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THE APPLICATION OF FAMILY APPROACH TOOLS IN A CASE OF
PARAPLEGIA
Hillary Lima Abade1
Marivone de Oliveira Monteiro2
Mirela Lopes de Figueiredo3
Dinariam Gonçalves Silva4
Ana Paula Ferreira Maciel5
Elisabete Cordeiro Muniz6
Maria Esméria Neta7
Silvania Godinho Souto8
Kátia Cristiane Soledade Dias9
Nadine Antunes Teixeira10
Ticiane Dias Prado11
Jeferson Sousa Pinheiro12
Reginalda Maciel13
Rafaela Barros Pinheiro14
1 Montes Claros State University
2 Montes Claros State University
3 Montes Claros State University
4 University Center of Northern Minas Gerais
5 Montes Claros State University
6 University Center of Northern Minas Gerais
7 Montes Claros State University
8 Montes Claros State University
9 Montes Claros State University
10 Montes Claros State University
11 Montes Claros State University
12 Faculty of Health and Humanities Ibituruna
13 Fipmoc University Center
14 Fipmoc University Center
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Brenda Cristina Rodrigues de Almeida15
Hanna Emanuelle Rocha dos Santos16
Isabella Batista Vieira17
Abstract: Objective: To describe the experience of applying family-centered care tools to a family that
recently underwent a change in its family context with the arrival of a member who is fully dependent
on care, as well as the interventions performed. Methods: A descriptive-narrative, qualitative study was
conducted in the second half of 2022 by the Family Health Strategy team located in the municipality
of Taiobeiras, Minas Gerais, Brazil. The family was chosen based on the identied needs of one of its
members, who had a recent history of hospitalization, was bedridden, paraplegic, and had a colostomy.
The instruments used were: Genogram, Ecomap, Life Cycle, FIRO (Fundamental Interpersonal
Relations Orientations), P.R.A.C.T.I.C.E., and Family Conference. Final considerations: The approach
made it possible to understand the family holistically, monitor and facilitate appropriate treatment for
the patient, as well as strengthen the bond between the Family Health Strategy and the users. The study
proved essential, providing information that coincides with the users’ experiences, also demonstrating
the relevance of applying the tools, since this process reects the evolution of the Brazilian health
system, being indispensable in Primary Health Care for Families and Communities.
Keywords: Family Health Strategy, Life cycle stage, Health care.
15 Faculty of Health and Humanities Ibituruna
16 University Center of Northern Minas Gerais
17 University Center of Northern Minas Gerais
INTRODUCTION
The Family Health Program (PSF), created in 1994 with the objective of restructuring
primary care in the country, gradually gained ground, demonstrating its relevance and becoming
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the main strategy for modifying the care model and the entry point into the Unied Health System
(SUS). In 2006, through the National Primary Care Policy (PNAB), it ceased to be a program, due to
its provisional nature, and was renamed the Family Health Strategy (ESF) (PINTO; GIOVANELLA,
2018).
The incorporation of the family as the center of Primary Health Care is a priority condition,
being presented as the main method of health reorganization (CHAPADEIRO et al., 2011) and considered
a basic relational means, and should be seen as an investigative dimension for understanding how the
subject lives with their real life context (NOBRE).et al.,(2015). The family approach is highlighted
as an important health care strategy, as it makes it possible to identify weaknesses and limitations,
understand the family structure, and comprehend how families organize themselves when facing
illnesses, problems, and difcult situations (TAKENAKA; BAN, 2016).
Through the consolidated and longitudinal relationship between family health teams and
the population assigned to the area, it is possible to obtain data that support information on family
groups, making it possible to understand the particularities of each family, identify needs and carry
out interventions when these become indispensable (BRASIL, 2011).
The family system exerts inuence among its members as well as the community in which
it is embedded. It is assumed that, through the study of the family, sufcient information can be
obtained to understand the impacts on health-disease conditions and family interaction. To this
end, it is necessary to apply family-based approach tools, such as: Genogram, Ecomap, Life Cycle,
FIRO (Fundamental Interpersonal Relations Orientations), P.R.A.C.T.I.C.E., and Family Conference
(JESUS).et al.,2020).
