FAMILY ASSESSMENT OF ELDERLY PATIENTS WITH LIVER DISEASE

Objective: to analyze the structure, development and operation of families of elderly patients with liver disease. Method: this is a qualitative-field study, which used the Calgary Family Assessment Model. The study had as its backdrop of research a philanthropic hospital. The study population consisted of five families of elderly hospitalized patients with liver disease. Results: from the five females families evaluated, two were characterized as extensive, one rebuilt, one was composed of brothers without ties of consanguinity and only one as the nuclear family. It was also possible to verify that the relatives presented themselves as the main caregiver, and that all families presented the monthly average of two minimum wages. Conclusion: taking into consideration that the family participation in the process of illness presents itself as a determinant factor for the satisfactory prognosis of patients, the role of nursing before the evaluation and intervention in the family context will contribute significantly to improved health status and wellbeing of patients and their families. Descriptors: Aged; Liver Diseases; Family; Nursing; Health; Alcoholism. RESUMO Objetivo: analisar a estrutura, desenvolvimento e funcionamento de famílias de pacientes idosos com hepatopatia. Método: trata-se de estudo qualitativo, de campo, que utilizou o Modelo Calgary de Avaliação Familiar. O estudo teve como cenário de investigação um hospital filantrópico. A população do estudo constituiu-se por cinco famílias de pacientes idosos hospitalizados com hepatopatia. Resultados: das cinco famílias avaliadas, duas caracterizavam-se como extensa, uma como família reconstruída, uma era composta por irmãos sem laços de consanguinidade e apenas uma como família nuclear. Foi possível, ainda, verificar que os familiares do sexo feminino apresentam-se ainda como o principal cuidador, e que todas as famílias apresentavam a média mensal de dois salários mínimos. Conclusão: levando em consideração que a participação da família no processo do adoecimento apresenta-se como fator determinante para o prognóstico satisfatório dos pacientes, o papel da enfermagem frente a avaliação e intervenção no contexto familiar contribuirá significante para melhora da condição de saúde e bem-estar dos pacientes e familiares. Descritores: Idoso; Hepatopatias; Família; Enfermagem; Saúde; Alcoolismo. RESUMEN Objetivo: analizar la estructura, desarrollo y funcionamiento de las familias de los pacientes ancianos con enfermedad del hígado. Método: este es un estudio cualitativo de campo, que utiliza el Modelo de Evaluación de la Familia de Calgary. El estudio tuvo como telón de fondo de la investigación un hospital filantrópico. La población del estudio consistió en cinco familias de pacientes hospitalizados con enfermedad hepática. Resultados: de las cinco familias evaluadas, dos fueron caracterizadas como extensas, una como la familia reconstruida, una estaba compuesta de hermanos sin lazos de consanguinidad y sólo una como la familia nuclear. También fue posible verificar que los familiares mujeres se presentaban como el cuidador principal, y que todas las familias presentaron el promedio mensual de dos salarios mínimos. Conclusión: teniendo en cuenta que la participación de la familia en el proceso de la enfermedad se presenta como un factor determinante para el buen pronóstico de los pacientes, la función de la enfermería hacia adelante la evaluación e intervención en el contexto familiar contribuirá significativamente a mejorar el estado de salud y bienestar de los pacientes y sus familias. Descriptores: Anciano; Hepatopatías; Familia; Enfermería; Salud; Alcoholismo. Nurse, Resident of the Program of Multidisciplinary Residency in Family Health and Community – RMSFC/JP. João Pessoa (PB), Brazil. Email: gabriele_132@hotmail.com ORCID ID: http://orcid.org/0000-0002-3123-1712; Doctors, College of Nursing of the University Center of João Pessoa/UNIPÊ. João Pessoa (PB), Brazil. Email: marcellasouto@hotmail.com ORCID ID: http://orcid.org/0000-0002-64011898; Email: karlaalbuq@hotmail.com ORCID ID: http://orcid.org/0000-0002-0385-0540; Nurses (recent grads), University Center of João Pessoa/UNIPÊ. João Pessoa (PB), Brazil. Email: pksvlads@gmail.com ORCID ID: http://orcid.org/0000-0002-9116-091X. Email: stellasoares1@hotmail.com ORCID ID: http://orcid.org/0000-0001-6935-0138; Email: marques.carminha@gmail.com ORCID ID: http://orcid.org/0000-0001-6934-1055; Master (PhD student), Graduate Program in Nursing, Federal University of Paraíba/UFPB. João Pessoa (PB), Brazil. Email: carlabrazevangelista@gmail.com ORCID ID: http://orcid.org/0000-0001-7063-1439 ORIGINAL ARTICLE Souza GP, Duarte MCS, Vieira PKS et al. Avaliação familiar de pacientes idosos... English/Portuguese J Nurs UFPE online., Recife, 12(10):2690-702, Oct., 2018 2691 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i10a235085p2690-2702-2018 The process of demographic transition occurred in Brazil in recent decades has resulted in accelerated growth of the population of elderly individuals, a factor attributed to the reduction of mortality rates and fertility