The assessment and care of elderly clients is complex and multidimensional. A comprehensive holistic picture of clients and their environment is imperative to truly assess their situation and intervene to meet their many needs. The need for this type of picture drew me to the use of genograms as one part of a comprehensive systematic assessment.
A genogram is an elaboration of a family tree. Drawing family trees is an ancient practice, but more recently family clinicians have elaborated on the technique for clinical use. A genogram, more technically, is a clinical method of taking, storing, and processing information.1 The information gathered may include genetic, medical, social, behavioral, and cultural aspects of a family. Although traditionally used by physicians as a means to obtain and display genetic and medical information about a family, genograms have been used by psychologists to examine patterns of interactions within families.2 Nurses, too, are beginning to utilize the genogram, but with an emphasis on the social, behavioral, and cultural aspects of a family. Their use as an assessment tool with elderly clients, however, has not been documented in the nursing literature.
APPLICATION TO CLINICAL PRACTICE
Over the past several years, I have incorporated genograms in my clinical and educational practice. They have been used with more than 60 elderly clients, including an additional 22 clients cared for by graduate nursing students. The tool's usefulness and effectiveness was measured by evaluation questionnaires that were completed by SO elderly clients. The genogram was found to be useful as both an assessment tool and as an appropriate intervention strategy in certain specific situations. Its dual purpose is supported by Watztowich, who proposes that since a genogram is pictorial, it may appeal particularly to the right side of the brain and thus assist healing.3
Genograms can follow several formats. The format I developed and used with elderly clients in outpatient and home settings was an adaptation and expansion of the traditional format utilized by medical physicians. This adapted format focused on environmental and psychosocial aspects affecting the client. The focal point is the client; details about others (family and significant others) are shown in the genogram as they relate to the client.
The development of a genogram involves a complex process in which the interview plays a significant part. The manner in which a genogram is taken is perhaps more important than the information elicited and the technique of recording. The interaction that occurs between the nurse and the client can be conceptualized as involving several processes: social interaction, reminiscing, and evolving of self. Each of these processes are inter-related and build on each other. When using the genogram, it is impossible to differentiate between its value to the health-care professionalclient relationship, or on the quality and quantity of information acquired, and its affect on the client.4·5
Few tools are needed to construct a genogram. A large flip chart (32 in x 24 in) enables the elderly client to participate more fully despite possible decreased visual acuity, impaired visual tracking, and decreased manual dexterity. Colored pencils (black, red, blue, green) rather that pens are helpful so changes can be made and differences can be visualized easily. Color coding of certain information (Figure 1) can facilitate visualization and interpretation of the data. The client is encouraged to write on the genogram; this is not something that only the nurse records, but is a shared endeavor. Drawing of a genogram through a computer is possible; however, this limits the interaction and the therapeutic involvement of the client.6
The time needed to complete a genogram with a client varies with the complexity of the client's history and the client's present physical and emotional status. Completion time may range from 20 minutes to more than an hour and may occur over several sequential sessions, especially if shortened attention span, fatigue, anxiety, or pain are present. Sensitivity to the needs of the client is paramount. Prior to using the genogram, it is useful to determine baseline mental functioning because much of the data gathered depends on an adequate level of cognitive functioning. Numerous mini-mental status tests are available and can easily give the baseline data needed.
The genogram begins by drawing the basic family structure and those identified as significant others as far back as the client can remember (Figure 2). This has often been through the client's grandparents, and clients need to be reassured that they are not expected to remember distant relatives and specific dates. The interview is begun by discussing easy, factual matters. Once the basic skeleton has been drawn, the actual addition of significant information begins. Information is gathered in three categories: demographic, functional status/resources, and critical events/dynamic changes (Table).
Demographic information involves a factual database that includes age, present location, major role/occupation/ retirement status, major health problems, educational level, and, for deceased individuals on the genogram, the date and cause of death. Careful recording of all dates will identify pertinent data that may indicate areas of which to be aware. For example, knowing the exact day and month of the death of a significant other may enable plans to be made to cope with anniversary reactions.
Obtaining functional and resource information involves questioning present functional health status in the context of available and significant intrapersonal and environmental resources. Resources are considered to enhance or distract from a level of health; therefore, this information is vital.
GENOGRAM INFORMATIONAL CATEGORIES
Critical events and/or dynamic changes are those events that the client perceives as significant. It is helpful to begin questioning in this area with a general question and then proceed to more specific questions concerning successes, losses, and transitions in physical, emotional, social, and financial aspects of life. Critical events may be recorded either in the margin of the genogram or, if necessary, on an attached sheet of paper.
Genograms can become very complex, but it is important to keep them as simple and clear as possible; too much data will cause confusion, and the purpose of the genogram will be lost. The major advantage of the genogram is its graphic format. The nurse can glance at it and get an immediate picture of the situation without wading through a stack of notes, and critical information can be flagged and quickly seen.