Given the above, this study aims to describe the experience of applying family-centered
therapy tools in a family that recently underwent changes in its family context and routine. with the
arrival of a member who is entirely dependent on care, as well as the interventions performed.
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METHODS
This is a descriptive-narrative, qualitative study, developed in the second semester of 2022
by the Family Health Strategy team, a branch of the Multiprofessional Residency Program in Family
and Community Health at the State University of Montes Claros (UNIMONTES), located in the
municipality of Taiobeiras, Minas Gerais, Brazil.
The family’s choice was based on the identied needs of one of its members, as well as the
sudden change in the family structure. The patient is bedridden, paraplegic, and recently underwent
exploratory laparotomy due to acute perforated abdomen, followed by a left Hartmann hemicolectomy
with colostomy bag placement.
Seven home visits were conducted by the community health worker, nurse, nursing
technician, pharmacist, doctor, and dentist, as needed, not necessarily with the presence of all, and
a family conference was promoted by the Specialized Reference Center.AssistanceSocial (CREAS)
with the Family Health Team and all those residing in the household, conducting semi-structured
interviews supported by family approach tools,”They are:”Genogram, Family Life Cycle, Firo and
P.R.A.C.T.I.C.E.
This study was submitted to the Research Ethics Committee of UNIMONTES and approved
on October 26, 2016, according to opinion number 1.792.192, complying with Resolution No. 466/2012
of the National Health Council for research with human beings. The family was informed about
the objective of the research, condentiality, ethics, and the right to refuse participation. Therefore,
the family members signed the Informed Consent Form. It is important to note that to protect the
anonymity of the participants, maintaining condentiality and ethical standards, [the following was
done/the study was conducted/the study was carried out/the study was conducted/the study was
conducted/the study was conducted/the study was conducted/the study was conducted/the study was
conducteddoIn this study, the names of all those involved have been replaced with ctitious names.
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RESULTS AND DISCUSSION
Gabriel (35 years old),divorced,Retired, literate, paraplegic, ostomized, alcoholic and chronic
smoker (currently abstinent). He was married to Luiza for 12 years, with whom he had three children:
Laura, Liz, and Gael, aged 12, 8, and 6 respectively. After their marriage, he and Luiza sought better
living conditions in the state of São Paulo; however, due to his abusive use of illicit drugs, the family
lived in a state of conict until the accident involving Gabriel. 4 years ago. In 2019, he returned with
his family to the municipality of Taiobeiras, now completely dependent on care.
Gabriel uses controlled medications for continuous use, prescribed by his psychiatrist. These
include: Bromazepam 6 mg (1 tablet at night); Valproic Acid 250 mg (1 tablet in the morning and 1
tablet at night); Neozine 100 mg (1 tablet in the morning and 1 tablet at night).Promethazine25 mg (1
tablet in the morning and 1 tablet at night); Risperidone 2 mg (1 tablet at night) and Paroxetine 20 mg
(1 tablet in the morning).
For four years, Luiza, Gabriel’s ex-wife, was responsible for his full care while they lived
together, and refrained from seeking help from family members and other members of the healthcare
network. This led to a worsening of her already fragile health, which included chronic hypertension,
spinal bone degeneration, incident dorsal spondylitis, and acute cholecystitis. She was awaiting her
cholecystectomy surgery, which coincided with Gabriel’s emergency hospitalization due to acute
perforated abdomen. Realizing that both would need full care, Luiza asked Gabriel’s closest relatives
to take over his care. This resulted in the couple’s divorce and a conict with Maria (Gabriel’s mother).
Currently, Luiza lives in a rented house with basic sanitation, which has seven rooms: two
bedrooms, two bathrooms, a living room, a kitchen, and a service area. She is unemployed, with
a current income of R$ 600.00 (six hundred reais) from the Auxílio Brasil program, and is in the
process of retiring. Even during her post-surgical recovery and despite all the fragilities of her health,
she managed to fulll her role as a mother, caring for her ve minor children: Laura, Liz, and Gael,
from her marriage to Gabriel; and Enzo and Théo, 18 and 16 years old respectively, from previous
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relationships.
