Patient profile: 4-year-old biracial male living with his grandmother in a high-density public housing complex.

Gathering data to structure the history includes the identifiers including name, date and time of visit, age, gender, race, source of information, and referral source. Other data to be included in the patient’s history is the chief complaint or concern, the reason for the visit. Include any history or present illness or problems (HPI), past medical history (PMH), and family history (FH). A review of systems (ROS), and personal and social history is documented to assess the social determinants of health.

It is important to include in a 4-year-old child’s history any perinatal issues during pregnancy such as gestational month, gravidity and parity, and birth weight. Any maternal history of drugs or alcohol, radiation exposure, and emotional behavior toward pregnancy.

Communication and interview techniques for the 4-year old child with his grandmother begins with establishing a positive relationship built on courtesy, comfort, and connection at a professional level. I would introduce myself to both patient and guardian and welcome them to the office visit. I would ask open-ended questions such as tell me how old are you? What grade are you in? What’s your teacher’s name? Do you have a favorite friend, and what is their name? How are you feeling today? I would sit close to the patient and allow the grandmother to hold him so he feels safe. I would observe the interaction between the two and assess the dynamics, and allow the child to input as age-appropriate (Ball, Daines, Flynn, Solomon, & Stewart. 2019).

A risk assessment instrument is a questionnaire for triage to screen and assess the health and well=being status of a patient and to personalize for feedback about actions taken to maintain health and prevent disease. It also includes screening for child trauma and other mental and physical risks. I would use the child welfare.gov assessment tool because it is approved at the federal level for child care management and safety.  Five questions I would ask in my assessment are

1. Was the child in any other family unit care or in the custody of any substitute caregivers at any time?

2. Does the caregiver have legal custody of the child and what is the whereabouts of the parents?

3. Was the birth of the child a normal pregnancy? Any mental health or substance use in the mother?

4. Did the child achieve developmental milestones within normal percentile, for example, is the child potty trained, is speech clear for age with complete sentences?

5. Any financial issues or housing concerns, what social support is in place, and is there any other children or adults living in the house?

These questions are in guidelines with safety and risk assessment frameworks (Pecora, Peter & Chahine, Zeinab & Graham, James. (2013).

References

Ball, J. W., Daines, J.E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An Interprofessional approach (9th ed.) St. Louis, MO: Elsevier Mosby

https://www.childwelfare.gov/topics/responding/iia/investigation/safety-risk/

Pecora, Peter & Chahine, Zeinab & Graham, James. (2013). Safety and risk assessment frameworks: Overview and implications for child maltreatment fatalities. Child welfare. 92. 143-60.

 

response

It would be hard gathering information from the 4-year-old, so having the family give information would be useful. Depending on how the grandmother is, and how her cognitive ability to answer questions. It might be hard to get all correct or detailed answers. Knowing the ethnicity of the biracial male can help determine if the child is predisposing to any disease. Heredity can lead to some patient’s having certain disease process.

I want to know why the parents is not in the picture to answer some of these health questions, the grandmother might not know all the answers. Especially the questions pertaining the mother gestational health and if the patient had any difficulty during the birthing process. For example, if the kid was premature or underweight. If the mother was using any substances during the perinatal stage.

Establishing rapport with the child and the grandmother would be key to having them tell the APRN the honest answers. Creating rapport at the beginning of a conversation with somebody new will often make the outcome of the conversation more positive. (Skills You Need, 2020). If they are living in a public housing complex, most likely they do not have the income to or health insurance to come for regular checkups. The patient might be underweight or overweight depending on the patient’s dietary intake. If you are a nurse, you know that a comprehensive patient health assessment is an important first step in developing a plan to deliver the best patient care. (TAMIU, n.d.).

I also believe that the APRN should ask questions involving any trauma or abuse the child might have met earlier in his life. If the biological parents are not involved in the child’s care, there must be a reason why. It could be due to neglect, abuse, or not wanting the child altogether. Social services might have more information if the APRN contacts them of any history the patient might have dealt with in the past.

References

Skills You Need. (2020). Building rapport. Retrieved on June 3, 2020 from https://www.skillsyouneed.com/ips/rapport.html

Texas A & M International University, TAMIU. (n.d.). Importance of comprehensive health assessments in nursing. Retrieved on June 2, 2020 from https://online.tamiu.edu/articles/rnbsn/importance-of-comprehensive-health-assessments.aspx

 

response 2

Great post. While communicating with the child is very beneficial, I feel that best results will be yielded from building a good rapport with the grandmother (Ball, Dains, Flynn, Soloman, & Stewart, 2015).  I personally feel that if this is done the health history will be more focused on the patient’s problems. When assessing the patient, it is important to assess the patient and their developmental mile markers. This can be done through getting to know the patient better and maintain direct eye contact when communicating (Bell & Condren, 2016). I also feel that attaining as much information as one can about the patient’s biological parents will be beneficial.