The information gathered through the genogram can play a critical role in the development and implementation of preventive health plans and health promotion activities. The goal is to describe the client accurately and to organize the data in such a way that strategies with which to protect, promote, and maintain the health of the client are apparent.
The completed genogram should not become the property of the nurse. When the genogram has been completed, the nurse keeps a copy and gives the original to the client (Figure 3). The clients often share it with family members and friends so that the therapeutic process can continue. Several clients have used their genogram as the beginning of a diary to give as a gift to their children or grandchildren.
ASSESSMENT USING THE GENOGRAM
The ability of the elderly client to actively participate in making a genogram provides assessment data about the client's functioning in sensoriperception, memory, functional communication, fine motor skills, and behavioral areas. Sensoriperceptual data include any obvious functional hearing and/or visual problems, the client's state of attention (absent, inconsistent, consistent, length of attention span), and alertness. Memory assessed during the process includes long-term, short-term, and remote memory with areas of deficits noted. Functional communication data assessed include expressive (verbal quantity and quality and nonverbal communication) and receptive ability (comprehension). Fine motor skills are assessed as the client writes and draws on the genogram chart. Behavioral data assessed include such behaviors as distractibility, nervous tics, inappropriate physical activity, and appropriate or inappropriate participation in conversation. Normal age-related changes that are noted can be discussed with the client and thus provide an opportunity for the nurse to teach and give appropriate support. This is often a time in which the nurse can find out what the specific concern, change, and/or impairment means to the individual in daily functioning.
USES AND BENEFITS
The uses and benefits of a genogram in assessing and intervening with the elderly client are endless. The genogram provides a ready framework for establishing non-threatening communication. Elderly clients are often afraid of health-care professionals and, for some, their exposure to the health-care system has been limited to or thought of as a last resort. Thus, a way to establish a supportive, caring relationship is extremely important. Of all the clients I completed a genogram with, only one felt threatened by it; 99% said they loved it and felt it opened up communication.
The genogram provides a fairly quick psychosocial risk assessment including type, significance, and availability of support systems; presence of multiple losses and possible anniversary dates; presence of crisis points; and an awareness of themes of memories that may reflect priority needs. In addition, it also helps elderly clients realize how they have survived, recognizing past effective skills or survival that may help them draw on these skills to cope effectively with their present life situations.
A genogram can stimulate reminiscing in the elderly client. Reminiscence is important to the elderly as it provides the individual with an inner source of continuity through memory introspection of feeling and sharing. It has been reported that these memories may actually help the aged work through losses and maintain their self-esteem.7 The individual may come to believe the pleasures of life outweigh the pains and even the loss of roles, relationships, and worldly possessions that may occur with aging. Genograms address the concern of universality. One of the ways the elderly resolve fears of death is to gain a sense of other family members having died before them. The elderly begin to take interest in their own parents and grandparents, as well as distant ancestors, as they strive to find themselves in history and to take comfort in the fact that they are part of a long line of relatives. Burnside identified this as the search for universality, a sense of the long chain of birth and death and the basic fairness of each person having a life to live that must eventually be given up. 8 The use of a genogram provides the opportunity to do this. The genogram also allows the individual to see old age not as a stage of alienation from one's earlier life, but instead as a continuation of the process of life, growth, and experience. This is probably one of the most exciting aspects of the genogram as it can boost self-esteem and. reaffirm a sense of well-being.
The following case study illustrates the use of the genogram with an elderly client. John Doe entered the Family Practice Clinic for evaluation of mobility limitation and increasing pain due to osteoarthritis of bilateral hips and knees and lower spine. Initial assessment data noted about Mr. Doe during the process of the genogram interview included:
Sensoriperceptual: Alert, oriented, and attentive; diminished hearing bilaterally; diminished visual acuity.
Memory: Minimal short-term, longterm, and recent memory changes (age appropriate).
Functional communication: Expressive and receptive skills appropriate with slight interference related to diminished hearing.
Fine motor skills: Minimal senile tremor or dexterity difficulties (age appropriate).
Behavioral: Active participation in genogram process without excessive distraction or nervous mannerisms.
In analyzing the completed genogram, the following clinically relevant data were noted:
Demographic: Elderly retired bricklayer with a limited support system; all relatives are deceased with the exception of his daughter and brother-in-law. His relationships with both are distant and poor. His daughter resides at home but is in poor health. He is close to a female friend of the family and his minister.
Functional status/resources: Limited mobility (walking, bending) due to severe osteoarthritis of hips, spine, and knees; his general health is good. He cares for himself and his adult daughter in his own home.