Maria (60 years old), divorced, mother of twelve children: Gabriel, Nilton, Davi, Pedro, Isac,
Carla, Virna, Saú, Ana, Marco, Lói, and Elza. Living with Gabriel and Davi, she became responsible
for their care; she is in the process of retiring due to lumbosciatica evidenced by Magnetic Resonance
Imaging. She has recently nished taking Gabaneurin 300 mg (1 tablet in the morning and 1 tablet
at night), maintaining pain relief with analgesic medications, such as dipyrone, prescribed by her
orthopedist.
Davi (38 years old), Gabriel’s brother, single, retired, diagnosed with severe depression, lacks
the mental capacity to make decisions, has no children, helps care for Gabriel, and his retirement
pension allows him to cover part of the household expenses. He is currently taking Haloperidol 5 mg
(1 tablet in the morning, 1 tablet before lunch, and 1 tablet at night), Risperidone 2 mg (1 tablet in
the morning and 1 tablet at night); Biperiden 2 mg (1 tablet in the morning and 1 tablet before lunch);
Carbolithium 300 mg (1 tablet before lunch); Neozine 25 mg (2 tablets in the morning and 2 tablets at
night), provided daily by the Psychosocial Care Center (CAPS), where the morning dose is supervised
and the others are self-administered.
Pedro (36 years old), Gabriel’s brother, single, unemployed, lived with his mother and two
siblings, and is currently hospitalized in a rehabilitation clinic in the state of São Paulo, referred by
the CREAS of Taiobeiras, to protect Maria, in accordance with the elderly statute, preserving her
psychological and physical integrity. He is a person with a disability (apparent, mental disorder), a
drug addict with a history of hetero-aggression.
The family under study, consisting of Gabriel, Davi, Maria, and Pedro, lives in their own
home, which has nine rooms: ve bedrooms, two bathrooms, a living room, and a kitchen, without
any adaptations for people with disabilities. The property is in very poor condition in terms of
infrastructure and basic sanitation. Maria, the owner and Gabriel’s mother, says she plans to sell the
property and buy a smaller one in good living conditions so she can make the necessary adaptations.
José is Maria’s ex-husband and the father of her 12 children, including Gabriel, from whom
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he divorced 19 years ago. He was recently diagnosed with Parkinson’s disease and the human
immunodeciency virus (HIV). He is currently in a same-sex relationship with Carlos, who is
Charles’s father, and his relationship with his children, who do not live in the same municipality, is
hampered due to the distance between them.
From the genogram (Figure 1), it is possible to observe the interpersonal relationships and
family structure established by its members, represented by symbols that highlight information
such as age, sex, occupation, comorbidities, and bonds (NASCIMENTO et al., 2014). Among most
members of the studied family, the relationship is harmonious. Conicts are observed between Luiza
and Maria; between Pedro and Marco, due to Pedro’s abusive use of illicit drugs; and between Nilton
and Izac for undisclosed reasons. Gabriel has a distant relationship with Pedro, who is currently
hospitalized in a rehabilitation clinic in São Paulo..
Figure 1: Genograma familiar
Source: Authors’ own work, 2023.
Information derived from assessments of burden in the context of patient care makes it
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possible to measure the caregiver’s perception of the role assumed, observing the bond between the
caregiver and the dependent person (QUELUZ).al.,(2019). In this scenario, it is possible that Maria, as
a consequence of all the activities performed for the index patient, may present complications in her
health status, mental stress, and physical exhaustion. Therefore, it is essential that the Family Health
Strategy (ESF) acts as a supporter of the well-being of both, and that Maria recognizes Gabriel’s
condition and becomes aware that this support network is not only for him (HENRIQUES; CABANA;
MONTARROYOS, 2018).
Ecomapa
The ecomap, created in 1975 by educator and social worker Ann Hartmann, is a way of
representing a family’s personal and social ties with the environment and community where they live,
contributing to the assessment of the social and support networks accessed by family members, as
shown in Figure 2 (HARTMAN, 1978).
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Figure 2: The familiar ecomap.
Source:Authors’ own work, 2023.
It is possible to assess the social relationships built and the support network in which the
family is embedded, as shown in Figure 2. A strong link with the Family Health Strategy (ESF) is
observed, because it ensures the patient’s access to health services and related networks. Continuous
follow-up by the team facilitates the creation of bonds and trust, leading to more accurate and effective
diagnoses and treatments (STARFIELD, 2004).
