Assessment of the Child (Data Collection) Chapter 3

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Types of Data

•

Subjective data

– Information spoken by the child or family in a client interview •

Objective data

– Information obtained in a physical examination of the client •

Biographical data

– Basic information about the client and caregiver including name, address, and phone number Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Conducting the Client Interview With a Child

• The nurse should introduce herself to the child and caregiver and state the purpose of the interview • The nurse should maintain a calm, reassuring manner to establish trust and comfort • The caregiver and the nurse should be comfortably seated • The child should be included in the interview process • The family caregiver should provide most of the information needed in caring for the child Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Components of a Client History

• • Biographical data Chief complaint • • • • • • History of present health concern Health history Family health history Review of systems for current health problem Allergies, medications, substance abuse Lifestyle • Developmental level Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Information Obtained Regarding the Present Health Concern

• The current situation • The child’s symptoms • When the symptoms began • How long the symptoms have been present • A description of the symptoms • The intensity and frequency of the symptoms • Treatments to this time Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Information Included in the Health History of the Child

• The mother’s pregnancy and prenatal history • Common childhood, serious, or chronic illnesses • Immunizations and health maintenance • Feeding and nutrition • Hospitalizations and injuries Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Information Regarding Lifestyle of the Client

• School history • Social history • Personal history • Nutrition history Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Objective Data

• Height • Weight • Blood pressure • Temperature • Pulse • Respiration • Assessment of body systems Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Observations Made Regarding General Status

• The child’s overall general appearance • Facial expressions • Speech • Behavior Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Observations of General Appearance

• Observe physical appearance and condition • Observe nutritional status, hygiene, mental alertness • Observe body posture and movements • Examine skin for color, lesions, bruises, scars, birthmarks • Observe hair texture, thickness, and distribution Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Observations Related to Psychological Status and Behavior

• Factors that influenced the behavior • How often the behavior is repeated • Physical behavior, as well as emotional and intellectual responses • If behavior is consistent or unpredictable • Apparent reasons for changed behavior Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Factors to Consider When Assessing for Behavior in the Child

• The child’s age and developmental level • The abnormal environment of the health care facility • If the child has been hospitalized previously or otherwise separated from family caregivers Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Measuring the Child’s Height and Weight

• Measurements should be done each time the child has a routine physical examination • Measurements must be charted and compared with norms for the child’s age • In a hospital setting, the infant or child should be weighed at the same time each day on the same scales while wearing the same amount of clothing • The nurse must keep a hand within 1 inch of the child at all times to be ready to protect the child from injury Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

•

Oral Methods of Measuring a Child’s Temperature

• – Usual range is 36.4

° C to 37.4

° C (97.6

° F to 99.3

° F)

Rectal

– Usually 0.5

° to 1.0

° higher than oral method • •

Axillary temperature

– Usually 0.5

° to 1.0

° lower than oral method

Tympanic

– Is in the same range as the oral method Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Methods of Observing a Child’s Respirations

•

Pulse oximetry

– Measures the oxygen saturation of arterial hemoglobin •

Apnea monitor

– Detects the infant’s respiratory movement Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Common Sites Used to Obtain Blood Pressure Reading in Children

•

Upper arm

– The cuff should be wide enough to cover about two thirds of the upper arm and long enough to encircle the extremity without overlapping •

Forearm or lower arm

– A smaller cuff is used on the forearm •

Thigh, calf, or ankle

– A larger cuff is used on the thigh or calf Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Methods of Taking Blood Pressure Readings

• Auscultation • Palpation • Doppler • Electronic Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Physical Examination of the Child

• • • Head and neck Eyes and ears Nose, mouth, and throat • • • • • • Chest and lungs Heart Abdomen Genitalia and rectum Back and extremities Neurologic Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins