FAMILY ASSESSMENT

June 25, 2024
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Зміст

CHULD HEALTH NURSING

Theme: FAMILY ASSESSMENT. COMMUNITY AND HOME HEALTH NURSING. SCHOOL NURSING

OBJECTIVES:

1.           The Child in Context of the Family

2.           Community and Home Health Nursing

3.           School Nursing

The Child in Context of the Family

No other factor in a child’s life has a greater influence than the family, which is the first and generally, the most important socializing agent in one’s life. Successful socialization is the process by which children acquire the beliefs, values, and behaviors deemed significant by society and is, to a large degree, a function of parenting and other familial interactions. The family’s organization, structure, and function have significant impacts on children during growth and development. Nurses caring for children must consider the entire family, rather than just the child, as the client. This chapter reviews several family theories relevant to pediatric nursing, discusses the various family structures in today’s society, and concludes with a discussion of parenting.

DEFINITION OF THE FAMILY

The family, despite its changing and increasingly diverse nature, remains the basic social unit. Two ways that nurses identify families have been described by Gilliss (1993). The first views the family as context; the second sees the family as a client. When families are treated as the context within which individuals are assessed, the emphasis is on the individual (family as context).

Conversely when the nurse treats the family as a set of interacting parts and emphasizes assessment of the dynamics among these parts rather than the individual parts themselves (family members), the family as a whole, rather than the individual members, becomes the client (family as client). In either case, the nurse must grasp the interacting aspects of the family, to understand the context within which the individual lives and to which she or he reacts, or to work with the family as client (Hitchcock, 1999).

Definitions of the family differ depending on one’s discipline and theoretical orientation. The legal definition emphasizes relationships through blood ties, adoption, guardianship, or marriage. The biological definition focuses on perpetuating the species. Sociologists define the family as a group of people living together; psychologists define it as a group with strong emotional ties.

Traditional definitions usually include a legally married woman and man with their children. This narrow definition is reflected in the U.S. Bureau of the Census (2000) definition of family as a group of two or more persons related by birth, marriage, or adoption and residing together. The Census Bureau has used this same definition for years. However, this traditional definition fails to address the diversity of family structures present in U.S. society today. A broader definition of family is two or more persons who are joined by bonds of sharing and emotional closeness, and who identify themselves as members of the family  (Friedman, 1998). Another definition that reflects contemporary society is that a family is what the client says it is (Patterson, 1995). Nurses working with families should first ask their clients whom they consider to be in their family and then include those individuals in their health care planning.

THEORETICAL FOUNDATIONS OF FAMILY NURSING

Nursing has consistently had an interest in families and has acknowledged its importance in relation to health. A number of theories of families iursing and social sciences give insight into understanding its dynamics and processes.

Nursing Theories

Early nursing theories focused on the individual and considered the family only as part of the client’s context. However, some theorists have enlarged their perspectives to include the family as the client.

Neuman’s System Theory Neuman’s (1983) theory is consistent with a family systems approach. Originally, her theory did not discuss the family as  such, but it was later expanded to include the family as the recipient of nursing care (Neuman, 1972). The family is described as an appropriate target for both assessment and nursing interventions. The way each member expresses self influences the whole and creates the basic structure of the family. The major goal of the nurse is to help keep the structure stable within its environment.

King’s Open Systems Theory King viewed the family as a social system that influences the growth and development of individuals (King, 1981). The family is seen as both context (environment) and client. Her theory of goal attainment is useful for nurses when assisting families to set goals to maintain their health or cope with problems or illness. She believes that nurses are partners with families. The role of nursing is to help members become healthy enough to function in their roles.

Roy‘s Adaptation Theory In Roy‘s (1983) theory, the client is an individual, family, group, or community in constant interaction with a changing environment. The family system is continually changing and attempting to adapt. When the family is confronted with unusual stresses and coping patterns are ineffective, problems in family functioning occur. The goal of nursing is to promote adaptation and minimize ineffective responses.

Social Sciences Theories

A number of theories from the social sciences help to explain families; however, there is little consensus about which are the major ones. Therefore, for the purpose of this chapter, three will be examined: structural-functional, developmental, and general systems.

Structural-Functional Theory The structural-functional theory emphasizes the organization or structure of the family and how this structure facilitates its functioning. It characterizes the family as a social system and examines the relationship between the members as they carry out family functions (Friedman, 1998).  Basic assumptions of this theory are as follows:

• The family is viewed as part of the social system, with individuals being parts of the family system.

• The family, as a social system, performs functions that serve both the individual and society.

• Individuals act in accordance with a set of internalized norms and values that are learned primarily in the family through socialization.

Family structure refers to the ordered set of relationships among the parts, and between the family and other social systems. Family structure or organization is evaluated based on how well it fulfills its functions, and the goals important to its members and society. The structure serves to facilitate the achievement of the functions. To determine family structure, the nurse must identify the individuals that make up the family, their relationships to each other, and the relationships between the family and other social systems.

Five functions of the family have been identified that are important for nurses to understand (Friedman, 1998):

Affective

• Socialization and social placement

• Reproductive

• Economic

• Health care

The affective function is one of the most vital functions for the formation and continuation of the family unit. This function refers to the family meeting the needs for love and belonging of each member. The family is a home base where the individuals can express their true feelings and thoughts without fear of rejection. The family is the social milieu for the generation and maintenance of affection, where one is first loved and given to, and learns to love and give in return.

Although the affective function is important for all families, those that must focus on providing the basic physical necessities of life have minimal energy remaining to meet the affective needs. Socialization and social placement function refers to teaching children how to function and assume adult social roles. This function involves the acquisition of internal controls needed for self-discipline and values such as what is right and wrong according to society. Socialization occurs predominately in the family, and caregivers are the primary agent (Gelles, 1995). The continuity of both the family and society continues to be ensured through the reproductive function. In the past, marriage and the family were designed to control sexual behavior as well as reproduction. Individuals considered it their responsibility to marry, have many children, and rear those children within the bounds of marriage. The reproductive function is carried out very differently today. Many single people are having children, including adolescents, and many married couples are remaining childless. Reproduction  has also been influenced by technological advances such as artificial insemination, in vitro fertilization, and surrogate mothers.

The economic function involves the family’s provision of sufficient resources and their effective allocation. An assessment of the family’s economic resources provides the nurse with information about their ability to appropriately allocate these resources to meet needs such as food, shelter, clothing, and health care. By gaining an understanding of how a family distributes its resources, the nurse can also obtain a perspective about their value system. One responsibility of the nurse is to assist families in obtaining appropriate community resources to meet their needs.

The health care function includes provision of physical necessities to keep the family healthy, such as food, clothing, and shelter as well as health care (Friedman, 1998). The family keeps its members well by passing on attitudes, values, and behaviors that promote health and by caring for them in times of illness.

The structural-functional approach is very useful for assessing family life because it enables the nurse to examine the family system holistically, in parts, and interactionally with other institutions and the wider society. A limitation of this theoiy is that it tends to present a static view of the family and minimizes the importance of growth and change (Friedman, 1998).

Developmental Theory

The developmental or life-cycle theory is based on the premise that families evolve through predictable developmental stages, and experience growth and development in much the same way as individuals. Stages begin with marriage followed by childbirth and child rearing. Each stage is characterized by specific issues and tasks. Developmental theories explain the changes that occur in human organisms or groups over time. This approach is based on the following assumptions (Duvall, 1977):

• Critical role transitions of individual members, such as birth, retirement, and death of a spouse, are viewed as resulting in a distinct change in the family life patterns.

• Families develop and change over time in predictable ways.

• Families and their members perform certain timespecific tasks that are decided upon by themselves, within their cultural and societal context.

• Family behavior is the sum of the previous experiences of its members as incorporated in the present and in their expectations for the future.

The best known formulation of the developmental stages comes from Duvall (1977; Duvall & Miller, 1985), who identified eight chronological stages through which the family passes. Each stage includes predictable tasks that the family must master prior to proceeding to the next one. Table 3-1 delineates the stages of family development and tasks of each stage. An advantage of the developmental approach is that it provides nurses with information about what to expect of families at different points in their life cycle and, thus, what teaching and counseling services may be needed. This theory also provides criteria for assessing a family’s current stage and its ability to accomplish the tasks of this stage. The nurse is then able to support the family in order to progress smoothly from one stage to another.

