Ch. 29 Communication and Physical Assessment of the Child and Family

Review of Systems

(change of diet, illness, altered appetite), exercise tolerance, fevers (time of day), chills, night sweats (unrelated to climatic conditions), general ability to carry out activities of daily living Integument: Pruritus, pigment or other color changes (including birthmarks), acne, eruptions, rashes (location), bruises, petechiae, excessive dryness, general texture, tattoos or piercings, disorders or deformities of nails, hair growth or loss, hair color change (for adolescents, use of hair dyes or other potentially toxic substances, such as hair straighteners) Eyes: Visual problems (behaviors indicative of blurred vision, such as bumping into objects, clumsiness, sitting close to television, holding a book close to face, writing with head near desk, squinting, rubbing the eyes, bending head in an awkward position), cross-eyes (strabismus), eye infections, edema of lids, excessive tearing, use of glasses or contact lenses, date of last vision examination Ears/nose/mouth/throat: Earaches, ear discharge, evidence of hearing loss (ask about behaviors such as the need to repeat requests, loud speech, inattentive behavior), results of any previous auditory testing, nosebleeds (epistaxis), constant or frequent runny or stuffy nose, nasal obstruction (difficulty breathing), alteration or loss of sense of smell, mouth breathing, gum bleeding, number of teeth and pattern of eruption/loss, toothaches, tooth brushing, use of fluoride, difficulty with teething (symptoms), last visit to the dentist (especially if temporary dentition is complete), sore throats, difficulty swallowing, choking, hoarseness or other voice irregularities Neck: Pain, limitation of movement, stiffness, difficulty holding head straight (torticollis), thyroid enlargement, enlarged nodes or other masses Chest: Breast enlargement, discharge, masses; for adolescent girls, ask about breast self-examination Respiratory: Chronic cough, wheezing, shortness of breath at rest or on exertion, difficulty breathing, snoring, sputum production, infections (pneumonia, tuberculosis), skin reaction from tuberculin testing Cardiovascular: Cyanosis or fatigue on exertion, history of heart murmur or rheumatic fever, tachycardia, syncope, edema Gastrointestinal: Appetite, nausea, vomiting (not associated with eating; may be indicative of brain tumor or increased intracranial pressure), abdominal pain, jaundice or yellowing skin or sclera, belching, flatulence, distention, diarrhea, constipation, recent change in bowel habits, blood in stools Genitourinary: Pain on urination, frequency, hesitancy, urgency, hematuria, nocturia, polyuria, enuresis, unpleasant odor to urine, force of stream, discharge, change in size of scrotum, date and result of last urinalysis; for adolescents, sexually transmitted infection and type of treatment; for adolescent boys, ask about testicular self-examination Gynecologic: Menarche, date of LMP, regularity or problems with menstruation, vaginal discharge, pruritus; if sexually active, type of contraception, sexually transmitted infection and type of treatment; if sexually active with weakened immune system or if 21 years of age and older, date and result of last Papanicolaou (Pap) smear; obstetric history (as discussed under birth history, when applicable) Musculoskeletal: Weakness, clumsiness, lack of coordination, unusual movements, scoliosis, back pain, joint pain or swelling, muscle pains or cramps, abnormal gait, deformity, fractures, serious sprains, activity level Neurologic: Headaches, seizures, tremors, tics, dizziness, loss of consciousness episodes, loss of memory, developmental delays or concerns Endocrine: Intolerance to heat or cold, excessive thirst or urination, excessive sweating, salt craving, rapid or slow growth, signs of early or late puberty Hematologic/lymphatic: Easy bruising or bleeding, anemia, date and result of last blood count, blood transfusions, swollen or painful lymph nodes (cervical, axillary, inguinal) Allergic/immunologic: Allergic responses, anaphylaxis, eczema, rhinitis, unusual sneezing, autoimmunity, recurrent infections, infections associated with unusual complications Psychiatric: General affect, anxiety, depression, mood changes, hallucinations, attention span, tantrums, behavior problems, suicidal ideation, substance abuse

Guidelines Communicating With Adolescents

-Build a Foundation -Spend time together. -Encourage expression of ideas and feelings. -Respect their views. -Tolerate differences. -Praise good points. -Respect their privacy. -Set a good example. -Communicate Effectively -Give undivided attention. -Listen, listen, listen. -Be courteous, calm, honest, and open-minded. -Try not to overreact. If you do, take a break. -Avoid judging or criticizing. -Avoid the "third degree" of continuous questioning. -Choose important issues when taking a stand. -After taking a stand: • Think through all options. • Make expectations clear.

My Plate

1/2 plate = fruits & vegetables 1/2 plate = grains & lean protein Cup of low-fat or fat-free milk

Anticipatory Guidance—Sexuality (BOX 29.5)

12 to 14 Years of Age Have adolescent identify a supportive adult with whom to discuss sexuality issues and concerns. Discuss the advantages of delaying sexual activity. Discuss making responsible decisions regarding normal sexual feelings. Discuss the roles of gender, peer pressure, and the media in sexual decision making. Discuss contraceptive options (advantages and disadvantages). Provide education regarding sexually transmitted infections (STIs), including human immunodeficiency virus (HIV) infection; clarify risks, and discuss condoms. Discuss abuse prevention, including avoiding dangerous situations, the role of drugs and alcohol, and the use of self-defense. Have the adolescent clarify his or her values, needs, and ability to be assertive. If the adolescent is sexually active, discuss limiting partners, use of condoms, and contraceptive options. Have a confidential interview with the adolescent (including a sexual history). Discuss the evolution of sexual identity and expression. Discuss breast examination or testicular examination. 15 to 18 Years of Age Support delaying sexual activity. Discuss alternatives to intercourse. Discuss "When are you ready for sex?" Clarify values; encourage responsible decision making. Discuss consequences of unprotected sex: Early pregnancy; STIs, including HIV infection. Discuss negotiating with partners and barriers to safer sex. If the adolescent is sexually active, discuss limiting partners, use of condoms, and contraceptive options. Emphasize that sex should be safe and pleasurable for both partners. Have a confidential interview with the adolescent. Discuss concerns about sexual expression and identity.

