2 Child and Family Health Assessment
Foundations for Child and Family Assessment
Child Health Assessment Foundations
When analyzing patient problems most providers are comfortable with classification of diseases using categories found in the International Classification of Diseases, edition 9 revised, Clinical Modification (ICD-9-CM) (USDHHS, 2003), including infectious, endocrine, nutritional, metabolic, immunologic, respiratory, and cardiovascular. ICD-10-CM will be effective October 2013. Providers consistently record the disease diagnoses they make for problems in these body systems. One reason that providers use this classification system so easily is that the classic health history format drives diagnostic decisions into these categories. Box 2-1 shows this classic health history format.
BOX 2-1 The Classic Health History
I. Patient-identifying information: name, birth date, sex, address, record number, and name of historian, along with relationship to the patient stated
III. History of present illness (HPI)
IV. Past medical history (PMH)
A. Psychological—colic, breath-holding, thumb sucking, head banging, fears, tics, behavior disorders, temper tantrums, nail biting, hair pulling, masturbation. Adjustment to home, school, neighborhood. Temperament—activity level, predictability, moods, intensity of reactions, adaptability, initial responses, distractibility. Sleep—amount, habits, problems.
The classic medical history is written to expand on the chief complaint, which is generally a physical problem. Issues such as nutrition, development, and activities of daily living are included, primarily as they relate to various diseases. This classification system works well and has generally been taught to physicians, nurse practitioners (NPs), and other providers. The system fails, however, to provide a framework for integrating the daily living (also called functional health patterns) and developmental issues of children into the problem lists and management plans. Without that framework, primary care providers, especially NPs who emphasize developmental and functional health areas of practice, may fail to clearly identify and document many of the unique contributions they make to child health care. Without that identification, the special aspects of their work with patients remain invisible.
An alternate model is offered in this chapter that integrates the nursing and medical aspects of primary care work conceptually and clinically (see discussion of Box 2-3 later). This assessment model (Burns, 1991, 1992a,b) is based on the assumption that patient problems can be grouped into three distinct domains: developmental problems, functional health problems, and diseases (Box 2-2). Although it was originally developed for NPs, the framework is useful to all pediatric health care providers.
BOX 2-2 Suggested Integrated Classification System of Diagnoses for Use by Primary Care Providers
Domain II: Functional Health Diagnoses
Health Perception and Health Management Pattern
Role Relationships Pattern
Coping and Stress Tolerance Pattern
Domain III: Pediatric Disease Diagnoses (Diagnoses included are examples, not an exhaustive list)
Data from Burns C: Development and content validity testing of a comprehensive classification of diagnoses for use by pediatric nurse practitioners, Nurs Diagn 2:93-104, 1991; and Burns C: Development and content validity testing of a comprehensive classification of diagnoses for use by pediatric nurse practitioners, unpublished doctoral dissertation, University of Oregon, Eugene, 1989.
Diseases
Diseases are conditions assessed and managed at the tissue or organ level of analysis. The diagnoses found in the disease domain generally come from the ICD-9-CM. Otitis media, streptococcal pharyngitis, and appendicitis are examples of disease diagnoses. Providers should use the diagnosis that guides understanding of etiology and management.
Family Assessment Foundations
The Family’s Role in Health Care of Children
Research has provided definitive evidence that children, from birth through adolescence need nurturing and attention from the significant adults in their lives. These adults most often are the child’s birth or adoptive parents, but they may also be grandparents, extended family members, or foster parents. Evidence is strong that when children are raised without this consistent, affectionate attention and without sensitive interactions with a caring adult, the results can be devastating for both child and society (Kazak et al, 2010). For example, family cohesion, beyond dyadic family relationships, is related to adolescent hostility; the functioning of the family as a whole affects adolescent behavior and emotional health (Richmond and Stocker, 2006). In contrast, when a parent or another significant adult responds consistently and sensitively to a child’s needs, such as a need to play, to eat, to sleep, to be comforted, or to be left alone, the child is likely to grow up competent to initiate and build strong, nurturing relationships. Although inadequate or poor parenting is linked in the literature to factors such as poverty, substance abuse, and minimal education, research suggests that a poor “fit” between a child and a significant adult can occur in any family, including those in which the adults are well educated, socially competent, and economically successful. Issues of family relationships and family disruption are discussed in Chapter 17 more fully.
Family Assessment Basic Elements
Family assessment begins with the assumption that families are central to and inseparable from the health of children. It is based on a family health promotion framework that assumes that the vast majority of family members are competent, want to do what is best for their children, and desire to be active participants in their children’s health care. Family assessment in primary care practice with children requires attention to family structure, family life cycle stage, family functioning, and social network. In other words, a basic family assessment addresses characteristics of the family, transitions that the family is experiencing, how family members interact and get things done, what they believe and value, and how they interact with the community.
Essential components of the assessment of the child’s family are discussed later.
Family Structure and Roles
There are many types of families, including two-parent, single-parent, grandparent, or other family member–headed, blended or stepfamilies, foster, gay, extended families, and others. Specific issues for various family types are addressed in the section on targeted assessments later in this chapter with the genogram and ecomap and in Chapter 17 as well.
Parenting Issues for Different Family Structures
Family-related factors, such as the composition and structure of the family, socioeconomic status, and health status, have the potential to influence the health and well-being of children and adolescents in significant ways. Although much about family assessment remains constant across families, it is useful to pay attention to some of the unique potential family variations. Chapter 17 provides a broader discussion of family issues for different variations that must be considered in the assessment process. Some of these family structures and family issues include:
• Working parents and child care
• Displaced and homeless families
• Gay and lesbian parent families
• Grandparents raising grandchildren
• Families raising children with special needs
Some assessment questions that should be considered for these family situations are found in Table 2-1 later in the chapter.
The Environment for Data Collection
Setting Up the Assessment Environment
Health care is a family event in pediatrics, and pediatric primary health care is delivered in many settings, not just examination rooms in outpatient clinics. Wherever the patient and the family are to be cared for, privacy must be ensured. People should have places to sit down, and the room in which the examination is conducted should be well lighted and allow the patient to lie down comfortably. The examiner must be able to work comfortably, too. The health care provider should sit down during the history to make data collection a conversation, to equalize the status of clients and examiner, and to help clients feel that they have time to talk. Sitting also helps the provider conserve energy for a busy day. The environment must be safe, given the developmental ages of the children to be cared for, and should present an atmosphere of warmth and welcome.
Communication with Children and Families
The three elements they identify as essential to excellent communication are as follows:
• Communication needs to provide information.
• Communication should be sensitive interpersonally, with affective behaviors indicating the provider’s attention to and interest in the parents’ and child’s feelings and concerns.
• Communication should help to build a partnership among the three parties, allowing discussion of concerns, perspectives, and suggestions from all.
The Database
The Child Health History
The database described in this chapter summarizes the child health history and physical examination and the family assessment. The model presented uses a basic problem-oriented format that begins with subjective data (the history), moves to objective data (the physical examination, laboratory, and test data), then lists the problems by domain (identified through the subjective and objective data), and finally, outlines plans of care, problem by problem. The items listed under each topic are suggestions; they are not required data to obtain from every patient. As children age, the emphasis will change (e.g., less time spent on birth and infancy histories). The history needs to be individualized, considering family, culture, health status, and environment. The complete format should be mastered so that it becomes core to the provider’s approach to all patient situations. If data are omitted, the omissions should be by choice, not by an error committed through haste, distraction, ignorance, or habit. Box 2-3 provides a format for recording the data in summary form.
I Preliminary Patient Identification Information
Corrected age for preterm infant younger than 2 years:
Informant, relationship to patient, reliability as historian:
