Pediatric Assessment in the Home

Thompson, Janice M. PhD, MSN, RN, C

Author Information
Janice M. Thompson, PhD, MSN, RN, C, is Associate Professor of Nursing, Quinnipiac
University, Hamden, Connecticut.
Address for correspondence: Janice M. Thompson, PhD, MSN, RN,C, Quinnipiac University,
275 Mt. Carmel Avenue, Hamden, Connecticut 06518; e-mail:
janice.thompson@quinnipiac.edu
Abstract
Caring for children holistically in the home can be challenging and is dependent on working
closely with families. This article identifies the four roles a nurse performs when conducting
a home pediatric assessment. The Home Risk Assessment Tools presented assist nurses in
evaluating a child’s physical and psychosocial needs.

Providing and coordinating home care for children can be a challenging experience as the
demand for more experienced pediatric nurses continues to grow. Pediatric nursing requires
special knowledge and can be a difficult, demanding, and a sad specialty because it deals
largely with seriously ill children who may have chronic disabilities and may be dying.
Visiting children in the home demands an appreciation of the unique nature of childhood and
adolescence, the impact of the illness on the child’s growth and development, and the ability
to work with the family and caregivers. As consumer views of holistic health care are more
popular, understanding the physical, psychosocial, and environmental parameters become
essential when caring for children.
Pediatric home care is uniquely dependent on the commitment to caring shown by the child’s
family. Because families come in many sizes and shapes, they remain the primary
environment in which children thrive and are nurtured (Wong, 1993). In the home, we find
many new challenges when facilitating children and their family’s growth toward wholeness,
assisting them to recover from illness, or in the transition to a peaceful death (Dossey,
Keegan, Guzetta, & Kolkmeier, 1995). Children are often amazing, courageously strong, and
innocent in their words and actions. As in all home care and hospice environments, care can
be rewarding yet challenging because many children do not live in a safe and nurturing
environment.
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This article provides insight for the nurse on the best way to conduct a pediatric assessment
and deliver care to this population. Tools are presented that will assist in an effective and
efficient assessment and interventions for these patients.
Communication Is Vital to Effective Care
Children hunger for attention and need to be heard; therefore, they should be included in the
activities taking place unless parents or nurse believe it is not appropriate at that time.
Because many children distrust adults who come to see them, and the nurse is a guest in the
home, developing a trusting relationship with the family and child is critical. Because
children and parents tend to provide more information in a relaxed and unhurried atmosphere,
some simple hints can be helpful:
1. Always have the primary caregiver(s) be present at the initial home visit.
2. Be sensitive to the best way to address parents or caregivers. At least initially, it is better to
formally address them as “Mr. and Mrs. Smith,” until they suggest otherwise (Goldbloom,
1992).
3. Children should always be addressed by their name or, if preferred, by their nickname.
During discussions with parents, always refer to the child by name instead of the impersonal
“he” or “she.” This conveys to the parents that you appreciate the child’s individuality, and it
shows respect for all involved.
4. If the child is able to communicate, try to include the child in the conversation whenever
possible and make him or her feel part of the interaction (Engel, 1993).
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5. Act friendly; use a soft, reassuring tone, and appear interested in the child’s activities.
Roles of the Nurse in Working with Pediatric Patients
The next section discusses the four nursing roles involved in caring for pediatric clients in the
home:
* Provider of Care
* Patient and Family Educator
* Patient Advocate
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* Case Manager (Ball & Bindler, 1999)
Provider of Care
The nurse’s primary role is to provide direct nursing care to the child. Using the nursing
process as a framework for each home visit will keep you focused on setting priorities. As a
provider of care, the nurse coordinates all nursing care to meet the child’s physical and
psychological needs while involving the family when appropriate.
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It is important during the initial visit to assess the child’s growth and development as well as
behavior relative to the developmental age. Some areas that should be discussed include sleep
patterns, diet, play, stimulation, and routine for care. Knowledge of various developmental
stages is imperative and helps the nurse to weave growth and development principles into
their communication skills.
Growth and Development Review
Infants (1–18 months) communicate primarily by crying. They are very sensitive to tactile
stimulation such as holding, rocking, and patting. The developmental task of this first year of
life is to establish trust in the primary caregiver (Erikson, 1963). If a trusting relationship
does not develop, the infant will learn to mistrust individuals. This is often seen in infants
who fail to thrive during their first year of life if their basic needs are not met.