There are several limitations of the developmental theory. It has a middle class bias and it assumes homogeneity  (two caregivers, nuclear family) and that young adults marry in their early twenties before they develop a career. Additionally, this theory views the family from a traditional perspective. It does not take into consideration the diversity of family forms found in today’s society, such as divorced, remarried, single-parent, and gay or lesbian families. The focus of the developmental approach is primarily child rearing; however, today this activity occupies less than half of a woman’s adult life span. Thus, child rearing is no longer the central focus of the life cycle.

Family Systems Theory

The family systems approach is based on the general systems theory developed by von Bertanlanffy (1968), which describes principles that govern all living systems. One of the central propositions of the general systems theory is that the system is not the total sum of its parts but is characterized by wholeness and unity. Family theorists have applied these principles to explain how families interact with their members and with society. The family is defined as a system characterized by continual interaction between its members and with the environment. The interrelationships in a family system are closely tied together so that a change in one member results in a change in the other members. Therefore, one cannot understand the family as a whole by only knowing each of its members. The interrelationships of the members with each other and with the larger society must be analyzed.

FAMILY ASSESSMENT

Family assessment is the process of collecting data about the family structure, and the relationships and interactions among individual members. It is a continuously evolving process of data collection. Data about the family are systematically collected using predetermined guidelines or questions, and then classified and analyzed according to their meaning. Nursing diagnoses can then be generated, with goals and interventions for care created in collaboration with the child and caregivers.

Assessment Instruments

Two of the most commonly used instruments for developing a family database are the genogram and the ecomap. Neither requires the purchase of a standardized assessment instrument; yet, both have the advantage of providing a means for interacting with children and their family members in a nonthreatening way to obtain data about potentially complex and difficult issues (Kodadek, 2000).

A genogram is a format for drawing a family tree that records information about family members and their relationships over a period of time, usually three generations. It is a method of mapping the structure of the family and to record the health history of all members (morbidity, mortality, and onset of illnesses), thus revealing information about genetic and familial diseases. The genogram displays the family visually and graphically in a way that provides a quick overview of family complexities. It is also an efficient and nonjudgmental way to convey information about a family to other health care providers. Figure 3-1 is an example of a genogram/family tree.

An ecomapis a visual representation of a family in relation to the community. It demonstrates the nature and quality of family relationships and what kinds of resources or energies are going in and out of the family. Figure 3-2 shows a family ecomap. This assessment instrument is useful in identifying the strengths of family networks and what resources they have available during stressful times or crises.

An in-depth family assessment requires a significant amount of time, and every family does not need a comprehensive assessment. However, when a nurse identifies a family at risk for dysfunction, such an assessment may be required. Referral to other health care professionals and community organizations is appropriate in these situations. Assessment information can be obtained through interviewing and questioning, observing interactions between members, and utilizing a family assessment instrument. Ideally, all family members are included in the interview, and it takes place in the child’s home. At a minimum, the child and primary caregivers are assessed.

Several family assessment instruments are available. Criteria for the selection of an instrument are listed in

Box 3-1

. Many assessment instruments have been developed by family theorists, mostly nonnurses, and are used by the health care team to obtain information about family systems. Nurses have created some instruments, two of which will be presented: the Calgary Family Assessment Model (Wright & Leahey, 1994) and the Friedman Family Assessment Model (Friedman, 1998).

FAMILY STRUCTURE

The structure of the family refers to how it is organized— i.e., the manner in which members relate to one another, and the form it takes, such as nuclear or blended. During the past 40 years, U.S. society has undergone vast economic and social changes that have transformed the structure of the family, and the roles and responsibilities of women and men. Some of these societal changes are the increase in rates of divorce and remarriage, an increase in the number of mothers employed outside the home, the incidence of more adults waiting until they are older to marry or choosing to remain single, lower birth rates, and a longer life expectancy.

Today, society is composed of a greater multiplicity of values, lifestyles, and family forms than ever before. The two-parent nuclear family consisting of a mother and father bonded by marriage with one or more childreo longer reflects contemporary lifestyles. Knowledge of a child’s family structure helps the nurse to determine the communication patterns and decision-making authority within the family unit (Grossman, 1996). Such information is vital when the nurse is deciding who will be involved in making decisions related to heath care.

Nuclear Family

The nuclear family is defined as a husband, wife, and their children—biological, adopted, or both (Friedman, 1998) (Figure 3-4). No other individuals, relatives or nonrelatives, live in the household. The nuclear family form became common after World War II, and, until recently, it was considered the most common family form. However, with the increase in divorce rates, nonmarital childbearing, and cohabitation outside of marriage, family forms other than the nuclear family have proliferated. Currently, in the United States in 2001, families in the traditional pattern of a working father, homemaker mother, and one or more children are in the minority. The nuclear family has been credited with providing stability for children. However, concern has been raised about the limited number of adult role models in this type of family structure. Additionally, in the nuclear family, the two adults have many expectations placed on them, such as working to meet the financial needs, rearing the children, meeting the emotional needs of all members, and maintaining a home. In situations where both parents are employed, managing all of these responsibilities often results in significant stress in the family.

 

Figure 3-4 Family structure is different for every family; thus the nurse needs to understand this structure to determine communication patterns and decision-making authority.

Extended Family

The extended family consists of those members of the nuclear family and other blood-related persons such as grandparents, aunts, uncles, and cousins (Figure 3-5). This family structure was prominent in the 1800s in the United States because the family was the main unit of economic production. Several generations of a family lived together, worked together, and shared resources and responsibilities. Children were reared by not only their parents but also by grandparents, aunts, and uncles and had a choice of adult role models after which to pattern their behavior and personalities. With the advent of the Industrial Revolution, families were forced to move and seek employment in urban areas, and the nuclear family became more common. Extended family situations are still seen. Situations include elderly parents moving in with adult children or an adult child and/or their spouse and children moving back into the home of their older parents for financial reasons.

 

Figure 3-5 Members of an extended family benefit from the sharing of responsibilities and resources.

Blended (or Step) Family

A blended or stepfamily occurs when a divorced, widowed, or never-married single parent forms a household with a new partner; both partners or only one may have children. The formation of a stepfamily can present many stresses for the parent, stepparent, and children. In the new stepfamily, there has beeo time to blend family styles and traditions, or to negotiate parenting. Additionally, there has not been time to establish or nurture the marriage. A remarried parent must deal with many strong emotions, and feeling a special loyalty to one’s own biological children may create conflicts with the new spouse. The remarried couple may be unable to form a new spousal relationship because to do so would appear to be a betrayal of the intimacy between parent and child. This issue frequently conflicts with the needs of the new spouse, who may feel like an outsider in an established household. Stepfamilies in which both adults have children from a previous marriage living with them have the greatest incidence of redivorce (Witrak, 1997). Divorces occur more frequently and rapidly in remarriages than in first marriages, with onefourth of remarriages being disrupted within 5 years (Hetherington & Stanley-Hagan, 1999).

Stepparents and biological parents often believe that the growth of the new family will be instantaneous. The time required to create the stepfamily is usually longer than the adults expect. The stepparent should make clear to the children that she or he does not consider herself or himself to be a replacement for a dead or absent parent. Instead, the stepparent is another adult who can meet some of the child’s needs for closeness and love. Parental relationships need time to build. With older children, they may never fully materialize (Visher & Visher, 1995).

The transition to a stepfamily is also stressful for the children. Having suffered the loss of one of their parents and typically the loss of familiar surroundings, children may encounter a new series of losses, and suffer loyalty conflicts and loss of control. The adults have chosen to make major changes in their lives; the children have had those changes imposed on them. Feelings of sibling rivalry are more intense in the stepfamily as the children feel jealousy, insecurity, and a fear that a new sibling is more loved.

Children’s responses to stepfamilies vary depending on their age. The stress of a remarriage often causes preschoolers to cling to parents and to regress behaviorally. With their magical thinking, preschoolers may believe that their angry thoughts or behaviors led to the family disruption. They may also believe that they can magically reunite the divorced parents. School-aged children are often angry about their powerlessness to stop the dissolution of the family. Children at this stage are rarely able to express their feelings verbally and are likely to act out their anger. They may have fights with siblings or classmates, develop psychosomatic symptoms, become accident prone, perform poorly in school, or even try to break up the new marriage. On the other hand, they may act “angelic,” thus hiding their inner turmoil. Adolescents are dealing with their own issues of identity and autonomy, making the new relationships even more difficult to accept. Additionally, they are dealing with their own sexuality at a time when the addition of a stepsibling or stepparent of the opposite sex can create sexual tensions. Divided loyalties may cause them to act out in a negative way toward the stepparent (Visher & Visher, 1995).

Single Parent Family

While there has been a variety of shifts in family structures, none has been more dramatic than the shift toward families headed by a single parent. Single parenting occurs by means of divorce, separation, death of a spouse, or choice. A single parent family can be created when a single person acquires a child through birth or adoption, however, most single parent households have been created by divorce, and 90% of them are comprised of single mothers and their children (Lamb, 1999). It is estimated that 50% of all children born in the 1990s will spend some time in a single parent household (Tanner, 1995).

 

Figure 3-6 Major concerns of single parents are limitations of available resources such as money, time, and physical and emotional energy.

Major concerns of single parents are limitations of available resources such as money, time, and physical and emotional energy. Increasingly, two incomes are needed to raise children at a decent standard of living. Single mothers are three times as likely to be poor compared with other adults, and almost half of all poor children live in single parent families. Poverty for a three-person family is defined as an annual income of $13,003 (Children’s Defense Fund, 2000). Single parents who are employed often feel overwhelmed in an attempt to provide adequate time for the family, the job, and the endless details of daily life. The single parent must also provide the majority of emotional support and sustenance for the children. Managing all of these responsibilities leaves little time for the parent’s social or personal needs (Figure 3-6).

Single parent status is often born out of crisis such as separation or divorce. Such events have different meanings for the child than for the parent. For example, the parent may feel independence and relief due to the separation and divorce; however, the child may experience a sense of uncertainty, instability, and loss. There may be changes in the family home, the child’s school, friends, and community. The subsequent transitional period is likely to be disorganized and tumultuous until a realignment of roles, schedules, and expectations can permit a new and stabilized family life (Tanner, 1995). Chapter 20 offers more discussion on the feelings a child may experience due to separation and divorce.

Gay and Lesbian Families

Gay and lesbian families are increasing iumbers. Because homosexuality is stigmatized in our society, many of these parents are not open about their sexual orientation. Thus, good estimates of their numbers are not available. However, the estimates that exist suggest there are 1-3 million gay fathers and 1-5 million lesbian mothers. Estimates of the numbers of children of gay and lesbian parents range from 8 to 10 million (Gershon, Tschann, & Jemerin, 1999). Such families can be defined by the presence of two or more persons of the same sex, or by the presence of at least one gay or lesbian adult rearing a child (Allen & Demo, 1995). The structure of these families is quite variable. Many lesbians, single or in a relationship, are giving birth through artificial insemination. Gays are increasingly becoming parents through adoption or the use of a surrogate mother. Many legal barriers exist for lesbian and gay families.

Some of these include:

1. Same-sex relationships are often denied the legal benefits of marriage.

2. Gay and lesbian parents who were married are often denied custody and/or visitation with their children following divorce because of their sexual orientation.

3 . In many states, regulations governing adoption and foster care make it difficult for lesbians and gays to adopt children or become foster parents.

4. Medical procedures often require approval of the biological parent, meaning that a durable power of attorney might be necessary for the nonbiological parent to legally authorize health services.

Contrary to common opinion, no significant differences have been found in gender identity and sex role behaviors among children of gay and lesbian parents compared to children of heterosexual parents. Such children are no more likely to be lesbian or gay than are children with heterosexual parents (Patterson & Chan, 1999). Another common misconception is that children raised by gay men and lesbians have psychological problems. However, such children do not differ from children with heterosexual parents in terms of psychological health (Gershon, Tschann, & Jemerin, 1999).

 PARENTING

Parenting is a dynamic process that evolves over time as parents acquire experience and mature as individuals. The social goal of parenting is to guide and nurture children so that they become productive members of society. The personal goal of parenting is far more individualized, but, in general, it reflects a desire to raise a child, see aspects of oneself continue to exist such as perpetuating the family line, upholding family traditions, or in some cases, the fulfilling of personal dreams through the child’s accomplishments. Individuals approach the topic oi parenting from a unique, experiential base: each has been parented. In the parenting role, women and men create models incorporating those elements that they believe comprise “good” parenting. Whether this personal model is congruent with or antithetical to the parenting they received while growing up, it is nevertheless founded upon personal experiences, acquired knowledge, and beliefs about parents and children.

Social changes have influenced the timing of childbearing, so that large numbers of young people are delaying the start of families to meet other social expectations. The need to complete one’s education, initiate a career track, establish financial security, and build a committed relationship are fast becoming benchmarks to be achieved before one takes on the responsibility of raising a child. Parental roles are shaped by socially ascribed expectations for enacting the role; by family traditions, values, and cultural beliefs, which shape one’s personal perceptions; and by legal and ethical role sanctions and expectations. Principle among these expectations is the responsibility for preparing the child to become a productive member of society. Children learn from their parents how to behave in a manner consistent with their role in the family and appropriate to their culture (Gross, 1996).

While family traditions dictate much of the child-rearing strategies used by parents, they do engage in a process of adapting their actions to fit their personal model of parenting. Such a reflective adaptation of child-rearing strategies may be stimulated when the traditional strategies are not effective, when the parent is confronted with new situations, or when the traditional strategy is incongruent with the parent’s “good parent” model.

Parenting by Developmental Stage

Parenting is an evolving process that changes as parents and children grow and mature. Parents must actively adapt their parenting strategies to meet the needs of the growing child. The work of parenting is sustained by the attachment that develops between parents and their children—the strongest of all human relationships. Parents and children develop deep, personal attachments that enable them to care for and about each other, even when families experience great stress or the family system structure changes through divorce, death, or the addition of new family members. Such caring is essential for human survival. Indeed, small children cannot grow and thrive without care activities, including technical tasks like diapering and feeding, as well as those emotive, cognitive responses that support the growth of a centered well-integrated person.

In order to parent, individuals fulfill certain tasks. These parenting tasks are designed to both support the child’s development as well as maintain family functioning. As dren and their parents grow and develop as individuals, these parenting tasks change to reflect family development. See Table 3-2 for a listing of developmental-related parenting tasks. The growth and development chapters (7-12) in this text contain more detailed information on parenting by developmental stage.

Parenting Styles

Each child is unique in her or his own temperament and basic personality. Birth order, gender, and personality traits are a few of the characteristics a child brings to a family. The way caregivers respond to these attributes and interact with the child are related to the individual’s style of parenting. Four styles have been identified: (1) authoritarian or autocratic, (2) authoritative or democratic, (3) indulgent or permissive, and (4) indifferent or uninvolved (Macoby & Martin, 1983).

Authoritarian caregivers value obedience over independence and favor punitive measures, harsh disapproval, and withdraw of love when children question authority or disobey. They are likely to be less emotionally expressive and to use power to assert their will on their children. Deference and respect for authority are expected. They establish strict and rigid rules, which they don’t discuss with their child. Children whose caregivers are authoritarian tend to be dependent, passive, and less intellectually curious. They usually lack social competence and spontaneity, and have low self-esteem.

Authoritative, or democratic caregivers are warm buf firm. They provide opportunities for their children to develop a sense of autonomy and allow active involvement in decisions that affect them. They are consistent and clear about the expectations they have for their children and are firm when they are disobedient. They guide children’s behavior by sharing reasons for their decisions, rules, and standards. Independence is valued, and they are receptive to the child’s needs and desires. Children reared in this type of environment have self-control and high self-esteem, and are socially competent and self-reliant.

  

 Indulgent or permissive caregivers are interested and involved in their children’s lives but place few demands “on them and rarely attempt to control their behavior. With the indulgent style, there is an absence of restraints and maximum freedom for the child. Caregivers provide little input or direction, and seldom punish their children because they are encouraged to develop their own standards of behavior (most ol their behavior is considered acceptable by the caregivers). Although children are allowed freedom to set their own limits, most do not feel comfortable with this lack of direction. Additionally, the caregivers’ permissiveness doesn’t usually foster the development of internal control in these children, who tend to be disrespectful, defiant of authority, and irresponsible.

Indifferent or uninvolved caregivers attempt to minimize the amount of time and energy they must invest in their children’s lives. They tend to be very self-centered and structure their home life primarily around their oweeds and interests. They are rejecting of and unresponsive to their child’s needs. The child receives little guidance, and discipline is inconsistent. Children from indifferent homes are often more impulsive, demonstrate disregard for other’s rights, and are more likely to be involved in delinquent behavior (Macoby & Martin, 1983).

See also http://www.york.ca/Services/Public+Health+and+Safety/Child+and+Family+Health/Parenting+Your+Child.htm

Parental Role in Socialization of Children

Socialization is a process of learning the rules and expected behaviors of a society. Expectations for a child’s behavior depend not only on the society and culture, but also on the child’s developmental stage, and physical and cognitive capabilities, and on the values and beliefs of the family and home. One goal of parenting is to socialize children, which includes teaching which behaviors are expected and appropriate, and fostering the development of self-control. Initially, during infancy and early childhood, caregivers provide external controls. Gradually and eventually, children guided by caregivers take responsibility for that control and integrate the adults’ values, attitudes, and expectations into their behavior.

Thus, caregivers nurture their children so that they will achieve self-control, competence, and self-direction in order to be a productive individual in society. It could be said that this is also the goal of discipline, which comes from the root word disciplinare—to teach or instruct (American Academy of Pediatrics [AAP] Committee on Psychosocial Aspects of Child and Family Health, 1998). Discipline should be approached in the broadest sense of helping the child learn rules, regulations, and goals of living in a world with others— and not just as setting limits and punishing (Murphy, 2000). The AAP (1998) suggests that effective discipline should include three components: (1) a positive, supportive, nurturing caregiver—child relationship, (2) positive reinforcement techniques to increase desirable behaviors, and (3) removal of reinforcement or use of punishment to reduce or eliminate undesirable behaviors.

Increasing Desirable Behavior

Many desirable behaviors occur as part of a child’s normal development; however, others need to be taught such as empathy, sharing, telling the truth (not lying), and good study habits. Family members can teach these behaviors by role modeling since childreaturally learn through imitation. Other strategies that help children learn positive behaviors are listed in

Box 3-2

. By implementing these strategies, the desired behavior is more likely to become internalized by the child, and the new behaviors will become a foundation for other desirable ones.

Reducing or Eliminating Undesirable Behaviors

When undesirable behaviors occur, discipline strategies are necessary to reduce or eliminate such behaviors. Undesirable behaviors are those that put the child or others in danger, do not comply with expectations of caregivers or other appropriate adults (e.g., teachers), and interfere with social interactions and self-discipline (AAP, 1998). However, effective discipline cannot occur if caregivers do not develop their abilities to be positive and rewarding. An important quality of discipline is that the consequences are effective, constructive, and not unduly harsh (

Box 3-3

) (Wolraich, 1997).

Several disciplinary strategies are used by caregivers to deal with undesirable or unacceptable behaviors, including disapproval, verbal reprimands, time-out, and corporal punishment.

Disapproval can be verbal or nonverbal, and can be very effective. Tone of voice, facial expressions, and gestures often convey the caregivers disapproval of a specific behavior. Even young children can learn when a their caregiver is irritated by observing and responding to voice inflections, facial expressions, and gestures.

Many caregivers use disapproving verbal statements to alter undesired behavior. Such reprimands may be effective in immediately stopping or reducing the behavior when used infrequently and targeted toward specific behaviors. However, if caregivers use verbal reprimands frequently and indiscriminately, they may reinforce the undesired behavior because the child gets attention. It is important that reprimands should refer to the child’s behavior rather than him or her as a person. They should not slander the child’s character.

Time-out is an effective discipline strategy that involves removing positive reinforcement for unacceptable behavior. It is a defined period of time in which the child is removed from activities and social interactions. The goal of time out is to interrupt a pattern of negative behavior. The child should be placed in an area that is unstimulating and safe for a given amount of time (usually 1 minute per year of age). A timer can be used so the child knows when time is up. Verbal or physical interaction with the child tends to negate the effects of time-out because the child is given attention for unacceptable behavior.

IMPLICATIONS FOR NURSING

Parenting is a highly valued activity both on a personal as well as a societal level. Good parenting is necessary for the healthy functioning of children and to produce successful members of society. Parenting is learned through imitation, acquired knowledge, and practice. Nurses can play a vital role in supporting parenting as they work with families. This work must be done in collaboration with parents if positive results are to be achieved. Too often health care providers talk to parents rather than with them. Merely giving advice based on the providers’ background and knowledge may fail to address the parents’ personal and cultural beliefs. If the advice given is not congruent with the parents’ valued beliefs, then it will be ignored.

Assessment of parenting includes:

• The parent’s views on parenting

• Clarifying cultural and social expectations for parenting

• Identifying issues or children’s behaviors that are of concern to parents

• Evaluating the interactions between children and their parents during health care encounters

Potential sources of problems can be identified from the assessment data. The identified problems should:

• Be confirmed or clarified with parents

• Be mutually agreed upon as the priority issues parents wish to address

When a problem is identified, then the parents and nurse can collaborate on creating a plan of care. Collaboration with parents can improve the success of the plan as parents will be involved with identifying:

• Resources for implementing the plan

• Strategies that are congruent with parental beliefs

• Outcomes for determining effectiveness of the plan

The nurse will need to follow up with the parents at subsequent encounters to determine:

• How effective the plan of care was in achieving the stated outcomes

• Any adaptations the family made in the plan of care

• The parent’s satisfaction with this format for reducing or resolving the identified problem

It is crucial that nurses work with parents rather than against them if parenting is to be supported. Nurses should continually ask themselves whether they are imposing their personal beliefs about parenting when they evaluate others’ parent-child relationships. Parenting issues or problems will not be resolved in a single encounter. The work of parenting is ongoing and dynamic. It will take weeks or months for a problem to be resolved. By establishing an open exchange of ideas, and respecting parents’ personal and cultural values, nurses can support the work of parenting.

 

KeyConcepts

  • The definition of family varies widely. The most inclusive definition of family is when two or more  persons are joined by bonds of sharing and emotional closeness and who identify themselves as members of the family (Friedman, 1998).

  • The three family theories from the social sciences that have major relevance to nursing are the structuralfunctional, the developmental, and the systems theories.

  • The process of family assessment includes data collected in a systematic fashion using a family assessment tool in which information is then classified and analyzed as to its meaning.

  • The traditional nuclear family structure no longer reflects contemporary U.S. lifestyles. Other forms such as the single parent, blended, and gay and lesbian families have emerged in recent years.

  • Nurses have a responsibility to understand the influence of the cultural framework on a family’s child-rearing practices and attitudes about health and illness.

  • As children grow and develop, parenting tasks change to both support their development and maintain family functioning.

  • Parenting styles have an effect on the child’s personality outcomes.

  • A variety of special parenting situations can further increase the complexity of child rearing: adolescent parents, adoption, grandparents as surrogate parents, and foster care.

  • Nurses can play a vital role in supporting parents as they work with families. This work must be done in collaboration with parents if positive results are to be achieved.

Community and Home Health Nursing

Community health nursing is a broad category of nursing that can be defined by the area and focus of practice and by the population it serves. Home health nursing is one of the specialty areas under the umbrella of community health nursing and is defined as a variety of services provided to people, in this instance children, in their place of residence (Smith & Maurer, 2000). According to a report by the U.S. Department of Health and Human Sendees (DHHS, 1997), in 1996 there were 362,600 community health nurses practicing in a variety of settings. These 362,600 nurses constituted 17% of all employed registered nurses. Approximately one in four community health nurses were employed by local and state health departments or community health centers. The largest percentage of community health nurses worked in home health. School health, occupational health, hospice, and other settings make up the remaining areas where community health nurses are employed. School health nursing is discussed further. This chapter will focus on a broad discussion of community health nursing and home health nursing for children and their families.

COMMUNITY HEALTH NURSING

Community health nursing is defined as “the care provided by educated nurses in a particular place and time directed toward promoting, restoring, and preserving the health of the total population or community” (Smith & Maurer, 2000, p. 7). The community health nurse has a focus on health promotion and disease prevention. While that focus may be on the individual or family, the well-being of the community as a whole is the final objective. The community health nurse can focus on health promotion at an individual (child) or family level while promoting the well-being of the community by conducting well-child assessments, giving immunizations, conducting screening tests, teaching, and making referrals for the child and family to other health care associates and resources. The community nurse also has an instrumental role in immunization programs. “Community health nursing, with its population-based focus and emphasis on health promotion and disease prevention, has a unique opportunity to play a central leadership role in meeting the national health objective of increasing the number of children under age 2 who receive basic immunizations to 90%” (Moore, Fenlon, & Hepworth, 1996, p. 22).

Community health nurses who care for children and their families practice in a variety of settings that teach health promotion and disease prevention, including the child’s home, well-child clinics, migrant health clinics, neighborhood health centers, and centers that implement federally mandated or specific state-funded programs (Stanhope & Lancaster, 1996). The nurse may have a primary or team role during the delivery of services. Table 4-1 lists the various roles of community health nurses.

Governmental Influence

The government has influenced community health nursing for children and their families through federal programs such as Medicaid, public laws, and the Healthy People documents. The role of the community health nurse includes implementation of government-supported programs and referral of families who are eligible for these services.

Children with disabilities and those with chronic conditions can receive assistance with health care services through the Title V Children with Special Health Care Needs (CSHCN) programs. Community health nurses can be instrumental in referring children and families for services under this program. Promotion of adequate nutrition for poor families is important for growth and development and functioning in school (Smith & Maurer, 2000). Community and school nurses can assist families in obtaining services through the sup plemental food program for Women, Infants, and Children (WIC) and the federally funded school breakfast and lunch programs. In the mid-1980s, federal amendments to Medicaid expanded services to low-income pregnant women. As part of case management for these women, many states now reimburse for home visits by nurses employed by local health departments or health centers. Nurses who make home visits focus on teaching caregivers to implement measures to promote growth, development, and safety; ensuring that the child is being provided with proper nutrition; and assessing the child’s and family’s health care for its adequacy and accessibility (Smith & Maurer, 2000).

The Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program entitles qualified children to having their medical histories taken, physical examinations, immunizations, screening tests, nutrition assessment, and education at specified age levels from birth to 18 years. Nurses in well-child clinics and on home health visits can perform screenings. These include vision and hearing screening, lead detection, developmental assessments, and routine physical examinations (Bryan & Wirth, 1995).

Healthy People 2O1O Objectives

Changes and additions to the Healthy People 2000 national health objectives, which were reflected in Healthy People 2010 (DHHS, 2000), will specifically affect community health care of children and their families. These include (a) adding some new focus areas such as Medical Products Safety and Access to Quality Health Services and Programs, (b) combining violence and abusive behavior with unintentional injuries to become Injury/Violence Prevention, and (c) adding children to the maternal and infant priority area, becoming Maternal, Infant, and Child focus area. Some of the primary goals of community health nursing are also goals of Healthy People 2010. These are health promotion, health protection, and disease prevention.

Health Promotion

Health promotion is defined as “activities or interventions that identify risk factors related to disease; the lifestyle changes related to disease prevention; the process of enabling individuals and communities to increase control over and improve their health; these activities or strategies are directed toward developing the resources of clients to maintain or enhance their physical, social, emotional, and spiritual well-being” (Hitchcock, Schubert, & Thomas, 1999, p. 891). Health promotion is a major goal of community health nursing practice. Community health nurses facilitate health in the population through direct nursing interventions for health promotion and disease prevention with individuals, families, groups, and populations. The community health nurse develops, implements, and evaluates health promotion programs in schools, work sites, hospitals, faith communities, prisons, and community settings (Smith & Maurer, 2000). These health promotion strategies are implemented by nurses through counseling, education, and anticipatory guidance.

Health Protection

Health protection is defined as “activities designed to maintain the current level of health, actively prevent disease, detect disease early, thwart disease processes or maintain functioning within constraints of disease” (Hitchcock et al., 1999, p. 891). Screening programs for infants, children, and adolescents include blood lead levels, phenylketonuria (PKU), growth and development, hearing and vision, dental health, scoliosis, and testicular and breast self-examination.

Screening programs are conducted by nurses through health departments, clinics, schools, health fairs, community centers, and well-child clinics. Firearm and playground safety and car-seat loan programs are other examples of health protection programs. Community health nurses can assess these areas and provide guidance and educational resources for families who have needs in these areas. In 1997, firearm-related deaths accounted for 23% of all injury-related deaths in children and adolescents aged 1-19 (National Center for Injury Prevention and Control, CDC, 2000). Firearm-related injuries to children occur when children are left at home alone and firearms are kept in readily accessible places (McClelland, Thompson, Piete, & Hatcher, 1996). Community nurses need to routinely inquire about the presence of firearms.

Disease Prevention Services

“Disease prevention refers to those activities designed to protect jjersons from disease and its consequences” (Hitchcock et al., 1999, p. 13). Programs included in the area of preventive services for children and their families include immunization programs, environmental screening programs, hearing and vision screening programs, and screening programs for children at risk for developmental delay. Community health nurses have a major role in administration of immunizations to children at well-child clinics, at immunization clinics, and during special immunization days at schools. They also assist in measuring serum lead levels, performing vision and hearing screenings, and administering assessments to screen for developmental delays. Once an area of risk is identified, the community health nurse follows through by making referrals as needed, following up with home visits, or arranging return visits to the clinic. These interventions may be initiated through community health centers, school-based clinics, home health programs, public health departments, or health maintenance organizations. Some federally and state-funded programs can provide these services.

Standards

Standards have been developed by the American Nurses Association (ANA) (1986a) that guide the practice of community health nurses (

Box 4-1

). These standards reflect the steps of the nursing process and indicate that community health nurses are to apply this process to individuals, families, and groups to promote health and wellness throughout life. These standards provide guidelines for competent levels of practice and behavior for the community health nurse. They also help to define the scope and quality of community health nursing care (Smith & Maurer, 2000)’

 

HOME HEALTH NURSING

Stanhope and Lancaster (1996) define home health care as “an arrangement of health-related services provided to people in their place of residence” (p. 1094). The health-related services provided for children and their families range from providing direct hourly nursing care to children who are dependent on technology, to intermittent visits from nurses, home health aids, physical therapists, occupational therapists, speech therapists, or social workers. Home care for children is growing in the area of referrals for home antibiotic therapy, pediatric hospice programs, nursing care for children who are dependent on technology, home phototherapy, private-duty nursing, and home visits to new mothers who are discharged with their babies after brief, routine hospital stays because of uncomplicated deliveries.

Home care services can be provided for either shortterm or long-term needs. Referrals for home antibiotic therapy, home phototherapy, and home visits to new mothers are examples of children and families needing short-term home care services. The focus for short-term care is on primary and secondary prevention of disease. Primary prevention involves interventions for children that promote health and prevent disease processes from developing. Teaching new mothers how to perform infant care is one example of a home care service that is primary prevention. Secondary prevention aims to detect disease in the early stages before clinical signs and symptoms manifest in order to intervene with early diagnosis and treatment. The goal is to reverse or reduce the severity of the disease or provide a cure. Home phototherapy or short-term nursing visits to teach diabetes care would be examples of home care services that would provide secondary prevention (Stanhope & Lancaster, 1996). Tertiary prevention is directed toward children with clinically apparent disease. The aim is to ameliorate the course of disease, reduce disability, or rehabilitate. Examples of tertiary prevention include services provided by home care agencies that are long term, such as provision of care for a child who is dependent on technology, or hospice care (Smith & Maurer, 2000).

Many different factors have an impact on home care for children and their families. The three factors this section will focus on include (1) types of agencies and the impact of managed care on these agencies, (2) family needs (family and nurse interactions, respite care), and (3) the scope of nursing care (skills, case management, and the home visit).

Home Care Agencies and Managed Care

Home care agencies that provide care for children and their families fall into five categories: official, voluntary, combined, private, and hospital-based agencies. An explanation of these types of agencies is found in Table 4-2.

Managed care refers to cost-effective delivery of health care services. Home health care services are supported by managed care organizations in situations where they will result in shortened hospital stays. Caring for children at home with the assistance of home care services continues to be cost effective as compared with prolonged hospital stays. Early-discharge programs are encouraged by managed care organizations because of their cost effectiveness. Children with acute and chronic illnesses are being affected by early-discharge protocols. Managed care, by supporting these early discharges, has created a need for comprehensive home care programs for children. Children are going home sicker, and families are required to assume more responsibility for their care. These children and families have special needs and require comprehensive nursing care and teaching.

Respite Care

Respite care is short-term, temporary care that is normally provided in the home for a child who requires specialized care; it provides relief for the caregivers, which may help to prevent burnout and increase the caregivers ability to cope with stress. The home care nurse may provide this relief or may be instrumental in referring the family to sources for this care (Mausner, 1995). Unfortunately, respite care has often been viewed as a luxury rather than a necessity, and it has been arranged only after the family exhibits significant stress (Mausner, 1995). Families taking care of children at home who have medical complications have complex and conflicting feelings about using respite care services if they are unfamiliar with the caretakers who will provide the respite care. Families want to be familiar with the person to whom they are entrusting the care of their child. When caretakers begin to think in terms of their need for a break, it is natural for them to turn to the home health care nurse to assist them in making arrangements.

Some agencies have successfully developed formal programs of respite care that are available to families taking care of children with a chronic illness at home. The agency ensures that if the child is to remain at home under the care of a nurse, and the caregiver is absent overnight, a designated substitute caretaker with power of attorney is appointed (Hogue, 1993). When respite time is well planned, it can be therapeutic for the family and the child. Refer to Chapter 17 for additional information about respite care.

The Home Visit

Reifsnider (1996) describes how therapeutic relationships are developed between the nurse and caregivers when home visits are planned and implemented in phases. The phases of the home visit are:

Preinteraction—meeting the child and family and performing the assessments

• Engagement/active participation—outlining plans and initiating interventions

• Termination—evaluating the interventions and determining future rehabilitative needs

These phases can be generalized to most children who require home care nursing for either a short or long time.

Preinteraction Phase The preinteraction phase includes activities performed prior to the first home visit. Before making the home visit the nurse will benefit from collaborating with the physician either through direct contact or through the physician’s report sent to the agency. Physician’s orders and the medical plan of care should be reviewed. Contact should be made with other interdisciplinary team members involved in the child’s care. The home health care nurse should review available family data, including referral information and previous records, and establish a plan for the visit. The family should be contacted by telephone and services briefly discussed. The nurse should prepare for a safe visit (e.g., identify exact location of home, consider safety issues in relation to the neighborhood being visited, and request escort or shared visit services if needed) (Clemen-Stone et al., 1998). The neighborhood should also be assessed for environmental factors that may affect personal safety, including location of the home in relation to high crime areas and known drug and gang areas.

Engagement/Active Participation Phase

During this phase the home health care nurse begins to build the nurse-client relationship. The nurse carries out an initial client, family, and environmental assessment. Thorough assessments should be conducted. Collaboration with the child and caregivers and clarification of roles are done in the active participation phase (Reifsnider, 1996). Assessment of the adequacy and safety of the general living environment should be conducted. Some important areas to assess are (Ahmann, 1996; Stanhope & Knollmueller, 1992):

• Adequacy of physical space, cooking facilities, and heating

• Accessibility of the home environment for the child who may be wheelchair-bound.

• Presence and functioning of smoke detectors.

• Adequacy of electrical sources and back-up electrical source if the child has a respiratory ventilator that requires electricity.

• Condition of electrical cords and outlets. (Does the equipment require a three-pronged outlet but the outlets are two-pronged?)

• Functioning of telephones.

• Presence of rodents, roaches, loose plaster, and paint chips.

• Education about age-specific safety measures followed in a child’s home (i.e., gates on stairs for an active 15-month-old).

Documentation of assessment findings is necessary through all phases of the visit. Home care equipment should be assessed during the initial visit and reassessed periodically for adequacy of routine and emergency maintenance and replacement, and the presence of explicit instructions about the care and operation of the equipment. In the home, the family may initially view the nurse as a stranger or intruder since the nurse is basically a guest in their home. An awareness of and respect for the cultural and ethnic diversity of families is essential to gaining their trust. The family may have specific beliefs and practices about health and healing that the nurse should help them integrate into the treatment plan. The nurse should inquire about social customs usually practiced, such as removing shoes before entering the house or avoiding eye contact when talking, which may be considered impolite behavior. If these customs are breached, it may prevent the nurse from being able to interact effectively with the child and family.

Box 4-4

provides guidelines for providing culturally sensitive nursing care for children in the home.

Providing culturally sensitive nursing care in the home

• Remember that the setting for care is controlled by the family and not by the health care provider.

• Engage in social conversation to facilitate rapport since the nurse is often viewed as a guest by the child and family.

• Be nonjudgmental about the condition of the home (e.g., presence of clutter or disarray).

• Show respect and consideration for the child and family. For example, wipe your feet, or take off your shoes if it is a family custom, before entering the home; ask permission before moving items in the child’s room, and replace them after you have finished a task.

• Take advantage of the home environment to assess cultural values and norms. Cultural clues may include:

• Orderliness and decor of the home

• Assignment of family roles and tasks

• Types of family interactions

• Presence of religious objects in the home

• Value placed on privacy and possessions

Children who have complex medical conditions, are dependent on technology, and are being cared for in the home may be at risk for developmental delays and problems. A developmental assessment should be performed by the home health care nurse initially and periodically. When the child is assessed at regular intervals, objective data can be obtained so small developmental changes can be noticed. When problems are detected, the nurse can either provide treatment or, more likely, refer the child for early intervention services. The nurse needs to provide feedback to families about their child’s developmental level, strengths, and deficits. Caregivers need this information in order to meet the developmental needs of the child.

The home health care nurse should assess the appropriateness of third-party reimbursement systems and discuss with the caregivers the estimated length of service, including limits set by third-party payers. The home care nurse should become familiar with financial resources and therapeutic programs.

Termination Phase

The home health care nurse evaluates the child’s status and the caretakers’ ability to assume responsibility for the child’s total care. Part of the termination process involves collaboration and coordination with other disciplines involved in the care of the child. Plans for terminating home care should begin during the engagement and active participation phase so that the continuity of care that was started can be maintained. During the termination phase, it may be necessary to continue with some rehabilitative services, such as speech, physical, or occupational therapies. Allowing for the family to evaluate the home care services is important at this time. The home care agency should have standard forms that are sent to families that allow them to routinely evaluate the home care service received.

 

School Nursing

What does the nurse do all day in the school? In a place where children are supposed to sit in class and learn all day, why would a nurse be needed? This chapter will provide a brief review of the history of school nursing; types of health services, including the various screenings performed by the nurse; health education programs taught; and psychological services offered in which the nurse may be involved. The need for health services to be more accessible to children has led to the development of school-based and school-linked health centers. Both models will be discussed and their similarities and differences explored. Finally, the current roles of the school nurse will be described, as well as future issues facing her or him.

SCHOOL HEALTH SERVICES

The school nurse is involved in many school health services, including direct or indirect nursing care. Direct services include providing nursing procedures or care to individual students; indirect services include consulting with staff on behalf of a child’s health needs and providing community referrals and health education. Health services also include screening programs, communicable disease control, emergency care, and medication administration. Education and health promotion activities include presenting subjects such as personal care, sex education, substance abuse, and violence prevention programs. The school nurse may also collaborate with social workers and school psychologists to provide services to families after unusual events in a child’s life.

Screenings

One task of the school nurse is organizing and performing a variety of screening programs for school children. These screening programs assist in the early identification of possible problems related to children’s health. When abnormalities are noted, the nurse plays a vital role in referring the child for further evaluation and/or correction. Traditional screening programs offered in the school include vision and hearing testing, height and weight measurement, scoliosis and pediculosis screening, immunizations, and, in some districts, dental and tuberculosis screening (Adams, 1992; Kane, 1994).

Vision and Hearing Screening

Vision screening, one of the most common procedures performed in the school (Fryer, Igoe, & Miyoshi, 1997), is recommended by the American Academy of Ophthalmology and the American Academy of Pediatrics as part of routine school programs (Fryer et al., 1997). The purpose of vision screening is to identify children with potential problems in visual acuity and muscle balance so treatment can begin as soon as possible. Early vision screening can assist in detecting conditions such as strabismus, or lazy eye.

Screening also often includes inspecting the eye and evaluating visual acuity, muscle balance (phoria), excessive farsightedness (hyperopia), and color vision. Ideally, all students should be screened annually. A school-aged child who does not have visual acuity of at least 20/30 should normally be referred for further evaluation; however, the school nurse must verify the states referral criteria before referring children since all states do not follow the same criteria.

Numerous instruments are available for assessing vision in children, and the school nurse needs to be familiar with these products. The traditional Snellen chart, which uses letters in various sizes, is also available in tumbling letters and pictures to match the age and ability level of the child being screened. Stereoscopic instruments, which use mirrors, lenses, and occluders to screen for vision problems and require special training, are also used in mass screening programs.

Hearing screening is another responsibility of the school nurse (Figure 5-1). Hearing difficulties can have an impact on the child’s ability to learn. If the child cannot hear adequately, directions and important information may be missed, speech development impaired, and reading affected. The nurse can help prevent or limit this problem by annually testing the child’s hearing at 500, 1,000, 2,000, and 4,000 hertz in both ears at a fixed decibel (dB) level. Children with hearing loss between 70 and 90 dB are considered hard of hearing, and those with hearing loss greater than 90 dB are defined as having a severe or profound hearing loss (Copmann, 1996).

Identification is only the beginning of vision and hearing screening programs; the screening itself is of limited value without referral and follow-up care (Yawn, Kurkland, Butterfield, & Johnson, 1998). Statistics show that 1 in 5 children will need corrective lenses by the time they graduate from high school (Yawn et al.,1998), and the prevalence of deafness and hearing loss is estimated at 15.3 per 1,000 children (Ludder-Jackson & Vessey, 1996). Studies on follow- up care after a failed vision screening revealed that the time from identifying a vision problem until treatment averaged about 18 months (Mark & Mark, 1999; Yawn et al., 1998). In the school setting, that equals about a grade level and a half without proper treatment. The nurse can play a vital role in speeding up this process by consistently following up on students who failed screenings and knowing about existing local resources to share with caregivers. The school nurse also needs to be aware of organizations that can assist families in obtaining vision and hearing services for their children. If a permanent vision or hearing loss is detected, the nurse can assist in obtaining specialized services or needed adaptations.

Height and Weight Measurement

Height and weight measurements are usually taken at the physician’s office as part of a physical exam. However, some states require these measurements only on entry to kindergarten and 9th grade. Unless the child receives a yearly exam, height and weight can go unchecked for several years. A school nurse’s annual measurements of a student’s height and weight can provide valuable information for the health care provider, especially if a growth abnormality or weight problem is suspected.

Scoliosis Screening

Scoliosis is defined as a lateral curvature of the spine (Ludder-Jackson & Vessey, 1996), which occurs spontaneously or is associated with other diseases. It can cause gait disturbances, inflexibility, and back pain, and can affect posture. Scoliosis affects 0.5% to 2% of the population and is most often seen in the preadolescent or early adolescent because this is a period of rapid growth (NASN, 1995; Ludder-Jackson & Vessey, 1996). School nurses participating in scoliosis screening usually provide this service between 5th and 9th grades (NASN, 1995). Treatment options for scoliosis depend on the type of scoliosis diagnosed and are aimed at straightening and realigning the spine with exercise, external bracing, or surgical intervention. Because treatment/intervention may extend over several years, screening for scoliosis is considered less cost effective than other school screening programs, and in some cases, inadequate training in screening techniques may result in overreferral.

Immunization Monitoring

Another important role of the school nurse is monitoring student immunization records. Since the introduction and use of vaccines, the occurrence of communicable diseases such as diphtheria, tetanus, polio, and measles has decreased (Selekman, 1998). Immunizations are now available for hepatitis B, Haemophihis influenzae type b (HiB), chickenpox, and Lyme disease (Centers for Disease Control, 1999; Selekman, 1998). The school nurse is responsible for knowing about current immunizations, protocols, and schedules, and should also know when communicable disease outbreaks occur that may affect children.

By 1997, almost all 50 states had written policies excluding children from school without proper immunizations (Vernon, Bryan, Hunt, Allensworth, & Bradley, 1997). Depending on individual state guidelines, a student could be denied entrance to school or be required to obtain a physicianapproved schedule for immunization when there is no verification of completed immunizations or a statement of religious or medical objection. Different states enforce different immunization requirements (Boyer-Chuanroong & Deaver, 2000). For further information and recommended schedules on childhood immunizations and communicable diseases, see Appendix C.

Communicable Disease Control

Communicable disease control has been a major factor in developing school health services and the nurse’s role in these services (Constante & Smith, 1997; Wold, 1981). Specifically, the nurse’s role in communicable disease control revolves around the three factors necessary for spread of disease: transmission, susceptibility, and a favorable environment.

An infectious agent is an organism, such as a virus or bacteria, capable of producing an infection (Benenson, 1995). It may be spread by direct contact with an infected person, indirect contact with contaminated objects, or transmission by air, a vehicle, or a vector. Knowledge of how common childhood diseases are spread can assist the nurse in keeping transmission to a minimum since many illnesses seen in students are spread by direct contact. Handwashing has been shown to be an effective way to decrease the spread of communicable diseases (Kimel, 1996). The school nurse can provide valuable and creative ideas for educating children about the importance and correct method of washing hands. Participating in programs to ensure clean air and water and decreasing exposure to possible hazardous materials are other ways that the school nurse can decrease children’s potential for contact with infectious agents. School nurses can also help decrease the school child’s susceptibility to communicable diseases by confirming whether a child’s health record indicates whether he or she is up-to-date on all required immunizations. When a child’s immunization status does not show adequate protection, referral is necessary. Some school districts provide this service directly if they have established school-based or schoollinked clinics, and the nurse may be responsible for administering the immunizations (Figure 5-2). The nurse can also help decrease susceptibility to disease by providing education about health issues and promoting healthy living habits in students, especially in the early grades. Nutrition, exercise, adequate rest, and personal care can affect one’s ability to fight off infectious diseases; these are possible topics for health promotion classes. Lastly, the school nurse can help contain the spread of communicable diseases by providing a less favorable environment for their growth. By identifying children with communicable diseases and excluding them from school as policies dictate, the number of other children exposed can be decreased. Almost all states have laws requiring exclusion of students and mandatory reporting of certain communicable diseases; the school nurse needs to check with local or state health departments to determine which diseases are reportable.

Although the incidence of serious communicable diseases has decreased because of vaccination, other illnesses, such as strep throat, scabies, and lice, still need to be monitored. Even though these diseases are less serious than measles, they can spread quickly through the classroom and lead to complications in some children. For children who are immunosuppressed, caregivers must be notified if these diseases occur in classmates because of the need for special monitoring or prophylactic treatment to prevent serious complications.

