings.
• Provide healthy outlets for release of hostile feelings (e.g., punching bags, pounding boards). Involve in outdoor recreation program/activities.
• Provide opportunities for client to interact with others in a positive manner, promoting self-esteem.
• Assist client with problem-solving process. Identify and discuss responses to situation, maladaptive coping skills. Suggest alternative responses to situation to help client select more adaptive strategies for coping.
• Use confrontation judiciously to help client begin to identify defense mechanisms (e.g., denial/projection) that are hindering development of satisfying relationships.
NURSING PRIORITY NO. 3. To promote wellness (Teaching/ Discharge Considerations):
• Encourage client to learn relaxation techniques, use of guided imagery, and positive affirmation of self in order to incorporate and practice new behaviors.
• Promote involvement in activities/classes where client can practice new skills and develop new relationships.
• Refer to additional resources (e.g., substance rehabilitation, family/marital therapy) as indicated.
Documentation Focus
ASSESSMENT/REASSESSMENT
• Assessment findings/presenting behaviors.
• Client perception of the present situation and usual coping methods/degree of impairment.
PLANNING
• Plan of care and interventions and who is involved in development of the plan.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Response to interventions/teaching and actions performed.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Referrals and follow-up program.
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The Current State of Nursing Education
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compromised family Coping - Outcome, Intervention, Documentation
Criteria—Family Will:
• Identify/verbalize resources within themselves to deal with the situation.
• Interact appropriately with the client, providing support and assistance as indicated.
• Provide opportunity for client to deal with situation in own way.
• Verbalize knowledge and understanding of illness/disability/ disease.
• Identify need for outside support and seek such.
NURSING PRIORITY NO. 1. To assess causative/contributing factors:
• Identify underlying situation(s) that may contribute to the inability of family to provide needed assistance to the client. Circumstances may have preceded the illness and now have a significant effect (e.g., client had a heart attack during sexual activity, mate is afraid any activity may cause repeat).
• Note cultural factors related to family relationships that may be involved in problems of caring for member who is ill.
• Note the length of illness, such as cancer, multiple sclerosis, and/or other long-term situations that may exist.
• Assess information available to and understood by the family/SO(s).
• Discuss family perceptions of situation. Expectations of client and family members may/may not be realistic.
• Identify role of the client in family and how illness has changed the family organization.
• Note other factors besides the client’s illness that are affecting abilities of family members to provide needed support.
• Listen to client’s/SO’s comments, remarks, and expression of concern(s). Note nonverbal behaviors and/or responses and congruency.
• Encourage family members to verbalize feelings openly/ clearly.
• Discuss underlying reasons for behaviors with family to help them understand and accept/deal with client behaviors.
• Assist the family and client to understand “who owns the problem” and who is responsible for resolution. Avoid placing blame or guilt.
• Encourage client and family to develop problem-solving skills to deal with the situation.
• Provide information for family/SO(s) about specific illness/ condition.
• Involve client and family in planning care as often as possible. Enhances commitment to plan.
• Promote assistance of family in providing client care as appropriate. Identifies ways of demonstrating support while maintaining client’s independence (e.g., providing favorite foods, engaging in diversional activities).
• Refer to appropriate resources for assistance as indicated (e.g., counseling, psychotherapy, financial, spiritual).
• Refer to NDs Fear; Anxiety/death Anxiety; ineffective Coping; readiness for enhanced family Coping; disabled family Coping; anticipatory Grieving, as appropriate.
ASSESSMENT/REASSESSMENT
• Assessment findings, including current/past coping behaviors, emotional response to situation/stressors, support systems available.
PLANNING
• Plan of care, who is involved in planning and areas of responsibility.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Responses of family members/client to interventions/teaching and actions performed.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Long-range plan and who is responsible for actions.
• Specific referrals made.
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compromised family Coping - Definition, Related Factors, Characteristics
[Diagnostic Division: Social Interaction]
Submitted 1980; Revised 1996
Inadequate or incorrect information or understanding by a primary person
Temporary family disorganization and role changes
Other situational or developmental crises or situations the significant person may be facing
Little support provided by client, in turn, for primary person
Prolonged disease or disability progression that exhausts the supportive capacity of SO(s)
[Unrealistic expectations of client/SO(s) or each other]
[Lack of mutual decision-making skills]
[Diverse coalitions of family members]
SUBJECTIVE
Client expresses or confirms a concern or complaint about SO’s response to his or her health problem
SO describes preoccupation with personal reaction (e.g., fear, anticipatory grief, guilt, anxiety) to client’s illness/disability or other situational or developmental crises
SO describes or confirms an inadequate understanding or knowledge base that interferes with effective assistive or supportive behaviors
OBJECTIVE
SO attempts assistive or supportive behaviors with less-thansatisfactory results
SO withdraws or enters into limited or temporary personal communication with the client at the time of need
SO displays protective behavior disproportionate (too little or too much) to the client’s abilities or need for autonomy
[SO displays sudden outbursts of emotions/shows emotional lability or interferes with necessary nursing/medical interventions]
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