rates and the advances in the health area, what happened in the increase of life expectancy. Parallel to this process of demographic transition, the country goes through changes in the epidemiological profile with a significant increase of non-transmissible chronic diseases (NCD). Some studies report that the increase in the incidence of NCDS is correlated with highly prevalent factors, such as smoking, the abusive consumption of alcohol, high levels of cholesterol, sedentary lifestyle, among others. While it is natural, the aging process causes many physical and social changes. Associated with this process of transition, some feelings, like those of loneliness, abandonment and uselessness are found commonly among the elderly, which makes them even more susceptible and more likely to intensify less healthy habits, among them, the chronic and abusive consumption of alcohol. Alcoholism is a chronic and progressive disease characterized by the uncontrolled consumption of alcohol, with constant thoughts of ingestion of drink. The chronic consumption of alcohol can cause severe damage to health, in the short and long term, as the presence of insane frames and mental disorders, liver cirrhosis, pancreatitis, in addition to changes in mood and behavior. 4-5 In the elderly, alcoholism presents itself as a condition that intensifies the risk factors related to aging, considering that aggravates the distancing and social isolation, especially in the family. Chronic alcohol consumption in this population group can contribute to the consumption of other drugs, the appearance of other pathologies, worsening of preexisting and incapacitating sequelae. The abusive consumption of alcohol, as mentioned above, can contribute to the emergence of numerous pathological disorders, among them, the emergence of hepatic dysfunction, resulting from lesions of the liver cells. The hepatic dysfunction can be acute or chronic, being the chronicles the most common type. The abusive consumption of alcohol and infections by viruses of hepatitis B and C represent the largest portion of the cases of chronic liver diseases in the world. In this way, we can highlight the alcoholic liver disease (ALD), which is characterized by pathological changes in the liver. This is a liver disease induced by the prolonged and exaggerated consumption of ethanol, which results in multiple morphological alterations in the liver tissue, which vary from steatosis to cirrhosis and, in some cases, the hepatocellular carcinoma. The alcoholism, as well as the ALD has direct repercussions, not only the life of users, but in the lives of those who live directly or indirectly. The family dynamics of the alcoholic patient undergoes profound changes in the field of affective relationships, interpersonal and social. It is common that, in this context, the family gets ill together with the patient, thus affecting the quality of life and health of families. In this sense, it is notorious that care must be directed not only to the individual strength, but also to their families. The family is seen as the core of care, when affected by alcoholism, these should receive full and continuous treatment, so as to collaborate in the treatment of the member’s strength. In this way, it becomes evident the primary role of the family in the process of illness and the need of support to the family to care, so as to benefit the elderly with liver disease and relieve the family demands. Thus, it becomes essential to understand the family as a whole, and thus to be able to identify its weaknesses. Before this, it was used the Calgary Family Assessment Model (CFAM), which is a multidimensional model, composed by three categories: structural, developmental and functional and its various subcategories, which enables you to study and understand the family so integral, in their context and with its peculiarities to identify strengths and weaknesses for subsequent preparation of a plan of specific interventions. • To examine the structure, development and operation of families of elderly patients with liver disease. It is a qualitative-field study, which used the Calgary Family Assessment Model (CFAM). The study had as its backdrop of research a philanthropic hospital, located in the municipality of João Pessoa PB, Brazil. The study population consisted by families of elderly patients with liver disease who were hospitalized in this institution. For the selection of the sample, have adopted the OBJECTIVE