Emergency Care

Emergency care of the child at school centers on two main concerns: (1) basic first aid care for a child with an illness or injury and (2) emergencies requiring transport and more extensive treatment at a hospital (see Figure 5-3). Because the school nurse is often the only health professional in the school, that individual must have excellent physical assessment skills and be able to make quick and accurate decisions regarding the extent of illnesses or injuries. Education in triage skills, including classification of illnesses/injuries as emergent, urgent, or nonurgent will assist in making these decisions (University of Connecticut Health Center, Department of Pediatrics, 1997). When a student comes into the nurse’s office, an acrossthe– room assessment of the child is necessary in order to decide on the best course of action. The nurse must think:

• How does the child look and act?

• Are there visible signs of illness or injury?

• Does the child say one thing, but body language or physical signs say another?

• What brought this student to the nurse s office; what is his or her chief complaint?

Then the nurse should:

• Assess the child from head to toe while the child talks about the reason for seeking out the nurse.

Figure 5-3 A school nurse is responsible for administering emergency first aid.

• Check vital signs such as temperature, pulse, and respiration, as appropriate.

• Look for signs of bruising or bleeding if an injury was the cause for the visit.

Allow the child to rest quietly, observe changes, or assist the child in washing a cut and applying a bandage or an ice pack, and always watch for signs of a more serious problem or complaint that is not relieved with these measures. This information can assist in deciding if the child’s caregiver needs to be notified. Most school districts have developed a policy on specific instances when childreeed to be sent home. These policies may include a temperature over 100°F, an undiagnosed rash, and a constant productive cough. Sometimes physicians’ standing orders allow the nurse to treat minor illnesses at school with medications such as acetaminophen or cough syrup. However, before dispensing any medications, the nurse must know the district medication policy. See

Box 5-4

for a list of first aid supplies the school nurse should have readily available.

 One would think that school is the safest place for a child to be, but the potential for injuries in a school is nearly endless. Playground equipment, participation in gym and sports, and injuries in classes such as metal shop and chemistry can all lead to serious accidents. In the case of more serious injuries such as a fall with a possible head injury or broken bone, additional assessment is essential. If the child has fallen in gym and is complaining of ankle pain and difficulty walking, the nurse should look for swelling, bruising, deformities, and decreased movement, circulation, and sensation in the extremity. If abnormalities are found the extremity should be splinted as necessary. If there is a head injury, the child should never be left alone. Vital signs as well as vision disturbances, headaches, nausea, vomiting, and changes in level of consciousness or seizure activity should be noted. The caregiver should be notified and emergency services contacted as the assessment dictates. Knowing when to call for help when a child is injured is the most important aspect of caring for an injured child. Since extensive medical supplies and equipment are not always available in schools, help from paramedics who are often only minutes away can be essential.

Even though some days are filled with taking care of children with stomach aches and scraped knees, there is more to school nursing than just taking temperatures and supplying bandages. When the nurse assesses the child’s illness or injury, she can also teach children to care for themselves, promote self-esteem, and encourage healthy habits.

Ongoing Health Situations

An increasingly common school emergency today is a child experiencing difficulty breathing due to an asthma attack. Asthma is a chronic disease characterized by reversible airway narrowing, inflammation of the airway, and hyperresponsiveness of the airway to stimuli (McEwen, Johnson, Neatherlin, Millard, & Lawrence, 1998). Symptoms vary in severity and can include wheezing, cough, difficulty breathing, prolonged expiration, chest tightness, tachypnea, and excessive mucosal secretions. (For more information on the diagnosis and treatment of asthma, see Chapter 24.) The number of children diagnosed with asthma has risen in recent years and is estimated at 4.8 million (McEwen et al., 1998; Meurer, McKenzie, Mischler, Subichin, Malloy, & George, 1999). In the United States, asthma is the most common cause of school absence; McEwen et al., 1998).

Individualized Health Plan

When a child returns to school after having had a health problem, the school nurse must evaluate the incident and develop a plan for the child while at school. Since nurses are not always present wheeeded in an emergency, other school personnel may become responsible for administering first aid care and deciding when and if to transport a child to an acute care facility. Having a written plan available to assist in emergency situations can be invaluable. In the hospital, this is called the nursing care plan. In the school, this is known as the Individual Health Plan (IHP). An IHP is a document, based on the health assessment of a child, that outlines the special health needs, goals, and strategies necessary to improve/maintain the health of the child and allow full   participation in school experiences. The IHP can consist of a brief health history, base-line assessment data, medications, nutritional considerations, specialized equipment, possible problems, and interventions, and an emergency plan individualized for each child with a health problem (Porter, et al., 1997).

Box 5-5

provides an example of an Individualized Health Plan that could be used for Jimmy, the boy described in the case study. Since plans can be developed for the student with any health problem, school personnel should be educated on the IHP and how it works. In fact, the best health plan is of little use if others responsible for first aid are unable to follow it. By taking the time early in the year to provide the staff with a list of students with special health needs and to familiarize them with emergency procedures, health care can be delivered to students quickly and competently, and problems avoided.

Medication Administration/Monitoring

Another important service the school nurse provides is the monitoring and administration of medication children receive while at school (Figure 5-5). Although most children will not need to take medication during school hours, there are circumstances when it is necessary, as with chronic illnesses such as seizure disorder, diabetes, attention deficit/hyperactivity disorder (ADHD), and asthma. The nurse is responsible for making sure that children who must receive medication at school have written orders from their physicians and written permissions from their caregivers to receive the medication at school. All medications should be stored in a locked cabinet, and if the principal or another designated staff member is to administer medications in the nurse’s absence, the nurse should train these personnel and provide information on the medication itself and the five rights (right patient, right medication, right dose, right route, right time). All medication must be labeled by a pharmacy with the child’s name, medication name, dose, and time to be administered.

Many children attending school are taking stimulant medications such as methylphenidate (Ritalin) or dextroamphetamine (Dexedrine) for attention deficit disorder/attention deficit hyperactiviry disorder (ADD/ADHD). In fact, an estimated 3% to 5% of school-aged children have ADD/ADHD, with boys being affected almost six times as often as girls (Borowsky, 2000). The school nurse must be knowledgeable about the assessment procedures that accompany the evaluation of ADD/ADHD and the various medications prescribed for children with these conditions. Many medications are controlled substances (Ritalin, Dexedrine) and must be treated as such. However, medication is not the only treatment these children receive. Other measures include behavior modification, psychological counseling, and classroom intervention. By being knowledgeable about all medications and interventions, the school nurse can assist students, families, and teachers in delivering appropriate care.

HEALTH EDUCATION AND PROMOTION

Health education and health promotion principles have existed for many years, but how they have been defined has changed over time. For example, Green, Krueter, and Deeds (1980) described health education as a combination of learning experiences intended to help an individual change behaviors to be more favorable to health. The National Task Force on the Preparation and Practice of Health Educators (1983) described health education as assisting individuals to make informed decisions about matters affecting their personal health, which can include disease prevention, promoting optimal health, and illness treatment.

A health education curriculum should include information about these five preventative behaviors that often cause intentional or unintentional injury and increased morbidity in children (Vernon et al., 1997): (1) tobacco use, (2) alcohol and drug use, (3) sexual behaviors that lead to sexually transmitted diseases and pregnancy, (4) unhealthy diet, and (5) physical inactivity. Other important topics include personal and dental hygiene, safety, first aid, anger management, and conflict resolution.

Key Concepts

• The role of the school nurse, established to decrease the number of children out of school due to infectious diseases is influenced by societal, political, economic, and educational changes.

• The school nurse provides vision/hearing/scoliosis screening, height/weight measurement, as well as health education, which includes personal and dental hygiene, sex education, antismoking programs, and alcohol, drug use, and violence prevention information.

• Emergency care of children in the school includes basic first aid, deciding when to transport to a hospital, and the development of emergency plans.

• An Individual Health Plan—including goals, how they will be met, expected outcomes, and types of services needed—is developed and updated annually and as needed for students with special medical conditions.

• School-based health clinics and school-linked health clinics are located within or near schools to provide health services to children and families unable to secure health care.

• School nurses work as part of a multidisciplinary team, provide direct care to children with complex medical needs in a school setting, and delegate tasks, such as medication administration, to unlicenced assistive personnel.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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