References:

Ball, J., W., Dains, J., E., Flynn, J., A., Soloman, B., S., & Stewart, R., W. (2015). Siedel’s guide to physical examination (8^th ed.). St. Louis, MO: Elsevier Mosby.

Bell, J., & Condren, M. (2016). Communication strategies for empowering and protecting children. The Journal of Pediatric Pharmacology and Therapeutics, 21(2), 176-184. Doi: 10.5863/1551-6776-21.2.176

 

Discussion: Building a Health History

To prepare:

With the information presented in Chapter 1 of Ball et al. in mind, consider the following:

• By Day 1 of this week, you will be assigned a new patient profile by your Instructor for this Discussion. Note: Please see the “Course Announcements” section of the classroom for your new patient profile assignment.
• How would your communication and interview techniques for building a health history differ with each patient?
• How might you target your questions for building a health history based on the patient’s social determinants of health?
• What risk assessment instruments would be appropriate to use with each patient, or what questions would you ask each patient to assess his or her health risks?
• Identify any potential health-related risks based upon the patient’s age, gender, ethnicity, or environmental setting that should be taken into consideration.
• Select one of the risk assessment instruments presented in Chapter 1 or Chapter 5 of the Seidel’s Guide to Physical Examination text, or another tool with which you are familiar, related to your selected patient.
• Develop at least five targeted questions you would ask your selected patient to assess his or her health risks and begin building a health history.

By Day 3 of Week 1

Post a summary of the interview and a description of the communication techniques you would use with your assigned patient. Explain why you would use these techniques. Identify the risk assessment instrument you selected, and justify why it would be applicable to the selected patient. Provide at least five targeted questions you would ask the patient.

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link, and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!

Read a selection of your colleagues’ responses.

By Day 6 of Week 1

Respond to at least two of your colleagues on 2 different days who selected a different patient than you, using one or more of the following approaches:

• Share additional interview and communication techniques that could be effective with your colleague’s selected patient.
• Suggest additional health-related risks that might be considered.
• Validate an idea with your own experience and additional research.

 

I was assigned the interview with the 4-year-old biracial male living with his grandmother in a high-density public housing complex.

Scenario: A 4-year-old boy was brought to the primary care office by his grandmother due to complaints of irritability, fever and cough.

 

Interview: The interview began with introducing myself to the patient and the 4-year-old. In order to make the child feel more comfortable a sticker was given to him and setting at eye level to begin the interview. The first questions that were asked were general, such as “What is the reason for the visit today”. After gathering information of the patient’s signs and symptoms, a more in depth questioning began. Specific questions were asked about the home life of the grandmother and the child. Questions were asked about the use of tobacco in the home and the age of the housing complex they live in. After further questioning, it was determined that further tests need to be conducted so a treatment plan can be devised.

The factors that would change the techniques for building a health history are determinant on the patient’s age, gender, culture and sensitive areas such as abuse, whether it be physically, emotionally or drug related. An interview with a child would be different compared to an interview with an adult. Words must be simplified in order for the child to understand what is being asked. When interviewing children, the parent is usually the main resource for the history. There may be differences in verbal and nonverbal expression between cultures (Ball, Dains, Flynn, Solomon & Stewart, 2019). Touch in one culture could have a different meaning in another, so in order to be respectful and sensitive to the individuals beliefs, it would be important to verify that it would be an appropriate action before touching that individual.

According to Artiga and Hinton (2018), social determinants of health include factors that look at socioeconomic status, education, access to health care, social support systems, employment, and physical environment. The socioeconomic factors are important to obtain because they could have a direct or indirect impact on the individuals physical and emotional health. Questions could be asked about the patient’s current job; area where they live; if they are able to afford their medications; what level of education they hold; and if they have anyone to help with driving to doctors appointments, to name a few.

My patient is living in a high-density public housing complex with his grandmother. This could pose an issue because having the responsibility of raising a grandchild is an added stressor and the grandmother could be experiencing anxiety and depression. This could affect the quality of care that the child is receiving. The Family Psychological Questionnaire assesses the guardians presence of depression, abuse and available social support system (McCarthy et al., 2016). The Centers for Disease Control and Prevention (2019), also has a development milestone checklist for infants and children to monitor if the growth is appropriate for their age.

Individuals who are living in older public housing are at risk for lead exposure. It would be important to assess the child for any delays in development, behavioral problems, hearing and speech problems, as these are common signs of lead poisoning. By using the developmental milestone risk assessment, it can be determined whether the child is growing at an appropriate rate both physically and mentally.

Five Targeted Questions

1. What is the reason for the visit today? What symptoms is the patient experiencing? This could be directed to both the grandmother and the 4 year old. When asking the 4 year old to describe what is wrong, different wording should be used along with asking the patient to point to the body part that is bothering him.