The process of demographic transition occurred in Brazil in recent decades has resulted in accelerated growth of the population of elderly individuals, a factor attributed to the reduction of mortality rates and fertility rates and the advances in the health area, what happened in the increase of life expectancy. 1 Parallel to this process of demographic transition, the country goes through changes in the epidemiological profile with a significant increase of non-transmissible chronic diseases (NCD). Some studies report that the increase in the incidence of NCDS is correlated with highly prevalent factors, such as smoking, the abusive consumption of alcohol, high levels of cholesterol, sedentary lifestyle, among others. 2 While it is natural, the aging process causes many physical and social changes. Associated with this process of transition, some feelings, like those of loneliness, abandonment and uselessness are found commonly among the elderly, which makes them even more susceptible and more likely to intensify less healthy habits, among them, the chronic and abusive consumption of alcohol. 3 Alcoholism is a chronic and progressive disease characterized by the uncontrolled consumption of alcohol, with constant thoughts of ingestion of drink. The chronic consumption of alcohol can cause severe damage to health, in the short and long term, as the presence of insane frames and mental disorders, liver cirrhosis, pancreatitis, in addition to changes in mood and behavior. [4][5] In the elderly, alcoholism presents itself as a condition that intensifies the risk factors related to aging, considering that aggravates the distancing and social isolation, especially in the family. Chronic alcohol consumption in this population group can contribute to the consumption of other drugs, the appearance of other pathologies, worsening of preexisting and incapacitating sequelae. 6 The abusive consumption of alcohol, as mentioned above, can contribute to the emergence of numerous pathological disorders, among them, the emergence of hepatic dysfunction, resulting from lesions of the liver cells. The hepatic dysfunction can be acute or chronic, being the chronicles the most common type. 7 The abusive consumption of alcohol and infections by viruses of hepatitis B and C represent the largest portion of the cases of chronic liver diseases in the world. 8 In this way, we can highlight the alcoholic liver disease (ALD), which is characterized by pathological changes in the liver. This is a liver disease induced by the prolonged and exaggerated consumption of ethanol, which results in multiple morphological alterations in the liver tissue, which vary from steatosis to cirrhosis and, in some cases, the hepatocellular carcinoma. 9 The alcoholism, as well as the ALD has direct repercussions, not only the life of users, but in the lives of those who live directly or indirectly. The family dynamics of the alcoholic patient undergoes profound changes in the field of affective relationships, interpersonal and social. It is common that, in this context, the family gets ill together with the patient, thus affecting the quality of life and health of families. 3 In this sense, it is notorious that care must be directed not only to the individual strength, but also to their families. The family is seen as the core of care, when affected by alcoholism, these should receive full and continuous treatment, so as to collaborate in the treatment of the member's strength. 3 In this way, it becomes evident the primary role of the family in the process of illness and the need of support to the family to care, so as to benefit the elderly with liver disease and relieve the family demands. Thus, it becomes essential to understand the family as a whole, and thus to be able to identify its weaknesses.
Before this, it was used the Calgary Family Assessment Model (CFAM), which is a multidimensional model, composed by three categories: structural, developmental and functional and its various subcategories, which enables you to study and understand the family so integral, in their context and with its peculiarities to identify strengths and weaknesses for subsequent preparation of a plan of specific interventions. 10 • To examine the structure, development and operation of families of elderly patients with liver disease.
It is a qualitative-field study, which used the Calgary Family Assessment Model (CFAM). The study had as its backdrop of research a philanthropic hospital, located in the municipality of João Pessoa -PB, Brazil.
The study population consisted by families of elderly patients with liver disease who were hospitalized in this institution. For the selection of the sample, have adopted the following inclusion criteria: that the companion was a member of the family of the patient; that was older than 18; who was accompanying the patient at the time of data collection, and that had an interest and willingness to participate in the study. Exclusion criteria: age below 18 and who did not have physical and emotional conditions to participate in the research.
We worked with a sample of 5 families. This number is justified by being a study of a qualitative nature. In this sense, some authors 11 reported that qualitative research is not restricted to a numerical count or a description, and, yes, the search for the essence of the phenomenon investigated. Therefore, no matter the number of participants and yes the deepening of the phenomenon investigated. 11 The data collection occurred during the months of October and November 2016. To facilitate the collection of data, we used the genogram and ecomap family, developed according to the guidelines provided by the Calgary Model of Assessment and Intervention in families. For both, it was used the technique of structured interview from a script containing questions, relevant to the proposed objectives for the research.