Furthermore, a strong link with the church is noticeable, which, in addition to providing
religious support due to the difculties faced by the family, makes donations of basic food baskets as
a way to guarantee food security, contributing to coping with current difculties. In this perspective,
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Almeidaet al.. (2022) brings in his study the importance of working with and involving religiosity
within the family, in relation to biopsychosocial aspects. Thus, the ESF can encourage the connection
between the church so that the practice of spirituality becomes an increasingly effective point of
support.
Regarding the Specialized Social Assistance Reference Center, the bond is strong due to the
need for legal assistance and psychosocial support, according to Panisson.et al.(2022), they emphasize
the importance of CREAS as a facilitator of communication between the social assistance and health
sectors, so that the person can develop their autonomy and be the protagonist of their care. In this
way, the fact that CREAS fullls its social role, guaranteeing the rights of Gabriel and his family, is
explained.
Furthermore, it’s worth emphasizing the family’s relationship with the pet. This bond is
considered strong by the family, making it interesting to discuss this relationship. Therefore, Santoset
al.(2022) presents in its study the benets linked to the bond developed between humans and animals,
which contributes to physical and mental well-being, alleviating feelings of sadness. Regarding the
other bonds with the lawyer, the extended family and the neighbors, a resistance was perceived from
the members in going into details, hindering the understanding of the inuence and the association of
these links between the aforementioned people.
Family Life Cycle
Individuals and families have distinct life cycles. Their development occurs in a non-linear
fashion, according to the events they experience, whether predictable or unpredictable, which mutually
affects all those involved and thus shapes their future (CHAPADEIRO CA et al., 2011).
The rst cycle isfamily as a starting point(CHAPADEIRO CA et al., 2011), evidenced by the
recent separation of Gabriel and Luiza, making it necessary to renegotiate the marital relationship,
based on the acceptance of both parties and possible changes in the family composition.
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The second one ismiddle-aged familiesand the thirdaging families(CHAPADEIRO CA et
al., 2011), The index patient’s mother is in her aging phase, having new goals, needing to realign
relationships such as the inclusion of her grandchildren, and planning her nancial future through
attempts at retirement. In addition, she also deals with Pedro’s disability, who is hospitalized for
rehabilitation.
F.I.R.O
The “fundamental guidelines in interpersonal relationships” –Fundamental Interpersonal
Relations Orientations: (F.I.R.O) – seek to analyze the feelings of family members in everyday
relationships (ANDRADE AS and GOMES RLR, 2018).
The application of the F.I.R.O. model was necessary following the transition of responsibility
for the care of the index patient from Luiza to Maria, which resulted in changes to the daily routine
and roles of family members. In the inclusion category, Gabriel feels that his role as manager and
provider has not changed, with the only obstacle being his inability to move around. In the control
category, Maria holds the dominant role, performing most of the personal and medication care with
the help of Davi; however, Gabriel feels involved in family decision-making processes. Regarding the
intimacy category, he has the freedom to express himself and has accepted the end of his marriage,
although he misses his ex-wife and children with whom he maintains a good relationship.
The P.R.A.C.T.I.C.E. tool is used for family assessment, capable of identifying the main
problem, facilitating its resolution through interventions relevant to the family’s specic tribulations
(BRATE ARSD, et al., 2016).
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Table 1: P.R.A.C.T.I.C.E
PProblem The inability toGabriel It is the cause of existing conicts.
RRoles and structure Maria takes on the roles of mother and caregiver for both children,
in addition to managing household chores. Davi, despite being
the nancial provider, lacks autonomy in decision-making due
to his mental state. Gabriel assists.for household maintenance.
AAffect Maria has a good relationship with Davi, while Gabriel has a
strong and conicted relationship with his mother.
CCommunication It is noted that there is a deciency among the members, however
there is agreement on the decisions.
TTime in life (tempo no life
cycle)
Middle-aged family, with mother-grandmother, son-father-
uncle-brother. In the process of transitioning from work
to retirement and full pension contributions, with marital
renegotiations.