The sound of a soothing voice is very comforting to infants. Because older infants often
distrust adults who are not their primary caretakers, proper assessment and care is more
challenging. Nurses should carefully observe the parents’ or caretakers’ responses with and
interpretation of the infant’s behavior during the visit.
Toddlers (18 months–3 years) communicate with simple verbal communication and
expressive nonverbal behavior. These developing little people love to show their autonomy
by exerting control over all of their activities. Even though they can talk, expression is
limited in content.
Toddlers are quick to say “no” when asked to do something. Using short, concrete terms and
always telling toddlers in simple terms what you are going to do and what they may feel will
help develop a relationship quickly. If toddlers are continuously criticized for their
expressions of independence, they will develop a sense of shame and doubt their abilities
(Erikson, 1963).
Preschoolers (3–6 years) are becoming their own person and learning to act independently.
They have the ability to carry on a conversation and are usually willing to cooperate with
you. With children at this level, you should explain exactly what you are doing and
encourage the child to ask questions. It is very important to listen carefully to become clearly
aware of their fears and concerns. Let them know that what they say is important to you,
because at this age, they are open to new ideas and want to be involved and busy.
School-age children (6–12 years) are more sophisticated and think in concrete terms and also
have the ability to remember past hospital and healthcare experiences. They may be shy when
answering questions and look toward their parents to provide answers. It is appropriate to ask
the child whether they know why you are there. Children at this age take pride in their
accomplishments and want to be involved in age-appropriate care. They will feel a sense of
inferiority if they cannot accomplish what is expected of them (Erikson, 1963).
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Adolescents (12 years and older) can be a challenge to work with. The self,
family, and friends take on new meanings. Individuality, participation in their
care, and choices are very important to this age group (Engel, 1993).
Adolescents may respond to your questions with monosyllables, anger, or
indifference. They have a higher level of comprehension but still require you
to be concrete and include them in the decision-making process. Your
approach should be open-ended, always expressing a sense of alliance and
partnership (Ball & Bindler, 1999). In addition to growth and development
Table 1
patterns, ill children commonly use defense mechanisms. Defense mechanisms
are various techniques used by the ego (the realistic part of the person) to
unconsciously change reality, thereby protecting itself from excessive anxiety
(Ball & Bindler, 1999). When children feel anxious or unable to cope with a
given situation, they may use some of the defense mechanisms listed in Table
1.
The Home Environment
Home care is now considered an option for medically needy and technology-dependent
children and children with acute or chronic health care problems that have traditionally been
cared for in hospitals (Votroubek & Townsend, 1997). Poverty, environmental hazards, and
lack of educational and social services are areas that require extra attention when caring for
the child in the home environment (Chestnut, 1998). The place a family calls “home” is
supposed to be “safe,” but this is not always the case. Many families live without good
lighting, proper sanitary conditions, telephone access, and adequate economic resources from
full-time employment.
Special attention must be paid to the home environmental assessment relative to electricity,
heat, telephone service, and, for children with chronic respiratory diseases, air-conditioning
(Chestnut, 1998). If a phone is not connected to the home, make sure the family has plans for
phone access in case of emergency. This could be a neighbor’s phone or even a phone booth
down the street. If a phone booth is the only available means for calling for help, family
members should check the phone regularly to see whether it actually works.
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Substandard living conditions require the nurse to identify priority decision making and
referrals to appropriate sources. A thorough assessment of the home is necessary when caring
for children. Did you notice poor sanitation such as garbage all over the kitchen and living
areas? The presence of vector infestation, such as cockroaches? If present, check humidified
and nebulizer tubing where there is settled water for any living creatures. Is the living space
adequate for the number of occupants in the household? Does overcrowding or anything else
pose any potential safety or health hazards?
Using Specific Standards in Assessment
Specific pediatric standards recommended that all children, especially those
at or below the poverty level, be afforded access to the Universal Home Risk
Assessment presented in Table 2 to determine whether: Table 2
* there are risk factors that were not observed in a clinic or practitioner’s office;
* plans must be made for community services; and
* there is an ongoing need for home care services (Chestnut, 1998).