Habits to Explore During a Health Interview

• Behavior patterns, such as nail biting, thumb sucking, pica (habitual ingestion of nonfood substances), rituals ("security" blanket or toy), and unusual movements (head banging, rocking, overt masturbation, walking on toes) • Activities of daily living, such as hours of sleep and arising, duration of nighttime sleep and naps, type and duration of exercise, regularity of stools and urination, age of toilet training, and daytime or nighttime bedwetting • Unusual disposition; response to frustration • Use or abuse of alcohol, drugs, coffee, or tobacco

head and neck abnormalities

After 6 months of age, significant head lag strongly indicates cerebral injury and is referred for further evaluation. Hyperextension of the head (opisthotonos) with pain on flexion is a serious indication of meningeal irritation and is referred for immediate medical evaluation. If any masses are detected in the neck, report them for further investigation. Large masses can block the airway.

(Present Illness) Immunizations

All immunizations and "boosters" are listed, stating (1) the name of the specific disease, (2) the number of injections, (3) the dosage (sometimes lesser amounts are given if a reaction is anticipated), (4) the date when administered, and (5) the occurrence of any reaction following immunization.

Anthropometry

An essential parameter of nutritional status, is the measurement of height, weight, head circumference, proportions, skinfold thickness, and arm circumference in children. Height and head circumference reflect past nutrition, whereas weight, skinfold thickness, and arm circumference reflect present nutritional status, especially of protein and fat reserves. Skinfold thickness is a measurement of the body's fat content because approximately one-half the body's total fat stores are directly beneath the skin. The upper arm muscle circumference measures total muscle mass. Because muscle serves as the body's major protein reserve, this measurement is considered an index of the body's protein stores. Ideally, growth measurements are recorded over time, and comparisons are made regarding the velocity of growth and weight gain based on previous and present values.

Telephone Triage Guidelines

Date and time Background • Name, age, sex • Contact information • Chronic illness • Allergies, current medications, treatments, or recent immunizations Chief complaint General symptoms • Severity • Duration • Other symptoms • Pain Systems review Steps taken • Advised to call emergency medical services (911) • Advised to go to emergency department • Advised to see practitioner (today, tomorrow, or later appointment) • Advised regarding home care • Advised to call back if symptoms worsen or fail to improve

Children whose growth may be questionable include the following:

• Children whose height and weight percentiles are widely disparate (e.g., height in the 10th percentile and weight in the 90th percentile, especially with above-average skinfold thickness) • Children who fail to follow the expected growth velocity in height and weight, especially during the rapid growth periods of infancy and adolescence • Children who show a sudden increase (except during normal puberty) or decrease in a previously steady growth pattern (i.e., crossing two major percentile lines after 3 years of age) • Children who are short in the absence of short parents

Using Children as Interpreters

Do not use of children because they are often not mature enough to understand health care questions, answers, or messages (American Academy of Pediatrics, 2011). Children may inadvertently commit interpretive errors, such as inaccuracies, omissions, or substitutions. Children can be adversely affected by serious or sensitive information that may be discussed. In some cultures, using a child as an interpreter is considered an insult to an adult because children are expected to show respect by not questioning their elders. Some institutions prohibit the use of children as interpreters; check institutional policy for compliance. If a trained on-site or community-based interpreter is not available, a language line using a telephonic interpreter may be an option.

Communication Related to Development of Thought Processes: Adolescence

Anticipating shifts in identity allows the nurse to adjust the course of interaction to meet the needs of the moment. No single approach can be relied on consistently, and encountering cooperation, hostility, anger, bravado, and a variety of other behaviors and attitudes is common. It is as much a mistake to regard an adolescent as an adult with an adult's wisdom and control as it is to assume that a teenager has the concerns and expectations of a child. If the parents and teenager are together, talking with the adolescent first has the advantage of immediately identifying with the young person, thus fostering the interpersonal relationship. However, talking with the parents initially may provide insight into the family relationship. Privacy and confidentiality are of great importance when communicating with adolescents because it is consistent with developmental maturity and autonomy

Providing Anticipatory Guidance

Anticipatory guidance focused on providing families information on normal growth and development and nurturing childrearing practices. For example, one of the most significant areas in pediatrics is injury prevention To achieve this level of anticipatory guidance, the nurse should do the following: • Base interventions on needs identified by the family, not by the professional • View the family as competent or as having the ability to be competent • Provide opportunities for the family to achieve competence

Communicating With Parents

Assess child (verbal and nonverbal input), information from the parent, and own observations of the child Interpretation of the relationship between the child and the parent. When children are old enough to be active participants in their own health care, the parent becomes a collaborator.

Blood Pressure

Auscultation remains the gold standard method of BP measurement in children, under most circumstances. Oscillometric devices measure mean arterial BP and then calculate systolic and diastolic values. The algorithms used by companies are proprietary and differ from company to company and device to device. These devices can yield results that vary widely when one is compared with another, and they do not always closely match BP values obtained by auscultation. An elevated BP reading obtained with an automated or oscillometric device should be repeated using auscultation. BP readings using oscillometry, such as Dinamap, are generally higher (10 mm Hg higher) than measurements using auscultation

BMI

BMI for sex and age may be used to identify children and adolescents who are either: -Underweight = <5th percentile -Healthy weight = 5th percentile to <85th percentile -Overweight = ≥85th percentile and <95th percentile -Obese = ≥95th percentile

Encouraging the Parents to Talk

Be alert for clues/signals by which a parent communicates worries and anxieties. Careful phrasing with broad, open-ended questions (such as, "What is Jimmy eating now?") May be necessary to direct another question on the basis of an observation, such as "Connie seems unhappy today," or "How do you feel when David cries?" If the parent appears to be tired or distraught, consider asking, "What do you do to relax?" or "What help do you have with the children?" A comment such as "You handle the baby very well. What kind of experience have you had with babies?" to new parents who appear comfortable with their first child gives positive reinforcement and provides an opening for questions they might have on the infant's care

Ears and Nose

Ears ➢External structures ➢Internal stuctures •Positioning the child •Otoscopic examination •Auditory testing Nose ➢External structures ➢Internal structures

Being Empathetic

Empathy is the capacity to understand what another person is experiencing from within that person's frame of reference; it is often described as the ability to put oneself in another's shoes. The essence of empathic interaction is accurate understanding of another's feelings.