IIllness in family past and
present(illnesses in the
family)
Since Gabriel’s arrival with his physical limitations, it has
become evident that the family lacks the resources to handle
the daily care needs of all its members.
CCoping with stress Family members are willing to resolve problems when faced
with stressful difculties.
AND Environment/ecology The mother has a good relationship with the Family Health
Strategy (ESF) team and accepts assistance as needed based
on the demands identied by the team. She receives visits
from church members as an emotional support group. Gabriel
receives visits from his ex-wife and their three children.
Source: Authors’ own work, 2023.
The Individual Therapeutic Project (ITP) enables the production of interdisciplinary care,
including the patient and caregiver, generating synergy among those involved.It is dened as a cluster
of therapeutic proposals and behaviors designed for the individual or group, practiced in conjunction
with the user and family members (BRASIL, 2008). When the team observed Maria and Davi’s
insecurity in providing basic care to Gabriel, the Family Health Strategy (ESF) together with the Home
Health Care Program (Better at Home) developed a Personal Therapeutic Plan (PTS), guaranteeing
him autonomy and safety.
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Intervention
On October 24, 2022, Gabriel was admitted with acute perforated abdomen, resulting from
constipation, which culminated in fecal impaction, requiring surgical intervention, exploratory
laparotomy, which revealed an extensive sigmoid laceration. He underwent a left Hartmann
hemicolectomy and remained hospitalized in the ICU, receiving antibiotic therapy via central venous
access and right subclavian vein. He was discharged from the hospital on November 4, 2022, already
using a colostomy bag and with several pressure sores.
After hospital discharge, the nurse, along with the community health worker and the nursing
technician, conducted a home visit to assess the patient’s condition and the context in which they
were living. In the Family Health Strategy, the home visit is an activity that allows professionals to
get closer to the local reality, enabling them to effectively understand the situations associated with
the health-disease process, which involve social and economic variables, to help understand the way
of life of individuals (GOULART et al, 2021).
Family support depends on a proper understanding of the biopsychosocial characteristics
of its members. In this context, the family is considered the most signicant dimension of the users’
social environment (DIAS; LOPES, 2015). At the end of the visit, a municipal referral for colostomy
bags was requested, along with assessment and measurements to order the necessary materials, as
well as training for the family on how to care for this procedure. The ease of communication with
family members claried and highlighted the essential need for shared care with social services, the
home care team, and the Family Health Support Center (NASF). In this sense, this clinical condition
requires coordinated and multidisciplinary care from health services. This situation may be associated
with the various needs of the ostomy patient, with a view to adapting to the new clinical condition
(ARDIGO; LOVER, 2013).
With the goal of ensuring the user’s autonomy and adaptation, it is the responsibility of
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healthcare professionals to carry out educational actions, which include guidance on care in the
pre-operative period and, above all, in the post-operative period, since the user and their family
need information that enables them to care for the stoma at home. Implementing these strategies is
essential for the user’s rehabilitation and care at home.SILVA et al., 2017). It was understood through
the assessment that the index patient’s mother would assume the role of head of the household and
caregiver, even exceeding her physical and mental limitations. This was democratically accepted
within the family hierarchy.
On December 9, 2023, the Nurse, Pharmacist, Nursing Technician, and Community Health
Agent, along with the multidisciplinary team from CREAS, held a family conference to dene
responsibility for Gabriel’s care. The family conference is a strategy used in conict resolution where
professionals address health issues, interaction, and communication among family members. It is a
pre-arranged meeting among family members where information and feelings are shared, aiming
to change behavioral patterns among family members. Thus, through active listening, the family
conference allows for clarifying questions, discussing feelings, and reducing existing psychosocial
anxieties. It aims to resolve the doubts of users and family members, respect the autonomy of others,
and provide opportunities for individuals to make their own decisions (SILVA). et al., 2018).
At the end of the family conference, it was agreed that Gabriel would remain under Maria’s
care, staying at home until his siblings coordinate with foster care facilities that meet his needs for
institutionalization, or until the family must resort to hiring a caregiver.