The genogram is a graphical representation of family members and their relationships, the assessment of the family development along the vital cycle, with its tasks and bonds, functioning as instrumental and expressive. The Ecomap is a diagram of the relations between the family and the community, which helps to evaluate the networks and social support available and its use by the family. 12 In relation to the technique of structured interview, it uses a script previously established. So, the researcher can enter questions that feel the need for a better observation on the subject researched. It is also employed, the system of recording, with mp4 player, which allowed for the free and accurate description. However, only if you have used the appliance mentioned with the prior consent of the participant survey. It is important to mention that, in order to guarantee the anonymity of the patients were assigned to them fictitious names in the Bible, and for the family, random fictitious names.
From this perspective, nursing professionals and families participating in the study were informed about the following aspects: study objectives, rationale, procedure, contribution, guarantee of anonymity, trustworthiness in the analysis of the data and the right to freedom to participate or decline at any time from the study of the research process.
It is worth noting that the research proposal was forwarded to the Committee for Ethics in Research (CEP), University Center of João Pessoa -UNIPE, assessed and approved under CAAE Nº 59330016.9.0000.5176.
Participated in the survey five families of elderly patients with liver disease, which, through the Calgary Family Assessment Model, it is possible to understand its structure, development and operation.
The results of the research will be described in two phases: The first consists of the presentation of the family and its structure which will be illustrated by means of a genogram and ecomap. The second will be the structural analysis, developmental and functional, in the light of the Calgary Model. Eva, 79 years old, it is natural of Guarabira, white, single, catholic, studied up to the 3 rd grade of Fundamental Education, is retired and has its own residence. Eva has five children, three of whom reside in Rio de Janeiro and one in Rio Grande do Norte, leaving only Marcia for the achievement of care.

English
Eva presented the first symptoms in January 2016, being diagnosed initially with Chikungunya. After the symptoms persist, it was forwarded to Basic Health Unit where complementary exams were requested, being diagnosed with chronic liver disease, liver cirrhosis, malnutrition, dehydration and anemia. Eve, then, was referred to the hospital for hospitalization.
Eva, before the illness, she lived alone; currently resides with his daughter Marcia (54) and her spouse Cassio (49) and three grandchildren, João, Jorge and Augusto (26, 19 and 16). In addition to the three grandchildren who reside with her, Eva has more a granddaughter who participates in the implementation of careful, Miriam (27), married with Otavio (27) and has a daughter of 9 years old.
Eva follows the Catholic religion, as well as her family; however, do not have the habit of attending, with the exception of Miriam and Jorge who are evangelicals. In relation to the support in health, Miriam reported that Dona Eva was accompanied on her residence by a team from Basic Health Unit of its neighborhood; however, pointed out that the requests were directed only to her. The family claims to keep a good relationship with the neighbors. Sara's Family -Family 2 Sara, 66 years old, white, widowed, illiterate, is natural of Bananeiras -PB, where she resides with her mother Ruth (94), which has a total visual impairment in both eyes, his uncle Lucio (73) and his nephew Filip (26). Sara has two children who live in another residence, Luiza (28) and Luiz (37). Sara is part of a family with a total of 12 brothers and, of these, three have already died. Sara was always responsible for the care of the mother, assignment that was passed after her illness to her sisters Ana Diana, Ana Clara and her daughter Luiza. Family income is composed by the retirement of Sara and her mother Ruth, still being complemented by agriculture exerted by Lucio and Filip. Sara, 6 months ago, started presenting pallor, weight loss, loss of appetite, as well as pain in the upper right quadrant of the abdomen. Her sister Flor, realizing the symptoms, took it to the physician, who requested exams, diagnosing it initially with amebiasis. Sara took the treatment, but the symptoms persisted, being requested a total abdominal ultrasonography, which demonstrated the presence of liver disease and hepatic nodules that are still under medical research. Sara has been assisted by her sister Flor (52), married with Jaco (56), a farmer who has two daughters. Flor claimed to be responsible for the household of her mother, and for the care of her sister Sara, being responsible to draw retirement, make purchases, pay bills, take both the doctor, etc. Flor claimed that only two sisters, Ana Clara and Ana Diana, in addition to her niece Luiza, participates in the care with the patient, although a large part of the responsibilities is attributed to her.