2. Are there any existing health problems?

3. How has the patient been behaving at home?

4. What support systems are available to both the 4 year old and the grandmother?

5. Can you describe the family dynamic at home?

References:

Artiga, S., & Hinton, E. (2019). Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity. Retrieved June 01, 2020, from https://www.kff.org/disparities-policy/issue-brief/beyond-health-care-the-role-of-social-determinants-in-promoting-health-and-health-equity/

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

CDC’s Developmental Milestones. (2019, December 05). Retrieved June 01, 2020, from https://www.cdc.gov/ncbddd/actearly/milestones/index.html

McCarthy, M., Hearps, S., Muscara, F., Anderson, V., Burke, K., Hearps, S., & Kazak, A. (2016). Family Psychosocial Risk Screening in Infants and Older Children in the Acute Pediatric Hospital Setting Using the Psychosocial Assessment Tool. Journal of Pediatric Psychology,41(7), 820-829. doi:https://doi.org/10.1093/jpepsy/jsw055

 

response

Thank you, for your informative post. Please see my input as follows.

Additional Interview and Communication Techniques

As you mentioned, an essential part of interviewing a child is understanding their developmental stage. Mendelsohn et al. (2020) explained that the child’s developmental stage is a primary structural component that is likely to influence the physical location of the child during the interview, and both the content and sequence of the questions asked. Building a good rapport with the pediatric patient is crucial to communicate and derive information from them effectively. According to Ball, Dains, Flynn, Solomon, and Stewart (2019), rapport-building strategies most frequently used with children are talking, touching the child, making sounds, sharing toys, and holding the child. As you indicated, providers must validate their communication techniques with caregivers to show sensitivity towards the patient’s culture and beliefs.

Additionally, it is crucial, such as you specified, to include caregivers (the grandmother in this case) as she would be the primary source of information or inquire about other points of contact who can participate in the child’s health assessment. Holland (2016) indicated that communicate on children’s level might entail chatting with the family to get a sense of the child’s developmental level. For example, a patient might be 15 years old but developmentally be more like a 6-year-old (Holland, 2016). Also, Holland (2016) recommended engaging parents in diagnosing and treating pediatric patients. For shy or stoic children, providers could rely on parents for both information and assistance (Holland, 2016).

Additional Health-Related Risks

As you indicated, making sure that the patient is in a household that promotes a culture of safety is imperative. As you illustrated, being concerned with lead poisoning and environmental hazards such as smoking are valid safety concerns. APRNs in all venues must have a working knowledge of patient-safety to advocate for best practices that attend to risks that are unique to children, that identify and support a culture of safety, and that lead efforts to eliminate avoidable harm in any setting to children (Mendelsohn et al., 2020). The APRN must use effective communication to educate the grandmother about home hazards and other safety concerns for toddlers. It is essential to talk with caregivers about what problems could arise and safety measures to prevent them. Also, helping pediatric patients learn about dangers while teaching them some basic safety rules and precautions can help them practice safe habits. For example, teaching the child to wash their hands often, keep toys clean, use the car seat, wear helmets as indicated, and be cautious with ovens and toasters, which can cause burns, can help to keep them safe.

Additionally, the APRN must assess the child’s immunization records. Though some caregivers are reluctant about vaccinations, the APRN must provide them with support evidence to educate them. Likewise, the provider must provide information to reinforce the understanding of those caregivers compliant with child vaccination. More so, the APRN must emphasize the need for the child to attend all routine checkups. Other health-related risks could relate to child abuse and neglect. The APRN must evaluate the child for signs of child abuse and neglect and refer the child to the necessary services. Also, the APRN should inform the grandmother about social services or local recourses as appropriate. As you mentioned, the APRN must evaluate proper growth and development milestones and refer the child to therapy or specialist as needed.

Idea Validation with Personal Experience and Additional Research

As you illustrated, building trust between a healthcare provider and pediatric patients is necessary for an appropriate assessment of this population. A recent experience with a 4-year-old admitted in my unit could reveal the challenge of communicating with a pediatric patient. The given 4-year-old female patient was shy to open up despite all attempts to build rapport with her.

After inquiring with parents about the patients’ hobbies and interests, the provider found that the child loved singer, Taylor Swift. The provider left the room to return without the white coat on and a portable speaker, which she used and played a song by the given artist. Upon listening to the song, the child danced with the provider, then talked to us. Holland (2016) explained that finding common ground and having fun with pediatric patients makes the provider seem less intimidating — like someone they can open up to and trust. Sometimes it takes time to build a trusting rapport with the pediatrician population, but it’s important not to stop trying (Holland, 2016).

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby

Holland. T. M. (2016). Talking to your pediatric patients: Tips from a pediatric hospitalist. Retrieved from https://medschool.ucla.edu/body.cfm?id=1158&action=detail&ref=806

Mendelsohn, A. L., Cates, C. B., Huberman, H. S., Johnson, S. B., Govind, P., Kincler, N., Rohatgi, R., Weisleder, A., Trogen, B., & Dreyer, B. P. (2020). Assessing the impacts of pediatric primary care parenting interventions on EI referrals through linkage with a public health database. Journal of Early Intervention, 42(1), 69–82