Cultural Considerations Food Practices

Because cultural practices are prevalent in food preparation, consider carefully the kinds of questions that are asked and the judgments made during counseling. For example, some cultures, such as Hispanic, African-American, and Native American, include many vegetables, legumes, and starches in their diet that together provide sufficient essential amino acids even though the actual amount of meat or dairy protein is low. The most common and probably easiest method of assessing daily intake is the 24-hour recall. The child or parent recalls every item eaten in the past 24 hours and the approximate amounts. The 24-hour recall is most beneficial when it represents a typical day's intake. Some of the difficulties with a daily recall are the family's inability to remember exactly what was eaten and inaccurate estimation of portion size. To increase accuracy of reporting portion sizes, the use of food models and additional questions are recommended. In general, this method is most useful in providing qualitative information about the child's diet. To improve the reliability of the daily recall, the family can complete a food diary by recording every food and liquid consumed for a certain number of days. A 3-day record consisting of 2 weekdays and 1 weekend day is representative for most people. Providing specific charts to record intake can improve compliance. The family should record items immediately after eating.

Infant Assessment Prep

Before able to sit alone—supine or prone, preferably in parent's lap; before 4 to 6 months, can place on examining table After able to sit alone—sitting in parent's lap whenever possible; if on table, place with parent in full view If quiet, auscultate heart, lungs, and abdomen. Record heart and respiratory rates. Palpate and percuss same areas. Proceed in usual head-to-toe direction. Perform traumatic procedures last (eyes, ears, mouth [while crying]). Elicit reflexes as body part is examined. Elicit Moro reflex last. Completely undress if room temperature permits. Leave diaper on male infant. Gain cooperation with distraction, bright objects, rattles, talking. Smile at infant; use soft, gentle voice. Pacify with bottle of sugar water or feeding. Enlist parent's aid for restraining to examine ears, mouth. Avoid abrupt, jerky movements.

Recommended Temperature Screening Routes in Infants and Children

Birth to 2 Years of Age Axillary Rectal: if definitive temperature reading is needed for infants older than 1 month of age 2 to 5 Years of Age Axillary Tympanic Oral: when child can hold thermometer under tongue Rectal: if definitive temperature reading is needed Older Than 5 Years of Age Oral Axillary Tympanic

Listening and Cultural Awareness

Careful listening relies on the use of clues, verbal leads, or signals from the interviewee to move the interview along. Frequent references to an area of concern, repetition of certain key words, or a special emphasis on something or someone serve as cues to the interviewer for the direction of inquiry. Concerns and anxieties are often mentioned in a casual, offhand manner. Even though they are casual, they are important and deserve careful scrutiny to identify problem areas. -E.g., a parent who is concerned about a child's habit of bedwetting may casually mention that the child's bed was "wet this morning."

Communication Related to Development of Thought Processes: Early Childhood

Children younger than 5 years of age are egocentric. They see things only in relation to themselves and from their point of view. Focus communication on them. Tell them what they can do or how they will feel. Experiences of others are of no interest to them. Futile to use another child's experience in an attempt to gain the cooperation of small children. Allow them to touch and examine articles they will come in contact with.

family assessment

Collect data about the composition of the family & the relationships among its members. Refers to all those individuals who are considered by the family member to be significant to the nuclear unit, including relatives, friends, and social groups (e.g., school and church). Although family assessment is not family therapy, it can and frequently is therapeutic. Involving family members in discussing family characteristics and activities can provide insight into family dynamics and relationships ATI: Family assessment includes: -Medical history on parents, siblings, grandparents -Family structure including family members, family size, roles/position within family, occupation & education of family members -Support systems -Stressors

Blocks to Communication

Communication Barriers (Nurse) -Socializing -Giving unrestricted and sometimes unsought advice -Offering premature or inappropriate reassurance -Giving over-ready encouragement -Defending a situation or opinion -Using stereotyped comments or clichés -Limiting expression of emotion by asking directed, closed-ended questions -Interrupting and finishing the person's sentence -Talking more than the interviewee -Forming prejudged conclusions -Deliberately changing the focus Signs of Information Overload (Patient) -Long periods of silence -Wide eyes and fixed facial expression -Constant fidgeting or attempting to move away -Nervous habits (e.g., tapping, playing with hair) -Sudden interruptions (e.g., asking to go to the bathroom) -Looking around -Yawning, eyes drooping -Frequently looking at a watch or clock -Attempting to change the topic of discussion

Eyes

External structures Internal structures •Preparing the child •Funduscopic examination ➢Vision testing •Occular alignment •Visual acuity in children •Visual acuity in infants and difficult to test children •Peripheral vision •Color vision

Tests for Cerebellar Function

Finger-to-nose test: With the child's arm extended, ask the child to touch the nose with the index finger with the eyes open and then closed. Heel-to-shin test: Have the child stand and run the heel of one foot down the shin or anterior aspect of the tibia of the other leg, both with the eyes opened and then closed. Romberg test: Have the child stand with the eyes closed and heels together; falling or leaning to one side is abnormal and is called the Romberg sign.

Directing the Focus

For example, if the parent proceeds to list the other children by name, say, "Tell me their ages, too." If the parent continues to describe each child in depth, which is not the purpose of the interview, redirect the focus by stating, "Let's talk about the other children later. You were beginning to tell me about Paul's activities at school." This approach conveys interest in the other children but focuses the assessment on the patient.

Temperature

For rectal temperatures in children, a value of 37° to 37.5° C (98.6° to 99.5° F) is an acceptable range, where heat loss and heat production are balanced. For neonates, a core body temperature between 36.5° and 37.6° C (97.7° to 99.7° F) is a desirable range

Clinical Assessment of Nutritional Status (Table 29. 1, p. 754)

General growth Skin, hair, nails Head, neck, EENM Chest CVS, abdomen, musculoskeletal, neuro

Family Health History

Generally only 1st-degree relatives (parents, siblings, grandparents, and immediate aunts and uncles). Includes age, marital status, health status, cause of death if deceased, and any evidence of conditions, such as early heart disease, stroke, sudden death from unknown cause, hypercholesterolemia, hypertension, cancer, diabetes mellitus, obesity, congenital anomalies, allergies, asthma, seizures, tuberculosis, abnormal bleeding, sickle cell disease, cognitive impairment, hearing or visual deficits, and psychiatric disorders (e.g., depression, psychosis, or emotional problems).

Head Circumference

Head circumference is a reflection of brain growth. Measure head circumference in children up to 36 months of age and in any child whose head size is questionable. Measure the head at its greatest frontooccipital circumference, usually slightly above the eyebrows and pinna of the ears and around the occipital prominence at the back of the skull (Fig. 29.11). Use a paper or non-stretchable tape because a cloth tape can stretch and give a falsely small measurement Generally, head and chest circumferences are equal at about 1 to 2 years of age. During childhood, chest circumference exceeds head size by about 5 to 7 cm (2 to 2.75 inches).

Outline of a Pediatric Health History

Identifying information 1. Name 2. Address 3. Telephone 4. Birth date and place 5. Race or ethnic group 6. Sex 7. Religion 8. Date of interview 9. Informant Chief complaint (CC): To establish the major specific reason for the child's and parents' seeking of health care Present illness (PI): To obtain all details related to the chief complaint Past history (PH): To elicit a profile of the child's previous illnesses, injuries, or surgeries 1. Birth history (pregnancy, labor and delivery, perinatal history) 2. Previous illnesses, injuries, or surgeries 3. Allergies 4. Current medications 5. Immunizations 6. Growth and development 7. Habits Review of systems (ROS): To elicit information concerning any potential health problem 1. Constitutional 2. Integument 3. Eyes 4. Ears/nose/mouth/throat 5. Neck 6. Chest 7. Respiratory 8. Cardiovascular 9. Gastrointestinal 10. Genitourinary 11. Gynecologic 12. Musculoskeletal 13. Neurologic 14. Genitourinary 15. Gynecologic 16. Musculoskeletal 17. Neurologic 18. Endocrine Family medical history: To identify genetic traits or diseases that have familial tendencies and to assess exposure to a communicable disease in a family member and family habits that may affect the child's health, such as smoking and chemical use Psychosocial history: To elicit information about the child's self-concept Sexual history: To elicit information concerning the child's sexual concerns or activities and any pertinent data regarding adults' sexual activity that influences the child Family history: To develop an understanding of the child as an individual and as a member of a family and a community 1. Family composition 2. Home and community environment 3. Occupation and education of family members 4. Cultural and religious traditions 5. Family function and relationships Nutritional assessment: To elicit information on the adequacy of the child's nutritional intake and needs 1. Dietary intake 2. Clinical examination

Communication Related to Development of Thought Processes: Infancy

Infants communicate their needs and feelings through nonverbal behaviors and vocalizations that can be interpreted by someone who is around them for a sufficient time. Infants smile and coo when content and cry when distressed. Crying is provoked by unpleasant stimuli from inside or outside, such as hunger, pain, body restraint, or loneliness. Infants respond to adults' nonverbal behaviors. They become quiet when they are cuddled, rocked, or receive other forms of gentle physical contact. They receive comfort from the sound of a soft voice even though they do not understand the words that are spoken.

Interviewing Without Judgment

It is easy to inject one's own attitudes and feelings into an interview. Often nurses' own prejudices and assumptions, which may include racial, religious, and cultural stereotypes, influence their perceptions of a parent's behavior. What the nurse may interpret as a parent's passive hostility or lack of interest may be shyness or an expression of anxiety. For example, in Western cultures, eye contact and directness are signs of paying attention. However, in many non-Western cultures, including that of Native Americans, directness (e.g., looking someone in the eye) is considered rude. Children are taught to avert their gaze and to look down when being addressed by an adult, especially one with authority (Ball, Dains, Flynn, et al., 2014). Therefore, nurses must make judgments about "listening," as well as verbal interactions, with an appreciation of cultural differences.

Skinfold Thickness and Arm Circumference

Measure skinfold thickness with special calipers, such as the Lange calipers. The most common sites for measuring skinfold thickness are the triceps (most practical for routine clinical use), subscapular, suprailiac, abdomen, and upper thigh. For greatest reliability, follow the exact procedure for measurement and record the average of at least two measurements of one site. Arm circumference is an indirect measure of muscle mass. Measurement of arm circumference follows the same procedure as for skinfold thickness except the midpoint is measured with a paper or steel tape. Place the tape vertically along the posterior aspect of the upper arm from the acromial process and to the olecranon process; half of the measured length is the midpoint

Interpreting Blood Pressure

Measuring and interpreting BP in infants and children requires attention to correct procedure because (1) limb sizes vary and cuff selection must accommodate the circumference; (2) excessive pressure on the antecubital fossa affects the Korotkoff sounds; (3) children easily become anxious, which can elevate BP; and (4) BP values change with age and growth. In children and adolescents, determine the normal range of BP by body size and age. BP standards that are based on gender, age, and height provide a more precise classification of BP according to body size. This approach avoids misclassifying children who are very tall or very short.