In relation to the support in health, Flor reported that usually seek the Basic Health Unit (BHU). When questioned about the distance, the same cannot be said too close. As to religion, claimed that the family group follows the Catholic religion although she has not the habit of attending, with the exception of her daughter and one of her uncles, who are evangelicals. The family refers to maintain a good relationship with the neighbors. Paulo, 63 years old, is pardo, illiterate, farmer and retired, is natural from Areia, but lives in Sape with his wife Marta (45), and his son Isaias (21). Marta studied up to the 1 st grade of basic education, being retired by mental disability. Isaias works in a house of dog food, has a child of 2 years and 8 months old with Julia (21).

Paul's Family -Family 3
Paulo, long-drinker dates, was admitted to the hospital, forwarded to the Basic Health Unit (BHU) of Sape -PB, presenting dysphagia due to pain and swelling in the throat and presenting a cervical node. Paulo follows hospitalized for investigation and treatment.
Paulo has four brothers, but, according to the report, has no contact with any family member a few years ago, because all reside in Alagoa Grande -PB and do not usually go to João Pessoa. By phone, Marta rarely talked with an uncle of Paulo, but reported not being able to talk with him some time ago. On the other hand, the family of Marta, her seven brothers, all residing in Sape.
When questioned about religion, Marta claimed are all Catholics, but they usually do English/Portuguese J Nurs UFPE online., Recife, 12 (10)  Joabe (63), pardo, divorced, studied up to the 8 th year of basic education, resides in João Pessoa, alone, and works by collecting recyclable materials through the streets of the city. Joabe gave entry in the hospital presenting dyspnea and tachycardia, after medical consultation, received a diagnosis of malnutrition, dehydration and liver disease, is hospitalized for testing and treatment. Joabe is chronic drinker for many years, one of the main reasons of constant fights with his sister Jade.
Jade and Joabe are brothers without consanguineous consanguineous ties, both are neighbors and reported to be friends 22 years ago. Jade (39), housewife, studied up to the 4 th grade of Basic Education, is married and has two daughters who live with their grandmother and their mother. Jade said to be the only responsible for the care of Joabe, because the family of the same be of Bahia. Joabe, after the separation, moved to João Pessoa, leaving 6 children in the countryside of Bahia, having no contact since then, because their children believe they have been abandoned by the father.
Joabe still has two brothers, Santos (75), which was recently changed to an institution of Long-Term Care Facilities for the Elderly (LTCFE) after hospitalization of Joabe. Santos is a diabetic and went through a process of amputation of the right lower limb approximately a year ago, being dependent upon Joabe for his care. After hospitalization of Joabe, Santos was sent to an asylum. In relation to his other brother Francisco, Joabe reported not having contact many years ago.
As to religion, Jade reported following the Catholic religion, and Joabe, the Evangelical religion. With regard to support in health, Jade said to have strong ties with the hospitals, being the first choice in case of illness, different from the Basic Health Units, where the same reported ties have weakened due to the delay in service.

John's Family -Family 5
English/Portuguese J Nurs UFPE online., Recife, 12 (10) João (66), black, widower, studied up to the 1 st year of high school, is natural from Santa Rita, resides in João Pessoa with Claudia (57), with whom keeps a relationship for 9 years. João plays the role of a cleaning agent on Enlur company, where he was away due to illness. His wife Claudia is professor of the Center of Reference of Social Assistance -Crsa.
João was hospitalized with increased abdominal volume, headaches and fever. After exams, he was diagnosed with cirrhosis of the liver, liver disease, ascites and splenomegaly. João reported to be alcoholic and smoker for approximately 35 years, a factor that commonly causes conflicts with his wife Claudia.
João has only one daughter, Eliza, 27 years old, residing in Santa Rita. Claudia has five children from the first marriage, Joice (22) Regarding religion, Joana reported that only her mother Claudia follows the Catholic religion, although lately was attending the Evangelical religion, and her sister Janaina is from umbanda; others have no religion. In relation to the support in health, the family usually seek the Basic Health Unit, which is located next to the residence. And in relation to the neighborhood, the family reports keep away in order to avoid conflicts.

 Structural evaluation
The structural evaluation of the family tries to examine the components that integrate, as well as affective bonds between them and the context in which they are inserted. In the category of structural evaluation, three aspects can be assessed: internal structure, external structure and context. In this sense, two instruments, the genogram and ecomap, allow the understanding of family dynamics and their interaction and bonds with the society.