The psychosocial standards allow the nurse to determine the psychosocial level of risk, with
level 1 being minimal risk, level 2 being moderate risk, and level 3 indicating serious
potential risk to the physical well-being of the child as a result of psychosocial issues. These
levels provide guidelines by which your agency, healthcare provider, client, and insurer can
realistically plan for home care services.
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Please note that the scoring guidelines relative to psychosocial assessments on
Table 3 are found and are initially to be marked during the visit by using Table 2
under the section “Risk Assessment.” Once all items are assessed, the scoring
guide in Table 3 can be used to determine the number of visits and frequency
needed to reach clinical goals based on an objective assessment that supports
reimbursement. The higher the child scores, the greater psychosocial risk is
present, and the higher frequency and duration of visits need to be planned. Table 3
Nursing productivity and reimbursement is more clearly determined by using this
form.
After the Initial Assessment... Planning the Care
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After the initial assessment, a plan of care and frequency and duration of home visits should
be developed in compliance with agency policies, certification standards, as well as private
insurance/Medicaid regulations. Not all insurance policies include home care benefits, and
often the family is unaware of this lack of coverage until services are needed (Votroubek &
Townsend, 1997). The goals and objectives of the plan are based on the child’s individual
needs and risk levels. A major requisite for home care is a financial assessment that will
ensure adequate funding and family’s specific financial responsibility.
Patient and Family Educator
Empowering families to care for their children by being a family educator is a major task for
the home care nurse (Chestnut, 1998). This role involves thoroughly assessing the patient’s
and family’s learning abilities. One of five Americans reads at or below a fifth grade level
(Falvo, 1994). Because most educational materials are aimed at people who read at high-
school level or above, a substantial segment of the population is often confused by most
educational materials but may be too ashamed to admit it.
For example, the ability to interpret clocks and calendars is not universal; this can contribute
to the inability to follow instructions (Vexeau, 1991). Not all children or families can read,
write, or demonstrate knowledge of skills at levels you may expect. Education can be
especially difficult because home care nurses must take into account the many levels of
understanding and manual abilities of children.
The nurse should try not to teach too much in one session. Educational goals for children,
adolescents, and adults are different and will require different teaching styles (Wong, 1993).
Common methods used in teaching children and their families are individual lectures
followed by discussion or demonstrations for psychomotor learning supplemented by
teaching aids (written pamphlets). When cognitive and psychomotor learning is the goal, it is
imperative to set priorities and repeat information. Children and families love to look at
colorful pictures and fill in charts (Vexeau, 1991).
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The child and family should be co-participants in all phases of their care when age
appropriate and the nurse can determine what the child and family need to know or do to
function independently (Ball & Bindler, 1999). They may need to gain knowledge or perform
a certain skill (a dressing change, for instance) before being safely discharged from home
care. If the child is a newly diagnosed juvenile diabetic, both child (if age-appropriate) and
caretaker should be able to demonstrate insulin administration. The development of a written
teaching plan guides the process and coordinates teaching among all family members
involved in the child’s care. Well-documented client education is as important as
documenting any other aspect of client care.
Patient Advocate
All nurses must act as patient advocates. Ball & Bindler (1999) define advocacy as “acting to
safeguard and advance the interests of another” (p. 5). Advocacy is directed at enabling the
child and family to adjust to the changes in the child’s health in their own way. To be an
effective advocate, the nurse must be aware of the child’s and family’s needs, resources, and
available healthcare services.
A major goal is to minimize the many disturbances and stressors caused by a child’s illness,
because they have a great impact on the family’s daily routine. You can best assist the family
and child in making informed choices about services available and how to act in the child’s
best interests (Ball & Bindler, 1999). In this role, the key is to communicate effectively and
pay close attention to verbal and nonverbal cues. Avoid judging or criticizing the child or
parent’s comments or decisions for care.
Adolescents fluctuate between child and adult thinking. They are riding a current that is
moving them rapidly toward a maturity that may be beyond their coping abilities. Sometimes,
adolescents need or want to discuss their concerns and health care with an adult outside of the
family. This places the home care nurse in a key position to play the role of patient advocate.
All children need to express their feelings, wants, and desires as well as dissatisfactions and
dislikes. In essence, it is important to stress again that children need to be heard, so listening
is a critical skill to use and help parents develop (Dixon & Stein, 1987).
Dealing with the death of an adult is certainly difficult, but coping with the impending death
of a child is devastating. Families facing this situation need assistance in deciding how to use
medical care and technology. Parents may have to decide when and whether to start,
continue, or even stop medical treatments.