How to improve interviewing skills

One of the best methods for improving interviewing skills is audiotape or videotape feedback. With supervision and guidance, the interviewer can recognize the blocks and consciously avoid them

Initiating a Comprehensive Family Assessment

Perform a comprehensive assessment on the following: • Children receiving comprehensive well-child care • Children experiencing major stressful life events (e.g., chronic illness, disability, parental divorce, death of a family member) • Children requiring extensive home care • Children with developmental delays • Children with repeated accidental injuries and those with suspected child abuse • Children with behavioral or physical problems that could be caused by family dysfunction

Guidelines Performing Pediatric Physical Examination

Perform the examination in an appropriate, nonthreatening area: • Have room well-lit and decorated with neutral colors. • Have room temperature comfortably warm. • Place all strange and potentially frightening equipment out of sight. • Have some toys, dolls, stuffed animals, and games available for the child. • If possible, have rooms decorated and equipped for different-age children. • Provide privacy, especially for school-age children and adolescents. • Provide time for play and becoming acquainted. Observe behaviors that signal the child's readiness to cooperate: • Talking to the nurse • Making eye contact • Accepting the offered equipment • Allowing physical touching • Choosing to sit on the examining table rather than the parent's lap If signs of readiness are not observed, use the following techniques: • Talk to the parent while essentially "ignoring" the child; gradually focus on the child or a favorite object, such as a doll. • Make complimentary remarks about the child, such as about his or her appearance, dress, or a favorite object. • Tell a funny story, or play a simple magic trick. • Have a nonthreatening "friend" available, such as a hand puppet, to "talk" to the child for the nurse (see Fig. 4.26, A). If the child refuses to cooperate, use the following techniques: • Assess reason for uncooperative behavior; consider that a child who is unduly afraid may have had a traumatic experience. • Try to involve the child and parent in the process. • Avoid prolonged explanations about the examining procedure. • Use a firm, direct approach regarding expected behavior. • Perform the examination as quickly as possible. • Have an attendant gently restrain the child. • Minimize any disruptions or stimulation. • Limit the number of people in the room. • Use an isolated room. • Use a quiet, calm, confident voice. Begin the examination in a nonthreatening manner for young children or children who are fearful: • Use activities that can be presented as games, such as test for cranial nerves (see Table 29.11 or parts of developmental screening tests (see Chapter 28). • Use approaches such as Simon Says to encourage the child to make a face, squeeze a hand, stand on one foot, and so on. • Use the paper-doll technique: 1. Lay the child supine on an examining table or floor that is covered with a large sheet of paper. 2. Trace around the child's body outline. 3. Use the body outline to demonstrate what will be examined, such as drawing a heart and listening with a stethoscope before performing activity on the child. If several children in the family will be examined, begin with the most cooperative child to model desired behavior. Involve the child in the examination process: • Provide choices, such as sitting on table or in parent's lap. • Allow the child to handle or hold equipment. • Encourage the child to use equipment on a doll, family member, or examiner. • Explain each step of the procedure in simple language. • Examine the child in a comfortable and secure position: • Sitting in parent's lap • Sitting upright if in respiratory distress Proceed to examine the body in an organized sequence (usually head to toe) with the following exceptions: • Alter sequence to accommodate needs of different-age children (see Table 29.2). • Examine painful areas last. • In an emergency situation, examine vital functions (airway, breathing, and circulation) and injured area first. Reassure the child throughout the examination, especially about bodily concerns that arise during puberty. Discuss findings with the family at the end of the examination. Praise the child for cooperation during the examination; give a reward such as a small toy or sticker.

School Age Child Assessment Prep

Prefer sitting Cooperative in most positions Younger child prefers parent's presence Older child may prefer privacy Proceed in head-to-toe direction. May examine genitalia last in older child. Respect need for privacy. Request self-undressing. Allow to wear underpants. Give gown to wear. Explain purpose of equipment and significance of procedure, such as otoscope to see eardrum, which is necessary for hearing. Teach about body function and care.

Preschool Child Assessment Prep

Prefer standing or sitting Usually cooperative prone or supine Prefer parent's closeness If cooperative, proceed in head-to-toe direction. If uncooperative, proceed as with toddler. Request self-undressing. Allow to wear underpants if shy. Offer equipment for inspection; briefly demonstrate use. Make up story about procedure (e.g., "I'm seeing how strong your muscles are" [blood pressure]). Use paper-doll technique. Give choices when possible. Expect cooperation; use positive statements (e.g., "Open your mouth").

What is the gold standard for temperature with infants and children?

Rectal measurement remains the clinical gold standard for the precise diagnosis of fever in infants and children compared with other methods

Adolescent Assessment Prep

Same as for school-age child Offer option of parent's presence Same as older school-age child. May examine genitalia last. Allow to undress in private. Give gown. Expose only area to be examined. Respect need for privacy. Explain findings during examination (e.g., "Your muscles are firm and strong"). Matter-of-factly comment about sexual development (e.g., "Your breasts are developing as they should be"). Emphasize normalcy of development. Examine genitalia as any other body part; may leave to end.

Use of Silence

Silence permits the interviewee to sort out thoughts and feelings and search for responses to questions. Silence can also be a cue for the interviewer to go more slowly, re-examine the approach, and not push too hard (Ball, Dains, Flynn, et al., 2014).