Regarding the internal structure, the study showed that the families 1 and 2 were characterized as extended families, because they are constituted by three generations. Family 4 and family 5 presented different typologies. Family 4 was formed by two brothers without ties of consanguinity. Family 5, in turn, was characterized as a family rebuilt, because both spouses came from a previous marriage. Only Family 3 was presented as the nuclear family, seen to be composed by the couple and a son.
The study shows a variability in relation to the types of families; there are families who are scaping from classical concepts of family. These have originated and developed in more modern societies and, thus, are more tolerant. They are indications of experiences or approaches of the human behavior and inspire the evolution and change of habits. It is relevant to emphasize that the family composition changes during their life trajectory, may coexist in a same time and place. 14 With regard to gender, this subcategory refers to a series of values that shape our behaviors and ideas so, male and female, these are developed culturally by society, family, religion among others. 12 In this study, we could observe that the health care of the patients were in all the families evaluated, performed by the female figure, which corroborates with another study, where the representation of gender establishes the health care as allocation and destination of certain women. 15 In addition, the survey results have reconciled with another study where the role of caregiver were mostly developed by female relatives, who were in the adult stage of life, this way, taking the responsibility of reconciling the activities of mother, wife and work the role of caregiver. 16 For subcategory of sexual orientation, it is relevant to mention the Family 5. Joana, stepdaughter of the patient João, maintains a same-sex relationship with Luiza for two years and four months, according to the same, to announce her sexual orientation was scolded and physically assauted by her mother. When questioned about the current acceptance, the same reported: "She put up with, because that's the way, she's seen it's my option, but she gladly accepts no". (Joana, Family of João) According to some authors 17 , some families, when faced with a situation of homosexuality family, commonly use of assaults and other types of violence, which, in fact, present frustrations, intolerance and fear facing the situation, in addition, the family cannot perform its role of welcome and support. 17 In relation to the external evaluation, this is divided into extended family, which includes the family of origin and procreation, and subcategory, broader systems, which includes social institutions with which the families maintains a significant contact. In relation to the extended family, the family 1 reported a strong bond and family support with the family of origin, particularly as regards the financial support to care for the patient, although the geographical distance.
Family 2 reported that there is a strong family ties. Families 3, 4 and 5, in turn, reported not maintain ties with the family of origin.
As to the broader systems, all the families denied participation in welfare institutions, associations, etc. In relation to the support in health, the Families 1, 2, 3 and 5 reported to maintain moderate to strong bond with the Basic Units of Health of their neighborhoods. Now Family 4 reported to maintain strong bond with the hospital where he was hospitalized, because, according to the family, the basic unit of health of its neighborhood remains uncertain days of care, in addition to delay in appointing.
In relation to the category context, more specifically in relation to social class, the study demonstrated that the families 1, 2, 3 and 5 received, on average, 2 minimum wages; however, only Family 5 stated that the financial situation of the family interfered in patient care. Family 4, in turn, has no monthly income, surviving only on the collection of recyclable waste on the streets of the cities. When questioned if the financial situation of the affected patient care the same reported: Regarding schooling, the studied showed prevalence of people not attending school or with few years of schooling. The patients in the family 1 and 4 had incomplete elementary education (3 rd and 8 th grade, respectively), the patients of families 2 and 3 had no contact at school and both are illiterate, only the patient from the family 5 reached the middle school; however, abandoned it in the first year.
These data corroborate with information from the Demographic Census conducted by the Brazilian Institute of Geography and Statistics (IBGE), which showed that the population older than 65 remained presenting a greater incidence of illiteracy in relation to other age groups, approximately 25.7% in the year 2015. 18 According to a survey conducted in the city of Sinop, Mato Grosso, the lack of schooling among the elderly occurs due to the conditions of life of the era, where the urgency to assist parents in agricultural activities surpassed the need of studying, in addition, the scarcity of schools in the cities, the difficult access in terms of distance and other reasons, led to the interruption of the studies. 19 Religion and spirituality of the members of a family can influence both positively and negatively the approach of the family facing a problem; in other words, it can interfere with their ability to deal with a particular pathology. The spirituality and religion can still influence family habits, values and health care to the patient. 12 In this interim, it is necessary to thorough assessment of this subcategory. All the families in the study had at least one member who claimed to follow any religion. Family 5 was the only study that showed weak ties with religion and spirituality, with the exception of Claudia, who is Catholic, but that recently is attending the evangelical church, and Janaina umbanda, that is; the other members of the family have no religion and prove to be people hopelessness.
Families 1, 2, and 3, reported following the Catholic religion; however, do not have the habit of attending church regularly, either by lack of time due to the numerous daily demands, or by distance. However, the Sara's family (2) reported seeking help and hope in God, as observed by the following report: In situations limits as diseases, addictions, family problems among others, people often turn to religion as a form of support. 20 In a qualitative study 20 , the participants said that spirituality is a strategy used to cope with the illness, even presenting different conceptions about the concept of spirituality, the same is understood as a resource to strengthen different people facing the same situation. 21 Furthermore, religiosity can influence the physical and mental health of people, seen take vital role facing the adversities of life. 20

 Developmental evaluation
In the category of family development, it seeks to understand the stages of the lifecycle that family finds itself, and the route travelled by it. It is relevant to highlight that the vital cycle refers to the typical trajectories that cover a large part of the families as birth, home of the children, retirement and death, for example. However, the development of the family highlights the exclusive path that each family travels and which is commonly defined by the predictable and unpredictable events that occur during the life. 12 Furthermore, this category, assess the tasks of the vital cycle, which corresponds to the activities implied consistent for each phase. 12 In relation to the first family of research, Eva is an elderly single woman who never passed by marriage, currently lies in the late phase of life, having to adjust to the spouse of her daughter and grandchildren. This family comprises more than one stage of the cycle, because Eva lives with two grandchildren who are in the period of adolescence and the third grandson (João), which fits on the stage of the forwarding of young single adult, according to the stages proposed by Wright & Leahey.
The family nucleus of Sara, the second family of the study is composed of three generations and also have more than one stage of development. Her mother and uncle, as well as Sara, are in the final stage of life, and his nephew fits on the stage of the forwarding of young single adult.
The family of Paulo fits to the stage of forwarding of young single adult. This stage can last for several years; it is at this moment that the young people choose, in emotional terms, so that saved the families of origin, and that will go back to the extent that through the successive stages of the vital cycle. 12 Through the assessment, it might realize that Isaias, the son of Paulo, performs the task of "the establishment of the I in relation to the work and financial independence" so advantage and beneficial; however, there was difficulty in carrying out the task "development of intimate relationships with friends".
In relation to Joabe, a member of the fourth family of study, this is in the phase of post-divorce, however, in this case, it cannot be managed to maintain contact with the exspouse and not with the children. All members of the family are affected in case of divorce; however, few are those who are prepared for the physical and mental impact arising from it. 22 Divorce can occur at any stage of life, and brings significant consequences on family functioning. The power of recovery of a family is determined by the ability of family members to develop constructive relationships and mutual support, with the aim of protecting themselves in times of adversity. 12 In the case of the family of Paulo, there was success in the relationship after divorce, because the children felt abandoned after the divorce process, refusing until the current days any contact with father, which led to the construction of a new family, composed of Jade, which Joabe considers as a sister, and responsible for all your care. The family of João fits to the stage of families at the end of life, because they reside alone.

 Functional evaluation
In the functional evaluation we seek to understand how family members relate to each other. In this way, two subcategories comprise this category: the evaluation of the functioning instrumental and expressive function. In relation to instrumental evaluation, that seeks to assess how they are developed the routine activities of daily life, in a context where there is a state with health problems, the evaluation of this is of utmost importance. 12 In relation to the family of Eva, before the illness, the same lived alone and was fully responsible in performing its routine activities of daily life. However, after falling ill, Eva was at home with the family of her daughter Marcia, who together with her husband, Cassio, is responsible for performing the activities.
In what concerns the family of Sara, the same divided the bonds with her sister Flor. Sara, before becoming ill, was responsible in performing household activities, besides being the only responsible in providing the care of her mother Ruth, an old woman of 92 years old, who has visual impairment in both eyes. Flor, in turn, was responsible to draw pensions, make purchases, make payments, lead both to the physician, among other activities. Flor, in turn, was responsible to draw pensions, make purchases, make payments, lead both to the physician, among other activities. Flor reported that Sarah was totally dependent on her, and that they had the habit of leaving home alone, as reported: "[..] I was never alone no corner, that she does not know, it is as if he were a child knows, she knows no money, she does not know her age nor the children [...]" (Flor -Family of Sara) When questioned whether these obligations occupied her, the same reported: "It was, so let things to do to take care of her, right, for example, I had my home to make overalls, had a rice to cook, then I'll take her to the doctor, leaving everything aside and used to go." (Flor -Family of Sara).