Because many of these issues or wishes reflect philosophic, personal, religious, and spiritual
desires, they should be heard and discussed in detail (Ball & Bindler, 1999). Often, this role
needs to be shared with other care providers, the parent’s religious representatives, and other
helpful resources. The best way for nurses to assist in this area is to become a member of a
team that is seen as guiding and supporting the family without giving specific directions. This
is where the nurse is most likely to experience personal anxieties and dilemmas.
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Often nurses who have children of their own get overly involved in pediatric situations with
the best intentions of expressing total empathy. As difficult as it may be to accomplish, the
child and parents are best served by the nurse taking the role of advocate and educator and
not personal friend. If you find yourself in a situation that is making you unable to fulfill the
role of educator and advocate, seek out support and guidance from your supervisor.
Case Manager
Economic forces continue to squeeze the healthcare of children and demand, more than ever,
that nurses provide short-term and long-term care to children and their families. Case
management is the process of coordinating the delivery of healthcare services in a manner
that focuses on both quality and cost outcomes (Ball & Bindler, 1999). Some pediatric
patients may have significant health problems or handicaps that will require an
interdisciplinary team to meet the child’s medical, nursing, developmental, and educational
needs.
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As the nurse, you have the ability to evaluate the entire home situation, because you know
more than any other healthcare professional about the family’s wishes and resources. The
goal is to assist the child and family to achieve the best outcome while controlling the cost of
healthcare services. It is the nurse’s responsibility to be familiar with community resources
and services reimbursed by the family’s health plan or other financial resources. In this
regard, caring for children is a lot like caring for adult patients. Removing the emotionality of
the situation as best as possible means that you must be able to make the best judgment for
the case while considering and coordinating all of the factors involved.
Conclusion
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As in all nursing care, the nurse conducting pediatric home care assessments must deliver
care with a delicate blend of caring, compassion, creativity, and objectivity. Understanding
the entire home environment and how that relates to the child’s and family’s lives can
provide great assistance for those experiencing situational crisis from a disease or injury and
for those facing chronic or terminal care. As a specialty, pediatric nursing requires unique
knowledge and the ability to make tough, objective choices in caring for children.
guidelines for communicating with children
* Ask the parents what they have told the child about the home care visit.
* Inquire about how the child usually copes with new or stressful situations.
* Observe the child’s behavior for clues to readiness.
* Consider the child’s developmental level and attention span.
* Encourage the child to ask questions, but do not pressure them.
* Explain the home visit routine in terms consistent with the child’s developmental level.
* Present small amounts of information at a time.
* State expectations clearly and simply.
* Do not offer choices if there are none.
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* Praise the child and family when appropriate (Engel, 1993).
REFERENCES
1. Ball, J., & Bindler, R. (1999). Pediatric Nursing Caring For Children. East Norwalk, CT:
Appleton & Lange. [Context Link]
2. Chestnut, M. A. (1998). Pediatric Home Care Manual. Philadelphia: Lippincott Williams
& Wilkins. [Context Link]
3. Dixon, S. D., & Stein, M. T. (1987). Encounters with children: Pediatric behaviors and
development. St. Louis: Mosby. [Context Link]
4. Dossey, B., Keegan, D., Guzetta, C., & Kolkmeier, L. (1995). Holistic Nursing. MD:
Aspen Publications. [Context Link]
5. Engel, J. (1993). Pocket guide to pediatric assessment. St. Louis: Mosby Book Company.
[Context Link]
6. Erikson, E. H. (1963). Childhood and society. New York: WW Norton. [Context Link]
7. Falvo, D. (1994). Effective patient education: A guide to increased compliance.
Gaithersburg, MD: Aspen Publishers. [Context Link]
8. Goldbloom, R. (1992). Pediatric Clinical Skills. New York: Churchill Livingstone.
[Context Link]
9. Vexeau, T. (1991). Literacy levels in maternal child population. Nursing Times, 87 (33),
48–54. [Context Link]
10. Votroube, W., & Townsend, J. (1997). Pediatric Home Care (2nd ed.). Maryland: Aspen
Publishers. [Context Link]
11. Wong, D. (1993). Whaley & Wong’s Essentials of Pediatric Nursing (4th ed.). St. Louis:
Mosby. [Context Link]

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