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High-Risk Family Assessment and Health Promotion

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Assessment is the first step of the nursing process and a basic nursing skill. Sadly, there are too many nurses who fail to realize that addressing the family needs are as important as addressing the needs of the individual patient and that assessment should extend beyond the patient to the entire family unit. This is especially crucial when working with patients in high-risk groups. Woods and Lasiuk (2008) define risk as “the probability that a particular adverse event occurs during a stated period of time, or results from a particular challenge” (p. 1). In health care, then, high-risk families are those more prone to disease or injury because of their circumstances.

War veterans and their families are a high-risk group. There are over half a million new veterans from the Iraq and Afghanistan conflicts. These veterans are older and include more women than before (Chandler, 2010). Many veterans develop Post Traumatic Stress Disorder (PTSD), an anxiety disorder that can cause physical, psychological, and social issues and impair one’s ability to function (Chandler, 2010). These problems can extend to the family of the veteran dealing with the aftermath of combat. Health Profile of PTSD

PTSD is “a mental health condition that is triggered by a terrifying event- either experiencing it or witnessing it” (Mayo Clinic, 2014, p. 1). Combat and war are extremely stressful environments and veterans have often experienced fearful conditions, horrifying occurrences, and/or life threatening incidents. During these traumatic events, they believe that their lives and the lives of others are out of their control and in danger (USDVA, 2014). Some veterans will experience symptoms that begin right away, while others develop symptoms over time. Some will never develop PTSD; it is not clear why some do and some do not (USDVA, 2014).

There are four classifications of symptoms of PTSD: reliving the event, avoiding situations that remind veterans of the event, negative changes in beliefs and feelings, and hyperarousal (USDVA, 2014). Reliving the event involves intrusive memories that can cause flashbacks, upsetting dreams, and emotional distress (Mayo Clinic, 2014). Avoidance can apply to intrusive thoughts, discussing feelings, and people, places, and activities (Mayo Clinic, 2014). Negative changes in thinking and mood include feelings about themselves or others, inability to have positive emotions, feeling numb, lack of interest in activities, hopelessness, memory issues, and difficulty sustaining intimate relationships (Mayo Clinic, 2014). Hyperarousal can be manifested by angry outbursts, aggressive behavior, trouble concentrating, difficulty sleeping, and being easily startled (Mayo Clinic, 2014).

The high-risk behavior that many veterans turn to may be attempts to relieve symptoms. These can include smoking, social isolation, abuse of alcohol and drugs, reckless activities, such as driving fast or unsafe sex, and violent behavior (USDVA, 2014). The symptoms that veterans may experience and the efforts to relieve them can lead to other significant issues such as depression, anxiety, despair, shame, addiction, chronic pain, employment trouble, and loss of relationships (Mayo Clinic, 2014). The stress of these symptoms and behavior increases the chance of having chronic health issues.

Veterans experiencing PTSD can also suffer from hypertension, stroke, digestive disorders, pulmonary disease, diabetes, and cardiovascular disease. Mental health issues can be severe and lead to self-harm and suicide (USDVA, 2014). The behavior of the veteran experiencing these symptoms can severely affect the family. Withdrawal, depression, self-harm, intimacy issues, and parenting issues can cause stress, which frustrates and angers the family, putting all the members at risk of a variety of mental health disorders (USDVA, 2014). The veteran’s substance abuse, violent outbursts, and high-risk, reckless behavior put the entire family in danger of physical harm. Assessment of the Family

For combat veterans and their families to receive effective treatment for PTSD, nurses must recognize the disorder. According to the USDVA (2014), PTSD goes often goes unrecognized. Those suffering from it may feel shame about symptoms and underreport them. One of the symptoms of PTSD is avoidance, which makes seeking mental health care even more difficult for veterans. They may report some of the manifesting symptoms, but not relate them to traumatic experiences. Nurses must recognize the symptoms and assess for a history of trauma (USDVA, 2014).

Assessing for PTSD by military nurses may seem obvious, but the first clue a civilian nurse may have that a veteran is suffering from the disorder may come from caring for the veteran’s family members. Civilian nurses may not have as much experience with combat veterans, but also need to be vigilant when caring for them and their families. Many veterans have private insurance and are only eligible for five years of free VA health care (Chandler, 2010). Nurses should be on the lookout for possible PTSD when they learn a combat veteran or their family member has reported any of the symptoms that were previously discussed. This requires an accurate history and careful notation of all the symptoms reported (USDVA, 2014).

Once a nurse suspects that a veteran or their family is dealing with PTSD, proper referrals should be made. There is a screening tool available from the USDVA that is very quick and very simple to do. It is the Primary Care PTSD Screen (PC-PTSD) and consists of four yes or no questions. If three of the four questions are answered “yes,” then the patient may have PTSD and they and their families should be referred to a mental health professional (USDVA, 2014). Of special concern should be suicidal ideation or reports of violence in the home.

Nurses must keep in mind that often veterans and their families are ashamed of how they feel or what is happening. As Briere and Scott (2007) explain, the nurse must be empathetic, avoid judgmental body language, show sensitivity, sense when avoidance is being used, and remember that speaking about past traumatic experiences may cause violent or emotional outbursts from veterans.

A useful theoretical framework for family assessment is Hill’s Family Stress Theory. Hill focused his research on wartime separation and reunion, and the stressors that develop with the family. Using this theory, the nurse would focus on the family’s actual and perceived stressors, resources available to the family, coping mechanisms utilized by the family, and how the stressors have disrupted the family (Friedman, Bowden, & Jones, 2003). Healthy People 2020

Healthy People was developed by representatives from the U.S. Department of Health and Human Services (USDHHS) and other federal agencies. It “provides science-based, 10-year national objectives for improving the health of all Americans” (USDHHS, 2014, para. 1). The established benchmarks allow Healthy People to encourage collaboration, empower individuals, and measure the progress of prevention (USDHHS, 2014).

There are a number of Healthy People 2020 objectives that apply to veterans with PTSD and their families. They fall under the Mental Health and Mental Disorder topic. Objectives include: Reducing the suicide rate

Reducing the proportion of people who experience major depressive episodes Increase the number of persons with serious mental illness who are employed Increase the number of persons with mental health disorders who receive treatment Increase the proportion of persons with co-occurring substance abuse and mental disorders who receive treatment for both disorders Increase depression screening by primary care providers (USDHHS, 2014, p. 1) Nurse Intervention Strategies

Once a complete assessment has been preformed on the patient and family, the nurse can develop appropriate nursing diagnoses, which will then provide a framework for planning and intervention. According to NANDA International (2011), Nursing diagnoses are descriptive phrases used to describe actual or potential human responses to health issues or alterations in life processes. There are several diagnoses that may be appropriate for a veteran with PTSD and their family: Risk for suicide related to feelings of hopelessness and helplessness as evidenced by verbal statements Ineffective coping related to PTSD as evidenced by inability to keep a job, suddenly leaving his wife and children, and wrecking his car in a high speed collision Disturbed sleep pattern related to her recurring and distressing dreams of fire and explosion as evidenced by verbal statements, irritability, and chronic fatigue Dysfunctional grieving related to loss of her veteran husband who has left her without explanation as evidenced by misuse of alcohol which she verbalized was to “numb out” Anxiety related to husband’s PTSD symptoms of random, sudden, violent outbursts as evidenced by her irritability, tearfulness and verbalization of feeling like she is “walking on eggshells all the time” (Hamilton, 2011)

The primary goals of treatment for veterans and their families dealing with PTSD are to achieve reintegration and personal growth. Clinicians follow these basic principles: Respect and positive regard for trauma survivors, hope and expectation of recovery, safety from further trauma, physical and emotional stability, consistent therapeutic relationships with caregivers, and individualized treatment plans that are sensitive to gender and cultural issues and that are supported by family (Hamilton, 2011).

Elements of treatment for families dealing with PTSD include interventions from many different members of the health care team. Trained mental health professionals should do most of the work, but the nurse is an important part of helping ensure that all treatment elements are provided (Hamilton, 2011). 1) A healing environment is established- families need to feel safe in a predictable environment with genuine and consistent caregivers. 2) Education about trauma facilitates healing and validates what the families are experiencing. 3) Distress reduction and emotion regulation- families must learn how to manage the anxiety and negative emotions. 4) Cognitive interventions- the veteran with PTSD is prone to have negative beliefs and perceptions about themselves.

Cognitive reframing can help to reevaluate those thoughts and replace them with positive ones. 5) Emotional processing helps the veteran to be able to recall the trauma without experiencing the fear and horror. This is achieved by a desensitization process. 6) Increasing identity and relational functioning allows the veteran to regain his identity and dignity and to communicate effectively and relate to others without it triggering distrust and avoidant behavior. 7) Psychopharmacology is the last element of treatment that is sometimes necessary and monitored by physicians (Hamilton, 2011). Role of the Advanced Practice Nurse as Case Manager

Whereas most nurses encounter veterans and their families at the bedside in an acute care setting, using advanced practice nurses in the case management role is essential for all high-risk populations. Although the immediate health care needs of the PTSD veteran are paramount, the healing of the family is a vital part of the recovery process. As a case manager, the nurse can address the entire family’s immediate health needs but also can be an advocate in arranging post-acute care by providing support and resources. The physical and psychological issues of the veteran will always affect his or her loved ones. Often the initial symptoms of PSTD spill over creating health disorders in the veteran and in their family members. The advance practice nurse is put in a position of trust to observe, assess, and work cohesively with the family to develop appropriate plans of action during hospitalization and upon discharge of all members involved. While the most urgent issues must be addressed immediately, the family nurse must also transition into the case management role to promote health and prevent avoidable disease and injuries in the future.

Briere, J. & Scott, C. (2007). Principles of Trauma Therapy: A Guide to Symptoms, Evaluation, and Treatment. Thousand Oaks, CA: Sage. Friedman, M. M., Bowden, V. R., & Jones, E. G. (2003). Family nursing: Research, theory, & practice (5th ed.). Upper Saddle River, NJ: Prentice Hall. Healthy People. (2012). Healthy People 2020. Retrieved from http://wwwhealthypeople.gov Chandler, H. K. (2010). Recognizing posttraumatic stress disorder in military veterans. American Nurse Today 5(2). Retrieved from http://www.americannursetoday. com/recognizing-posttraumatic-stress-disorder-in-military-veterans/ Mayo
Clinic. (2012, March). Post-traumatic Stress Disorder (PTSD). Retrieved from

hhtp://www.mayoclinic.com/health/posttraumaticstressdisorder/DS00246/DSECTION National Center for Biotechnology Information (NCBI), National Library of Medicine at the National Institutes of Health. (2010). Post-traumatic stress disorder. Retrieved from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001923/. Nayback, A. (2008). Health disparities in military veterans with PTSD: Influential sociocultural factors. Journal of Psychosocial Nursing & Mental Health Services, 46(6), 42-53.doi:10.3928/02793695-20080601-08 NANDA International. (2011). NANDA nursing diagnoses: Definitions and classifications, 2009–2011. Philadelphia, PA: NANDA International. US National Security Archive. (2006, October). VA takes nine months to locate data on disability claims by veterans of Iraq and Afghanistan wars. Retrieved from the George WashingtonUniversityWebsite: http://www.gwu.edu/%7Ensarchiv/news/20061010/index.htm Department of Veterans Affairs (USDVA) (2014). PTSD: National center for PTSD. Retrieved from http://www.ptsd.va.gov/public/PTSD-overview/basics/what-is-ptsd.asp Woods, P. and Lasiuk, G (2008). Risk prediction: a review of the literature. Journal of Forensic Nursing 4(1), 1-11. doi: 10.1111/j.1939-3938.2008.00001.x.

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