Critical events/dynamic changes: Multiplicity of tosses (wife to cancer after caring for her for 3 years, and suicide of one daughter within the past 9 months).
Strengths: Hobbies and musical talent.
Anniversary dates: 1/20/88 and 2/15/88.
Based on this analysis, the following nursing diagnoses were made:
* Potential for dysfunctional grieving related to multiplicity of losses (wife and daughter within past 9 months), traumatic nature of both deaths (cancer and suicide), and limited support system.
* Alteration in family processes related to coping with multiple Stressors (death of wife and one daughter, infirmity of adult daughter at home, change in role, and impaired mobility).
* Potential for social isolation and loneliness related to decreased mobility, increased jouit pain, and death of significant others.
* Alteration in sensory perception related to hearing and visual deficits.
* Impaired mobility related to decreased joint motion and pain on movement secondary to osteoarthritis of hips, knees, and lower spine.
* Alteration in comfort related to joint pain.
* Susceptibility to environmental hazards related to mobility limitation and sensory perceptual deficit.
The genogram served a dual purpose during the intervention phase of the nursing process with Mr. Doe. It recognized Mr. Doe's past achievements and effective coping skills, thereby boosting his self-esteem . It further stimulated the process of reminiscing and grief work. The genogram also provided material for possible interventions. Specifically, Mr. Doe's hobbies, interests and strengths, and possible informal and formal resources were graphically visualized. Further areas of concern were explicated, such as the dysfunctional relationship between Mr. Doe and his daughter and brother-inlaw. Upon completion of the genogram, Mr. Doe was encouraged to share a copy with his daughter, thereby providing a possible avenue for opening communication. His daughter became very interested and a door to communication was opened.
Further interventions collaboratively planned with Mr. Doe based on the information gathered are listed below.
* Discuss grief work and the grief process using the genogram as a starting point.
* Provide the opportunity for and encourage expression of feelings through professional and informal support networks.
* Determine bereavement support needs; involve daughter, friend, and minister along with referral to support group and/or counselor if appropriate.
* Mobilize and encourage continued contact with informal support networks (friend, minister).
* Reinforce strengths and abilities and encourage involvement with others and in hobbies/interests (ham radio, fiddle).
* Encourage involvement in community groups (senior citizen activities) through providing information and evaluating transportation needs.
* Further evaluate strengths and Stressors on father-daughter relationship and identify possible and realistic ways of strengthening the relationship, including referral, if appropriate.
* Discuss the full range of care options for the adult daughter at home, including a social worker and counselor, if appropriate.
* Further evaluate the nature of the hearing and visual loss and possible remediation.
* Instruct on various measures to increase mobility through appropriate exercise, pain relief measures, and use of necessary aids and adaptive devices.
* Assess home for environmental hazards and assist in making appropriate modification.
* Provide information on pain and its management.
* Provide encouragement, information, and support of noninvasive measures to deal with pain.
Mr. Doe's case illustrates how a genogram provides a rich source of client and family data, contributes to the nursing diagnosis of client/family problems, and guides therapeutic interventions. It is important to note that the development of a genogram is not a one-time event, but rather an evolving process such that the review of the existing genogram together with an interval history occurs with each successive contact with the client.
PROFICIENCY IN THE USE OF GENOGRAMS
The skill and proficiency of the nurse is extremely important to the overall effectiveness of the genogram. Proficiency in the use of genograms comes in steps. The first step involves reviewing the interactional interview skills related to working with the elderly population with a focus on use of self and therapeutic reminiscence. The second step involves reviewing the genogram format and breaking the genogram into its three major informational categories (demographic, functional status and resources, and critical events/dynamic changes). Initially it is helpful to complete only one category, preferably demographic, with the client using the genogram format. Once a satisfactory level of competency is obtained, the next category of functional status and resources can be added, and finally the critical events/dynamic change category. This two-step method of review will allow for increasing competency and feelings of comfort in using the genograms, which will be reflected in the plan of care for the client.
A genogram creates a powerful experience for everyone involved, including the nurse. It provides a highly organized and easily visualized method of gathering and displaying information, and communicating this information to the client and to other healthcare professionals. It can serve as a tool to stimulate reminiscing and to further growth and self-esteem. The value of introducing this technique in client care has not yet been empirically demonstrated, although its informal usage indicates greater client satisfaction and improved client care. Rogers and Durkin (1984) compared the value of conventional history taking with a semi-structured genogram. The latter was found to elicit four times as much medical and family information as the conventional interview. In this study, 96% of the patients felt that the genogram would improve their communication with their health-care provider. It is a powerful tool that must be used appropriately and with good judgment. Studies designed to measure changes in outcome related to the use of genograms with the elderly are difficult, but necessary if this tool's validity is to be established.
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GENOGRAM INFORMATIONAL CATEGORIES