Toddler Assessment Prep

Sitting or standing on or near parent Prone or supine in parent's lap Inspect body area through play: "Count fingers," "tickle toes." Use minimum physical contact initially. Introduce equipment slowly. Auscultate, percuss, palpate whenever quiet. Perform traumatic procedures last (same as for infant). Have parent remove outer clothing. Remove underwear as body part is examined. Allow toddler to inspect equipment; demonstrating use of equipment is usually ineffective. If uncooperative, perform procedures quickly. Use restraint when appropriate; request parent's assistance. Talk about examination if cooperative; use short phrases. Praise for cooperative behavior.

(Present Illness) Previous Illnesses, Injuries, & Surgeries

Start w/general question - "What other illnesses has your child had?" -Ask about colds, earaches, childhood diseases (MMR, varicella, pertussis, diphtheria, TB, scarlet fever, strep, recurrent ear infections, GERD, tonsillitis, allergies -Injuries requiring medical intervention, hospitalization, surgeries, procedures, & dates of each incident -Injuries = falls, poisoning, choking, concussion, fractures, burns

Weight

Take measurements in a comfortably warm room. When the birth-to-2-year or birth-to-36-month growth charts are used, children should be weighed nude. Older children are usually weighed while wearing their underpants, a gown, or light clothing, depending on the setting. However, always respect the privacy of all children. If the child must be weighed wearing some type of special device, such as a prosthesis or an armboard for an intravenous device, note this when recording the weight. Children who are measured for recumbent length are usually weighed on an infant platform scale and placed in a lying or sitting position. When weighing a child, place your hand slightly above the infant to prevent him or her from accidentally falling off the scale (Fig. 29.10, A), or stand close to the toddler, ready to prevent a fall (see Fig. 29.10, B). For maximum asepsis, cover the scale with a clean sheet of paper between each child's weight measurement.

Dietary Intake

The Dietary Reference Intakes (DRIs) are a set of four evidence-based nutrient reference values that provide quantitative estimates of nutrient intake for use in assessing and planning dietary intake (US Department of Agriculture, National Agricultural Library, 2014). The specific DRIs are as follows: Estimated Average Requirement (EAR): Estimated to meet the nutrient requirement of one-half of healthy individuals for a specific age and gender group Recommended Dietary Allowance (RDA): Sufficient to meet the nutrient requirement of nearly all healthy individuals for a specific age and gender group Adequate Intake (AI): Based on estimates of nutrient intake by healthy individuals Tolerable Upper Intake Level (UL): Highest nutrient intake level likely to pose no risk for adverse health effects

(Present Illness) Birth History

The birth history includes all data concerning (1) the mother's health during pregnancy, (2) the labor and delivery, and (3) the infant's condition immediately after birth

Chief Complaint

The chief complaint is the specific reason for the child's visit to the clinic, office, or hospital. It's the theme, w/HPI as the description of the problem. Elicit CC by asking open-ended, neutral questions (such as, "What seems to be the matter?" "How may I help you?" or "Why did you come here today?"). Avoid labeling-type questions (such as, "How are you sick?" or "What is the problem?"). It is possible that the reason for the visit is not an illness or problem.

Assurance of Privacy and Confidentiality

The physical environment should allow for as much privacy as possible with distractions (such as, interruptions, noise, or other visible activity) kept to a minimum. The environment should also have some play provision for young children to keep them occupied during the parent-nurse interview

Length

The term length refers to measurements taken when children are supine (also referred to as recumbent length). Until children are 2 years of age and able to stand alone (or 36 months of age if using a chart for birth to 36 months), measure recumbent length using a length board and two measurers Because of the normally flexed position during infancy, fully extend the body by (1) holding the head in midline, (2) grasping the knees together gently, and (3) pushing down on the knees until the legs are fully extended and flat against the table. Place the head touching the headboard and the footboard firmly against the heels of the feet. A tape measure should not be used to measure the length of infants and children due to inaccuracy and unreliability (Foote, Brady, Burke, et al., 2014).

Psychosocial History

Through observation, obtain a general idea of how children handle themselves in terms of confidence in dealing with others, answering questions, and coping with new situations. Observe the parent-child relationship for the types of messages sent to children about their coping skills and self-worth. Do the parents treat the child with respect, focusing on strengths, or is the interaction one of constant reprimands with emphasis on weaknesses and faults? Do the parents help the child learn new coping strategies or support the ones the child uses?

(Present Illness) Analyzing the Symptom: Pain

Type Be as specific as possible. With young children, asking the parents how they know the child is in pain may help describe its type, location, and severity. For example, a parent may state, "My child must have a severe earache because she pulls at her ears, rolls her head on the floor, and screams. Nothing seems to help." Help older children describe the "hurt" by asking them if it is sharp, throbbing, dull, or stabbing. Record whatever words they use in quotes. Location Be specific. "Stomach pain" is too general a description. Children can better localize the pain if they are asked to "point with one finger to where it hurts" or to "point to where mommy or daddy would put a Band-Aid." Determine if the pain radiates by asking, "Does the pain stay there or move? Show me with your finger where the pain goes." Severity Severity is best determined by finding out how it affects the child's usual behavior. Pain that prevents a child from playing, interacting with others, sleeping, and eating is most often severe. Assess pain intensity using a rating scale, such as a numeric or Wong-Baker FACES Pain Rating Scale (see Chapter 30). Duration Include the duration, onset, and frequency. Describe these in terms of activity and behavior, such as "pain reported to last all night; child refused to sleep and cried intermittently." Influencing Factors Include anything that causes a change in the type, location, severity, or duration of the pain: (1) precipitating events (those that cause or increase the pain), (2) relieving events (those that lessen the pain, such as medications), (3) temporal events (times when the pain is relieved or increased), (4) positional events (standing, sitting, lying down), and (5) associated events (meals, stress, coughing).