A study with 124 caregivers of the elderly in the city of Ribeirão Preto, São Paulo, showed that the care entails workload and emotional distress to caregiver. 16 In addition, recalling that the present study has as object of study relatives of patient elderly, caregivers of elderly still share feelings of anxiety and nervousness at the time the elderly feels impatient front of inability to perform certain tasks, making the caregiver feeling tired and overwhelmed. 23 With the illness of Sara, household activities and watch your mother Ruth began to be shared with her sisters, Ana Clara and Ana Diana, in addition to her niece Luiza.
In the families of Paulo and João, routine activities of daily life, as well as the care with patient are carried out by wives, Martha and Claudia, respectively. Already in the family of Joabe, as the same lies alone, routine activities are carried out by him, occasionally Joab receives aid from his sister Jade; however, after the illness, health care of Joabe are exclusively performed by Jade. According to some authors 23 , take the health care for a family member alone becomes a difficult task because, in addition to dealing with many feelings, the caregiver is obliged to incorporate the care in his life routine. 23 In what concerns the evaluation of the functioning expressive, this involves nine subcategories. In this study, the evaluation will be directed to the communication of families evaluated. In relation to the other subcategories, in this study, was not mentioned any observation by the family who would rouse up the need for analysis.
The families of Eva, Sara and Joabe demonstrated have the habit of expressing feelings, and share sadness, anger, happiness among other feelings, with one another, showing a good family communication in a reciprocal way. When asked if there was someone who started conversations of feelings, families mentioned above claimed that yes. The family of Paulo, by its turn, presented difficulty in communication, demonstrating difficulty in expression of feelings. When asked to Marta, wife of Paulo, with whom she used to express feelings, the same reported that kept for herself, as well as the rest of the family.
Family relationships are fastened by means of efficient processes of communication, which allows for the stability of the family system. In this context, the communication is understood as one of the main factors to be structured in family dynamics, because, through her, sets the mechanisms of relational interaction, training, as well as of social integration. [24][25] Finally, the family of Paulo proved to avoid talking about certain subjects, such as the sexual orientation of Joana, for example. However, argued that Janaina usually initiate conversations of feelings. Some authors 26 reported that the dialog between parents and children about sexuality is permeated by numerous and varied difficulties that permeates cultural issues to personal issues. This communication can be facilitated through the aid of professionals of education and health. 26 Finally, considering that the family presents itself as the main core of patient care and that in the context of illness it is common that the family also gets ill, it is expected that the results of this study will contribute significantly to the performance of nursing forward to families who experience alcoholism and alcoholic liver disease, in order to benefit and improve the prognosis of the patient strength and relieve the demands families, performing a truly holistic intervention.
The family assessment performed by the Calgary Model enabled the analysis of the participants families on research to happen in a holistic way, contemplating all the essential factors of family dynamics, focusing on key points of its structure, its development and functioning. It is important to emphasize that, through study, it was observed that the uniqueness exists in each family context, although all families shared the fact of living with elderly patients with liver disease, all showed different ways to cope with the illness of a family member.
It is important to mention that, through research, we could see that the relatives of the females present themselves as the main caregiver, and that all families had low family income; however, part of the families surveyed reported seek in faith support to cope with the process of illness. In addition, the construction of the genogram and ecomap allowed families to reflect on the relevance of the family in the context of illness and other support systems, leading them to expand the possibilities in the coping of the disease.
In addition, the nurse through the family assessment may identify points of family dynamics that can be improved, through the development of interventions, which will be developed together with the members of the family, aiming to improve the quality of life of the patient and the family as a whole.
Taking into consideration that the family participation in the process of illness presents itself as a determinant factor for the satisfactory prognosis of patients, the role of nursing before the evaluation and intervention in the family context will contribute significantly to improved health status and wellbeing of patients and their families.
However, in the present study, it might highlight the need for studies that aim to evaluate the context of families who undergo stressful events, deepening the knowledge about the family in view of improving nursing care in relation to the different and complex family contexts.