AN ESSAY WHICH FOCUSES ON THE ASSESSMENT AND CARE REQUIRED BY A CHOSEN CHILD AND FAMILY
This report is written in response to recent work practice undertaken as experience working within child health care. I have chosen a placement with a local school nurse to gain this experience. The school nurse, Mrs Roberts, has been working at Worthington Primary School for ten years so she has excellent experience of what is required in the role of a school nurse. Worthington School is the school serving the nearby housing estate which is completely made up of social housing. Formby Road housing estate comprises a great many families on low incomes and, unfortunately, it has a very bad reputation with a high police presence required frequently.
Mrs Robinson was asked to intervene by Mary’s teacher as there were concerns that Mary had lost weight. Her teacher had established that Mary had a very poor diet and was lacking in many areas of nutrition. She ate a lot of processed foods, sweets and cakes, and also she very rarely exercised sufficiently and frequently failed to attend Physical Education sessions. Mary was often lacking in concentration and seemed to have a low level of outside stimulation.
The child, Mary, is a ten year old student in year 5. Mrs Roberts and her teacher has been concerned about Mary for several months and felt that intervention was needed. Mary’s family live in a house on the Formby Road estate. The family comprises of Mary’s mother, Glynis (36 years) who suffers from asthma and is unable to work. Mary’s father is not living with the family and does not have regular contact with them: a common state of affairs on this estate. Her maternal grandmother (60 years) lives with them but cannot contribute to the overall care of the family due to health problems. There is an ‘uncle’ Hugh (40 years) who lives with the family and who is employed as a bricklayer. Mary has three sisters who all live at home – Ann (16 years), Molly (18 years) and Julie (20 years). Julie is currently being monitored by a member of social services as she is 7 months pregnant and has not been attending regular anti-natal check-ups. Julie is very much the person in the family home who tries to keep everyone together. She acts as a substitute mother to Mary and her two sisters who are not that much younger than herself. Glynis is resigned to allowing this to happen and does little to interfere in the upbringing of the children.
The house is terraced and is on three floors. There are health concerns for the family because the house is in a bad state of repair and shows signs of damp in several of the rooms and is generally unclean and cluttered. The family also have several pets – four cats, two dogs, several budgies in a cage in the kitchen and gerbils and hamsters.
It has been established that the family do not have set meal times but all eat when they feel they want to. Family life is therefore totally unstructured: this could be said to be a typical dysfunctional family, actually. Mary does eat at a small table in the kitchen but generally tends to sit facing the wall during her meal leading to a feeling of isolation.
School nurses are very skilled at what they do. The old fashioned idea of the nit nurse now has no place within the educational environment. Their role is now far-reaching and aims to provide an amalgamation between the school and the family. The Department of Health tells us that the responsibilities of the school nurse cover the provision of health programmes for young people, to lend support to every pupil who has complicated health requirements, carrying out immunisation and vaccinations, giving assessments of every five year old and operating drop-in clinics to help young people, and their parents and carers, on a great variety of issues.
“School nurses work not just within schools, but also with individuals and communities as a whole. It’s this expansive public health role that has resulted in partnerships with organisations like the National Healthy School Standard (NHSS). Jointly funded by the DCSF and the DoH, the NHSS has an overall aim to help schools become healthier.” (Teachernet, 2010)
The needs of Mary were assessed using the recognised Roper-Logan and Tierney’s Model of Nursing (1998). The model was originally devised in 1980 but was revised in 1985 and 1999. It is based on activities of living (ADLs). (Roper, N, Logan, W. Tierney, A. 2000). In general, the needs of the patient can be broken down into twelve ADLs. It is ideal that the assessment is ongoing during the patient’s care but sometimes it is only possible to use the model at the outset of care. It can be used as a retrospective tool – to judge how the patient has been affected by illness or neglect, rather than planning for the future improvement of health and well being. Roper, Logan and Tierney propose the following as ADLs – maintaining a safe environment, communication, breathing, eating and drinking, elimination, washing and dressing, controlling temperature, mobilisation, working and playing, expressing sexuality, sleeping, and death and dying. When interviewed by members of the Royal College of Nursing’s (RCN) Association of Nursing Students at RCN Congress in 2002 at Harrogate, Nancy Roper stated:
“that the greatest disappointment she held for the use of the model in the UK was the lack of application of the five factors listed below, citing that these are the factors which make the model holistic, and that failure to consider factors means that the resulting assessment is both incomplete and flawed. She implored students to support the use of the model through promoting an understanding of these factors as an element of the model.”
Nancy Roper stated that the five factors were biological, psychological, sociocultural, environmental, politico economic.
The use of some of the twelve ADLs is dependent on age circumstances: e.g. death, sexuality, would not apply much directly in the case of certain groups such as young children. Some ADLs are common to all: e.g. nutritional concerns, maintenance of a safe environment.
With reference to Roper’s five factors influencing ADLs, Mary showed signs of bad nutrition and lack of weigh (biological). She exhibited attention seeking behaviour in the school environment and also has had a referral to the speech and language therapist. She does have emotional problems and can be disruptive in class (psychological). Her family are in a low income group receiving most of their income from benefits (sociocultural). Mary’s house is within the local housing estate where there is a high level of crime. Her home is also unclean and is thought to have damp (environmental). The house is really too small for the number of people living there but due to local government policies they are not considered eligible for a house exchange (politico economic).
After carrying out a regular school health examination, it was noted that Mary was underweight for her height and age. Previously she had presented as average on the percentile chart. Mary was also asked to describe her regular eating habits and what food she ate most of. Mary described how the family usually just eat what they want and when they want it, so meal times lacked any structure at all. No one in the family home cooks regular meals because they all prefer to eat take away meals, and snack and processed foods. There is no regular shopping routine. She said that none of the family liked sitting at the table to eat but preferred to sit in front of the television or computer.
A letter was sent to Mary’s mother advising her that there were concerns raised at school about Mary. The main issues of nutrition, weight and speech and language concerns were outlined in the letter. It was proposed that Mrs Roberts would ring Mary’s mother and arrange a home visit. The home visit was subsequently planned and carried out. We thus had a meeting with Mary, her mother and her eldest sister, and nan.
Mrs Roberts explained the concerns about Mary’s health and well being, and also stated that we were keen to rectify her problems very easily and quickly. It was stressed that our intervention should be seen as a positive action, in no way negative, and that it was to be beneficial to all family members. Mrs Roberts pointed out that the plan of action would be to monitor Mary’s weight and general health and advise the family on good nutrition and the need for physical exercise. It was also shown that good nutrition does not need to be expensive cost-wise but could be maintained on a low income budget – and that, in fact, take-aways and processed foods usually worked out much more expensive. Mary’s eldest sister agreed to this intervention although her mother said very little. This situation whereby Julie takes on the mother role was noted for further attention. It was agreed that there would be another meeting to be held at school, and then we would come back to the family home. It is a very sensitive area having to deal with a whole family who are required to amend their routines to help one vulnerable family member. It is also very easy for people to say they will change their lifestyles; whether they actually do or not is quite another matter.
Tassoni et al, (2005) tells us that there are developmental milestones for youngsters in the 9 – 11 years age range. It is considered that this age range is a prelude to the turmoil of puberty, often referred to as late childhood. Young people will by now have acquired many skills and have a sense of what they are confident and good at, as well as what they are not good at. Communication has reached a competent level and friendships have been established – and if they have not, then they will be hard to rectify by this age. Some in this age group, especially some girls, do start to enter the bodily and emotional changes of puberty and physical growth will be observed, though they are many reasons for this (e.g. nutritional, racial).
At this age Mrs Roberts is looking to see the following:
“Detailed and representational pictures, which children enjoy drawing.
Stories and writing that show imagination as well as being legible and reasonably grammatical.
Problem solving (e.g. how to play cooperatively, use materials fairly).
Enthusiasm when given areas of responsibility.
Greater coordination and speed when carrying out both fine and large movements.
Stable friendships (usually same sex).
Awareness of consequences of behaviour and increased thoughtfulness. “ (Tassoni, 2005, p118)
These may well be generalisations, and one should of course allow for multifarious personality traits, as well as gender differences; for example, boys may be more solitary and speak less than girls, and be more risk-taking in general, but this is perfectly normal and innate, it seems.
Adolescents need an increase in nutritional requirements because of the rapid growth and bodily development they experience. The body at this age is going through great change and this can result is adverse skin conditions such as acne. This can be minimised by consumption of plenty fruit and vegetables and the avoidance of fatty foods. Iron and protein are important, especially in girls, to avoid anaemia which is a side consequence of menstruation, though boys need a balanced diet with protein and iron too, and more zinc than girls, for example. Adolescents should also be warned of the adverse outcome of consumption of alcohol. This is a social problem which does affect this age band. Good role models such as adults who drink moderately have been shown to help this issue, and parents are the main role models here. (Tull,1996, p60-61)
Bruce & Meggitt states that a lot of families in the United Kingdom have a reduced income due to illness and / or unemployment. There are four main reasons why people who are dependent on state benefits do not provide adequate diets for their families. It is considered that healthy food is expensive, though this is disputed, especially as more in this group smoke expensive cigarettes. Fatty meats are often cheaper than lean cuts and wholemeal bread is dearer than white bread and rolls, though still affordable. Fuel cost are important – it is quicker to fry chips than bake a potato. Large supermarkets tend to be less expensive for food; because low income families tend to do shopping in local shops, the cost of food is higher. A certain level of knowledge is required to manage a low income/high nutritional diet, and this is the crux of the issue: these families do have enough money to feed themselves healthily but lack the knowledge and skills to do it. For example, pulses and grains can be used instead of meat, fat consumption can be reduced, meat consumption can be kept to a minimum, and vegetables, potatoes and rice can be substituted; moreover, snacks and take-aways can be avoided. However, one cannot escape the fact that some people just like to eat an unhealthy, high-fat, high-sugar, processed food diet, probably because that was the diet these people were eating in childhood.
A detailed meal planning schedule was prepared for Mary’s family. Tull tell us that a balanced meal is one that gives an individual all the nutrients needed on a daily basis. There needs to be a balance between texture, colour, taste and we should have a mixture of different foods to keep our appetite interested. Tassoni tells us that there is no single food which can provide all the essential nutrients for healthy and efficient functioning. We all need energy to live and the balance between carbohydrate, fat and protein needs to be correct for good health. School children are still growing and being more active so they need a good diet to maintain high energy levels. Children of Mary’s age need to maintain a stable weight and, despite growing in height, also need to increase weight slowly so there will be an acceptable weight for their height.
There should be set meals every day to encourage well being: breakfast is the first meal of the day on waking; lunch/dinner, which are the usual names for the meal in the middle of the day; the evening meal – tea or dinner– which is the meal usually taken at late afternoon/early evening.
Government guidelines tell us what comprises a healthy diet. It should include at least five portions of fruit and vegetables every day and a moderate amount of dairy products. There should be plenty of starchy food like potatoes, bread, pasta, rice cereals (usually wholemeal versions are preferable though not essential), and meals should be based around such staples. There should be amounts of meat, fish or suitable alternatives like eggs, beans and lentils – for protein and iron. Salt is to be kept to a minimum – (cutting out or reducing salt-laden snacks, ready meals and take-aways will cut out most salt) – though there must be some salt in any diet; no salt should be added at the table, however, to minimise consumption.
This type of diet is perfectly feasible for people on low incomes. Tull states that people on low incomes are more likely to suffer from health issues such as heart disease, strokes and cancer. Apart from possible hereditary reasons, this does not need to be the case. Some of the foods high in fat and sugar are used as comfort foods, despite fresh vegetables and fruit being cheaper. It is often a case of a lack of education, which can make the difference to diet. It was noted that Mary’s family do not have to adhere to any special diet due to cultural or religious reasons.
Mrs Roberts has spoken to Mary about an exercise plan. She has realised that Mary does, in fact, enjoy dancing like many girls her age. She is trying to encourage Mary to become involved in the school production where she can put her interests and love of music to a practical use.
Correct care of pet animals in the family setting is paramount to a healthy environment. The budgies, which are kept in the kitchen, are arguably a hygiene hazard. Frequently members of the family touch the animals and then fail to wash their hands before putting food in their mouths: this is a potential hazard. Dogs and cats can carry fleas, worms and can scratch, though this should not be a problem if the pets are cared for properly. Part of the care plan for Mary included information on the need that children should be supervised with hand washing after touching any of the animals.
The need for hand washing is essential after toilet trips, after playing outside, before eating or drinking, and before food is prepared and served.
The outcome of the intervention with Mary’s family has established a plan of action to address these problems. Mrs Robinson will provide Mary’s mother with a list of dietary menus which are low cost and highly nutritional. Glynis will actively be encouraged to carry out regular shopping trips and will hopefully be made more enthusiastic about cooking; this will be a long drawn out process but she does now actually acknowledge that diet is important. The school speech and language therapist has now been advised of the need for Mary to attend sessions, and she has talked to Mary about the importance of these sessions; consequently, they have decided to use some topics like music and fashion as subjects to base the time around. Mrs Roberts will be carrying out regular weight and general health checks on Mary, and she has shown Mary how to keep a food diary.
Social Services have been contacted to keep in touch with Mary’s family. They have been given details to consider including the following: whether further benefits are due to the family; whether to review the housing with the local housing authority (to address damp and also a review for a larger house); whether there is the possibility of a home help to assist with shopping and house cleaning.
Throughout this work experience and report I have kept the identity of the family totally confidential. This is important because both the school authorities and the family have allowed me access to information which would be helpful to me in working with their child. By breaching this confidentiality I would also be breaching trust and betraying a confidence. If this is to happen between families and professionals then the relationship also breaks down and it is the child who suffers. All contact details, medical information and any child’s records are confidential. All names in this report have been changed – people, school and housing details. Parental consent was given to have the professional support of professionals and the confidentiality issues were explained. It was evident that at no time has Mary been in an ‘at risk’ situation, so no confidentiality will be breached.
End of report
Roper N., Logan W.W. & Tierney A.J. (1980) The Elements of Nursing. Churchill Livingstone
Roper N., Logan W.W. & Tierney A.J. (2000) The Roper-Logan-Tierney Model of Nursing: Based on Activities of Living . Elsevier Health Services
Siviter, B. (2002) Personal interview of Nancy Roper at RCN Congress, Association of Nursing Students.
Tassoni, P. Bulman, K, Beith, K. Robinson, M. (2005) Children’s Care and Learning & Development.
Tull, A. (1996) Food and Nutrition, Oxford University Press
www.rgu.ac.uk/files/PE EU BOOKLET-final-pdf (Accessed 15 January 2010)
www.direct.gov.uk/en/healthandwellbeing/healthyliving (Accessed 16 January 2010)