Assessing the Child

Using developmental and chronologic age as the main criteria for assessing each body system accomplishes several goals: • Minimizes stress and anxiety associated with assessment of various body parts • Fosters a trusting nurse-child-parent relationship • Allows for maximum preparation of the child • Preserves the essential security of the parent-child relationship, especially with young children • Maximizes the accuracy and reliability of assessment findings

Height

Wall charts and flip-up horizontal bars (floppy-arm devices) mounted to weighing scales should not be used to measure the height of children (Foote, Brady, Burke, et al., 2014). These devices are not steady and do not maintain a right angle to the vertical ruler, preventing an accurate and reliable height. Measure height by having the child, with the shoes removed, stand as tall and straight as possible with the head in midline and the line of vision parallel to the ceiling and floor. Be certain the child's back is to the wall or other vertical flat surface, with the head, shoulder blades, buttocks, and heels touching the vertical surface (see Fig. 29.9, B). Check for and correct slumping of the shoulders, positional lordosis, bending of the knees, or raising of the heels. Nursing Alert Normally height is less if measured in the afternoon than in the morning. The time of day should be recorded when measurements are taken (Foote, Brady, Burke, et al., 2014). For children in whom there are concerns about growth, serial measurements should be taken at the same time of day, when possible, to establish an accurate growth velocity (see Evidence-Based Practice box: Linear Growth Measurement in Pediatrics). For the most accurate measurement, use a wall-mounted unit (stadiometer; see Fig. 29.9). To improvise a flat, vertical surface for measuring height, attach a paper or metal tape or yardstick to the wall, position the child adjacent to the tape, and place a three-dimensional object, such as a thick book or box, on top of the head. Rest the side of the object firmly against the wall to form a right angle. Measure length or stature to the nearest 1 mm or inch.

Dietary History

What are the family's usual mealtimes? Do family members eat together or at separate times? Who does the family grocery shopping and meal preparation? How much money is spent to buy food each week? How are most foods prepared (baked, broiled, fried, other)? How often does the family or your child eat out? • What kinds of restaurants do you go to? • What kinds of food does your child typically eat at restaurants? Does your child eat breakfast regularly? Where does your child eat lunch? What are your child's favorite foods, beverages, and snacks? • What are the average amounts eaten per day? • What foods are artificially sweetened? • What are your child's snacking habits? • When are sweet foods usually eaten? • What are your child's tooth brushing habits? What special cultural practices are followed? What ethnic foods are eaten? What foods and beverages does your child dislike? How would you describe your child's usual appetite (hearty eater, picky eater)? What are your child's feeding habits (breast, bottle, cup, spoon, eats by self, needs assistance, any special devices)? Does your child take vitamins or other supplements? Do they contain iron or fluoride? Does your child have any known or suspected food allergies? Is your child on a special diet? Has your child lost or gained weight recently? Are there any feeding problems (excessive fussiness, spitting up, colic, difficulty sucking or swallowing)? Are there any dental problems or appliances, such as braces, that affect eating? What types of exercise does your child do regularly? Is there a family history of cancer, diabetes, heart disease, high blood pressure, or obesity?

Observing Behavior

What is the child's overall personality? • Does the child have a long attention span, or is he or she easily distracted? • Can the child follow two or three commands in succession without the need for repetition? • What is the child's response to delayed gratification or frustration? • Does the child use eye contact during conversation? • What is the child's reaction to the nurse and family members? • Is the child quick or slow to grasp explanations?

Additional Dietary Questions for Infants

What was the infant's birth weight? When did it double? Triple? Was the infant premature? Are you breastfeeding, or have you breastfed your infant? For how long? If you use a formula, what is the brand? • How long has the infant been taking it? • How many ounces does the infant drink per day? Are you giving the infant cow's milk (whole, low-fat, skim)? • When did you start? • How many ounces does the infant drink per day? Do you give your infant extra fluids (water, juice)? If the infant takes a bottle to bed at nap or nighttime, what is in the bottle? At what age did the child start on cereal, vegetables, meat or other protein sources, fruit or juice, finger food, and table food? Do you make your own baby food or use commercial foods, such as infant cereal? Does the infant take a vitamin or mineral supplement? If so, what type? Has the infant had an allergic reaction to any food(s)? If so, list the foods and describe the reaction. Does the infant spit up frequently; have unusually loose stools; or have hard, dry stools? If so, how often? How often do you feed your infant? How would you describe your infant's appetite?

Communication Related to Development of Thought Processes: School Age Years

Younger school-age children rely less on what they see and more on what they know when faced with new problems. They want explanations and reasons for everything but require no verification beyond that. Interested in functional aspect of all procedures, objects, and activities. They want to know why an object exists, why it is used, how it works, and the intent and purpose of its user. They need to know what is going to take place and why it is being done to them specifically. School-age children have a heightened concern about body integrity. Because of the special importance they place on their body, they are sensitive to anything that constitutes a threat or suggestion of injury to it. This concern extends to their possessions, so they may appear to overreact to loss or threatened loss of treasured objects. Encouraging children to communicate their needs and voice their concerns enables the nurse to provide reassurance, to dispel myths and fears, and to implement activities that reduce their anxiety.

Appropriate Introduction

introduce yourself & ask the name of each family member who is present. Address by proper titles, "Mr." and "Mrs.," unless they specify a preferred name. Include children by asking their name, age, and other information

geographic location

the birthplace and travel to different areas in or outside of the country, for identification of possible exposure to endemic diseases. Include current and past housing, whether they rent or own, whether they reside in an urban or rural location, the age of the home, and whether there are significant threats such as molds or pests within the housing structure. Although the primary interest is the child's temporary residence in various localities, also inquire about close family members' travel, especially during tours of military service or business trips. Children are especially susceptible to parasitic infestation in areas of poor sanitary conditions and to vector-borne diseases, such as those from mosquitoes or ticks in warm and humid or heavily wooded regions.

