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For the purpose of this essay I will write a critical analysis of a case study assessing the health needs of a child within a family. The case study is of a two parent family of a two year old girl. The family had transferred from another area. Their daughter was born prematurely at thirty one weeks. She didn’t offer eye contact and had no voluntary speech. Full permission has been obtained to use the information in the case study. I used firstly Orems nursing model to assess the family’s needs. Then a more appropriate framework Family Health Needs Assessment.
The model is a behavioural model. Behavioural models are based on the hierarchy of human needs by Maslow (1993). The hierarchy starts at the bottom of a pyramid with essential needs, when these are met the person progresses up the pyramid until full potential is achieved (Maslow, 1993). Orem’s model is based on societies need for the client to be self caring (Henderson, 1990).
Orem’s (2001) model has a continuum of self care abilities, the aim being to move along this continuum to self care or adapt to a diminishing self care in terminal or chronic ill cases.
Orem (2001) states that the family and significant others in a person’s life must be involved in their self care. It is a model which values individual responsibility, prevention and health education as key aspects of nursing intervention (Aggleton and Chalmers 2000).
Orem lists the following key factors that influence health;
1. Adequate intake of air water and food.
2, Adequate excretion of waste.
3. A balance between activity and rest both mentally and physically.
4. Social interaction and solitude should be optimised.
5. The prevention or avoidance of hazards and danger.
6. The feeling of being and behaving normally leading to stress reduction.
By being able to carry out self care in these areas the person fulfils what Orem (2001) calls their Universal Self Care Demands. If there is illness injury or disease the individual has self care demands in three extra areas (Orem, 2001). These are known as the Health Deviation Self Care Demands.
Orem uses the Nursing Process starting with assessment of the family in order to discover their individual problems which are defined in terms of self care deficits (Orem, 2001). The first stage of Orem’s model identifies both the demands for and the ability to achieve, self care in an individual (Aggleton and Chalmers, 2000). I assessed the family the parents both worked dad is a chef and mum is a carer in a nursing home they are both supported by grandparents who lived across the street. Both were fit and well. The two year old daughter was causing her mother concern in that she was not speaking it was difficult to get her attention with very little eye contact. Using Orem’s list I asked questions about each of the six activities. The problems identified were related to the two year olds behaviour of pacing around the room not speaking no eye contact and slapping her hands one on top of the other.
After gathering information I had to decide why there was a self care deficit. This was difficult using Orem’s which states the self care deficit should be linked to a lack of knowledge or of skills to a lack of motivation to achieve self care (Aggleton and Chalmers, 2000). These don’t seem to apply to a two year old cared for by her parents. But clearly her behaviour was a cause for concern.
I had now completed a good deal of paperwork a fault recognised by Fawcett et al (2004) in many instances it has led to nursing models being a “bureaucratic chore” (Fawcett et al,2004). A checklist method and standard care plans would have allowed for a quick assessment of the Universal self care demands (Kitson, 2001).
The next stage is to plan and set goals (Salvage and Kershaw, 1990). The long term goal for each client would be the restoration of a balance between self care ability and self care needs (Salvage and Kershaw, 1990).
The implementation of the care plan may involve activities to meet self care demands (Pearson et al, 2004). In addition members of the family, or significant others, may provide some care. Orem (2001) has identified six broad ways in which assistance can be given to implement a care plan.
1.Doing for or acting for another
2.Guiding and directing another.
3.Providing physical support.
4.Providing psychological support.
5.Providing an environment which supports development.
However each of these methods of helping requires compliance (Pearson et al 2004). Orem’s model demands that clients and their families are willing and able to adopt certain roles achieve self care (Aggleton and Chalmers 2000).
Orem (2001) has suggested that the evaluation of care given should be measured in terms of the clients or families performance of self care.
Using Orem we should set out goals in terms of what the family will achieve (Pearson et al, 2004). It was difficult to set goals babies who are born prematurely can suffer from learning difficulties and to investigate the two year olds behaviour was the goal.
Orem’s model didn’t seem to fit well with this families care.
The major problem with nursing models concerns the relationship with the clients of the service. These are of two kinds. The employer for most nurses in the UK, the employer is the Government. The Government has aims and objectives for its health care system which is to use evidence based practice which may conflict with a particular nursing model or philosophy (Mckenna et al, 2008). Orem’s model is over fifty years old and is not evidence based.
The problems mainly being centered on the daughter’s behavior the following framework was more appropriate for this family.
An evidence based framework The Family Health Needs Assessment was introduced into the health visiting service in 2003 and is based on the Framework for the Assessment of children in need and their families (Department of Health et al, 2000). The Assessment Framework was intended to help practitioners to become child-centered (Horwath, 2010). The aim being to do an assessment of the family’s health and parenting needs. A triangle is used as an illustration of the Framework the child being in the centre (Rose, 2009).
The three sides of the triangle represent the key factors that influence the Childs health; child developmental needs, parenting capacity and family health and environmental factors. Each one has sub headings specific to the main heading.
Child’s Development Needs
Emotional & Behavioral Development
Family & Social Relationships
Self Care Skills
Guidance & Boundaries
Family history & functioning
Family’s Social Integration
The aim of the initial Family Health Needs Assessment (FHNA) is to undertake a full
assessment of the family’s health and parenting needs. The impact of parenting
capacity, family health and environmental factors on the child’s health and well-being
is assessed to identify children and families who may require additional support to
achieve the 5 outcomes identified in Every Child Matters (2004).
Enjoying and achieving
Making a positive Contribution
Achieving Economic well-being
There is research evidence to suggest that low birth weight and prematurity indicates a greater risk of not achieving the 5 outcomes identified in Every Child Matters (2004).
Then a family health plan can be developed to include the family’s needs as agreed in partnership with the parent/carer. How the family wishes to address these needs
An action plan which identifies specific interventions/support and who this will
be provided by as well as the date for review and a review of progress made against the action plan.
The assessment took some time I had to reword some of the questions for fear of giving offence. The assessment forms were lengthy and there was some duplication. Emotional warmth under parenting Capacity and Emotional and behavioral development under the heading Childs developmental Needs. I found it difficult to know what to include under some of the headings. In Calders study (2003) the practitioners found the heading for ‘the child’s developmental needs’ the most challenging of the three headings. A number got confused between ‘social presentation’ and ‘self-care skills’ and the majority struggled with assessing ‘identity’.
The task for practitioners is to specify what, in relation to health and development, the child is at risk of and how significant they consider this risk to be (Horwath, 2010).
The original Framework for the assessment of children in need and their Families has guidance and support materials which explain the risk of harm, reducing the Framework to ‘the Triangle’ and a set of descriptions separates the needs from the risk of harm. Which could lead to a loss of focus on the child and their needs (Platt, 2006).
Both parents in this case were happy to carry out the assessment some parents can be unco-operative or even hostile Brandon et al, (2009). This could also cause a lack of focus on the needs of children. Brandon et al, (2009) found that good parental engagement can also disguise risk of harm to a child.
It is important hear what children have to say (Archard and Skivenes, 2009). I did engage the two year old with my identity badge which she recognized the picture but in this case I wasn’t able to interview the child because of her understanding and limited speech. I was able to observe her though and record my observations. Brandon et al. (2009) describe the various ways in which professionals don’t include children in the assessment. These include young people and siblings and a failure to address the needs of children who chose not to or are unable to speak because of disability, trauma and fear (Brandon et al 2009).
Groups of children in need that are hard to assess included: disabled children; adolescents; children of different cultures and faiths; and children in asylum-seeking
and refugee families (Brandon et al, 2009). Another group of children that also
has been found to be difficult to assess are children in need from higher socioeconomic groups. These cases were found challenging by social workers because:
the parents were more aware of their rights (Brandon et al, 2009). Care must be given to recording accurately what the child says and managing that information,
especially if it is negative about the parents so not to expose the child to any more risk
Practitioners are responsible for gathering information and they also have to share the findings of the assessment with family members.
From the assessment I identified a problem under the heading Child Developmental Needs Health the two year old daughter was growing physically but was not developing speech and had limited eye contact. The family had just moved from another area. Their daughter had been born premature at 31 weeks and she had had follow up appointments at hospital now that they had moved the hospital was too far away.
The follow up at hospital was important for her developmental reviews. So the first identified need was to register at the Doctors and explain that she needs a referral to the hospital for a full pediatric review.
Speech was a problem in that she was making the occasional sound and not forming her words properly. I made the speech therapy referral and gained assurances that her parents would take her. We discussed taking her to a nursery to mix with other children. After talking it was decided so that mum could go too to join a mother and toddler group. So things moved swiftly we put a time scale on these three major things of three weeks. I arranged to visit again in two weeks.
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