Based on data obtained from the assessment and development of the Individualized Treatment
Plan (ITP), guidelines were provided regarding Gabriel’s care, including: changing his position every
2 hours, keeping the sheets clean and taut, removing feces from the colostomy bag whenever it
reaches the indicated limit, maintaining good hygiene for the patient and the environment, keeping
him hydrated and fed, and administering medications at prescribed times.
Following daily assessments, it became evident that the medication treatment used by the
index patient was no longer having the expected effect; consequently, the multidisciplinary team
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referred him to the CAPS (Psychosocial Care Center), where the psychiatrist, after evaluation,
prescribed a new pharmacotherapy, with satisfactory results so far. In this sense, interprofessional
work in health, based on collaborative practice, is presented as one of the most effective strategies to
face the highly complex challenges of the health sector and the materialization of interdisciplinarity
(PEDUZZI et al., 2013).
The pharmacist, together with Maria, reviewed all medications available in the home, providing
guidance on their correct use at pre-established times. According to this study, this professional’s
role in the Family Health Strategy (ESF) includes dispensing medications and providing specialized
pharmaceutical guidance, as well as home visits, matrix support to family health teams, individual
or shared assistance, and participation in interdisciplinary health groups. In addition to managing
medication, this professional assists in building healthcare for users, monitoring treatments, and
contributing to the team’s actions promoting health and quality of life (DIEL). et al., 2019).
Due to Maria’s stress and anxiety, the primary care nurse referred her for psychological
counseling. In this context, with the evolution of the Unied Health System, new actors have gained
prominence in the health sector, among them the psychologist (SPINK; MATTA(2010). It is noteworthy
that the process of insertion at this level of care has been accompanied by intense discussions, which
indicate difculties for psychology in the face of the reality of the Unied Health System, especially
in the context of primary health care. A medical evaluation was also requested to provide a report
proving the inability to perform work activities and the need for retirement.
Given the physical limitations of the index patient, it was necessary for the dentist to assess
the oral region during a home visit, where deciencies in hygiene were observed. Initially, a home
visit by a dental hygienist was scheduled for deep cleaning of the teeth. Subsequently, a routine of
consultations was dened for maintaining oral integrity and possible interventions. It is important to
emphasize that, as an operational strategy, dentistry utilizes the ideological framework of the Family
Health Strategy, that is, it aims to work through client registration, focusing on the family nucleus and
basing itself on epidemiology as a decision-making strategy, guiding the principles of prioritization,
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through a risk perspective. It also seeks to defend multidisciplinary work, incorporating the collective
into the individual and prevention into cure, based on an understanding of the inuence of social
determinants in the health-disease process through humanized care.FARIAS; SAMPAIO, 2011).
At the end of the proposed and implemented interventions to date, Maria highlights Gabriel’s
clinical and mental improvement, feeling secure due to all the support from the team responsible for
the interventions. It is worth remembering that Gabriel was completely unassisted by the Health Care
Network while living with Luiza, who did not seek help or multidisciplinary care, which culminated
in a serious condition with an imminent risk of death.
In this sense, knowledge about the family enables an evaluative parameter of the health needs
of users and helps to reduce the chances of numerous negative outcomes, allowing for appropriate
interventions. A family-centered approach requires changes in the practice of health teams and has
been conducted through the Family Health Strategy since 1994, allowing for personalized actions
over time through an understanding of the family structure (MACHADO; MENDES, 2012). This
study reinforces the favorable possibilities that this approach brings to the effective care of families.
Final considerations
The application of family-centered therapy tools allowed for an understanding of the
family and its unique characteristics, enabling a holistic view of the family being studied. This is a
dysfunctional family, economically disadvantaged, with limited resources, at different stages of life,
and with debilitating comorbidities. Despite some conicting episodes most of the time, the family
lives together harmoniously.
Even with the work carried out by the entire multidisciplinary team, including proposed
interventions and referrals, the participants studied have chronic physical and mental limitations,
making it important for continued care from qualied professionals.
This study demonstrates the relevance of applying these tools, as this process portrays the
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evolution of the Brazilian health system, making visible the study of life and all its complexity and
uniqueness, considering not only the disease but all the aspects that permeate it. The study proved
essential, providing information that coincides with the users’ experiences, being indispensable in
planning actions designated to Primary Health Care for Families and Communities.
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