Suggestions for breaking the silence include statements such as the following:

• "Is there anything else you wish to say?" • "I see you find it difficult to continue. How may I help?" • "I don't know what this silence means. Perhaps there is something you would like to put into words but find difficult to say."

Communicating With Children

• Allow children time to feel comfortable. • Avoid sudden or rapid advances, broad smiles, extended eye contact, and other gestures that may be seen as threatening. • Talk to the parent if the child is initially shy. • Communicate through transition objects (such as, dolls, puppets, and stuffed animals) before questioning a young child directly. • Give older children the opportunity to talk without the parents present. • Assume a position that is at eye level with the child (Fig. 29.2). • Speak in a quiet, unhurried, and confident voice. • Speak clearly, be specific, and use simple words and short sentences. • State directions and suggestions positively. • Offer a choice only when one exists. • Be honest with children. • Allow children to express their concerns and fears. • Use a variety of communication techniques.

encouraging deep breaths

• Ask the child to "blow out" the light on an otoscope or pocket flashlight; discreetly turn off the light on the last try so the child feels successful. • Place a cotton ball in the child's palm; ask the child to blow the ball into the air and have parent catch it. • Place a small tissue on the top of a pencil, and ask the child to blow the tissue off. • Have child blow a pinwheel, a party horn, or bubbles.

Using an Interpreter

• Explain to interpreter the reason for the interview and the type of questions that will be asked. • Clarify whether a detailed or brief answer is required and whether the translated response can be general or literal. • Introduce the interpreter to the family, and allow some time before the interview for them to become acquainted. • Communicate directly with family members when asking questions to reinforce interest in them and to observe nonverbal expressions, but do not ignore the interpreter. • Pose questions to elicit only one answer at a time, such as "Do you have pain?" rather than "Do you have any pain, tiredness, or loss of appetite?" • Refrain from interrupting family members and the interpreter while they are conversing. • Avoid commenting to the interpreter about family members, because they may understand some English. • Be aware that some medical words, such as allergy, may have no similar word in another language; avoid medical jargon whenever possible. • Be aware that cultural differences may exist regarding views on puberty, sex, marriage, or pregnancy. • Allow time after the interview for the interpreter to share something that he or she thought could not be said earlier; ask about the interpreter's impression of nonverbal clues to communication and family members' reliability or ease in revealing information. • Arrange for the family to speak with the same interpreter on subsequent visits whenever possible.

(Present Illness) Taking an Allergy History

• Has your child ever taken any prescription or over-the-counter medications that have disagreed with him or her or caused an allergic reaction? If yes, can you remember the name(s) of this medication(s)? • Can you describe the reaction? • Was the medication taken by mouth (as a tablet or syrup), or was it an injection? • How soon after starting the medication did the reaction happen? • How long ago did this happen? • Did anyone tell you it was an allergic reaction, or did you decide for yourself? • Has your child ever taken this medication, or a similar one, again? If yes, did your child experience the same problems? • Have you told the physicians or nurses about your child's reaction or allergy?

(Present Illness) Review the child's growth including the following:

• Measurements of weight, length, and head circumference at birth • Patterns of growth on the growth chart and any significant deviations from previous percentiles • Concerns about growth from the family or child • Developmental milestones include: -Age of holding up head steadily (3 months) -Age of sitting alone without support (8 months) -Age of walking without assistance (12 months) -Age of saying first words with meaning (2 months, single vowel sounds) -Age of achieving bladder and bowel control (2 years) • Present grade in school • Scholastic performance • If the child has a best friend • Interactions with other children, peers, and adults

Temperature Nursing Implications

• No single site used for temperature assessment provides unequivocal estimates of core body temperature. • Studies show that the axillary and tympanic measures demonstrate poor agreement when these modes are compared with more accurate core temperature methods. The differences are more evident as temperature increases, regardless of age. • TAT is not predictable for fever and should be only used as a screening tool in young children. • When an accurate method for obtaining a correct reflection of core temperature is needed, the rectal temperature is recommended in younger children and the oral route in older children. For infants younger than 1 month of age, axillary temperatures are recommended for screening.

Length Quality Control Measures

• Personnel who measure the growth of infants, children, and adolescents need proper education. Competency should be demonstrated. Refresher sessions should occur when a lack of standardization occurs. • Length boards and stadiometers must be assembled and installed properly and calibrated at regular intervals (ideally daily, at least monthly, and every time they are moved) due to frequent inaccuracy and the variability between different instruments. Calibration can be performed by measuring a rod of known length and adjusting the instrument accordingly. • All children should be measured at least twice (ideally three times) during each encounter. The measurements should agree within 0.5 cm (ideally 0.3 cm). Use the mean value. If the variation exceeds the limit of agreement, measure again and use the mean of the measures in closest agreement. If none of the measures are within the limit of agreement, then (1) have another measurer assist, (2) check technique, and (3) consider another education session. • Children between 24 and 36 months of age may have length and/or height measured. Standing height is less than recumbent length due to gravity and compression of the spine. Plot length measurements on a length curve and height measurements on a height curve to avoid misinterpreting the growth pattern

Promoting Relaxation During Abdominal Palpation

• Position the child comfortably, such as in a semireclining position in the parent's lap, with knees flexed. • Warm your hands before touching the skin. • Use distraction, such as telling stories or talking to the child. • Teach the child to use deep breathing and to concentrate on an object. • Give an infant a bottle or pacifier. • Begin with light, superficial palpation, and gradually progress to deeper palpation. • Palpate any tender or painful areas last. • Have the child hold the parent's hand and squeeze it if palpation is uncomfortable. • Use the nonpalpating hand to comfort the child, such as placing the free hand on the child's shoulder while palpating the abdomen. • To minimize the sensation of tickling during palpation: -Have the child "help" with palpation by placing a hand over the palpating hand. -Have the child place a hand on the abdomen with the fingers spread wide apart, and palpate between his or her fingers.