Assessment of the Child Data Collection

1
Assessment of the Child(Data Collection)

• Chapter 3

2
Conducting the Client Interview

• The interview helps establish a relationship
  between the nurse, the child, and the family.
• Listening and using appropriate communication
  techniques helps promote a good interview.

3
Conducting the Client Interview

• Using focused questions and allowing time for
  answering will help the child and family feel
  comfortable.
• A private, quiet setting and a calm and
  reassuring manner is important to establish trust
  and comfort.
• Past experiences influence the interview.
• The child should be included in the interview
  process.
• Being aware of the primary language spoken and
  using an interpreter when needed will help in
  gaining accurate information.

4
Interviewing Family Caregivers

• The nurse may ask the questions and write down
  the answers this process gives the opportunity
  to observe the reactions of the child and the
  caregiver as they interact with each other.

5
Interviewing Family Caregivers

• The nurse must be nonjudgmental and must allow
  the caregiver to express concerns and anxieties.
• If a certain topic seems uncomfortable for the
  caregiver to discuss in front of the child, that
  topic should be discussed later when the child
  cannot hear what is being said.

6
Interviewing the Child

• It is important that the preschool child and the
  older child be included in the interview.
• Use age-appropriate questions.
• Showing interest helps both the child and the
  caregiver to feel comfortable.

7
Interviewing the Child

• By being honest when answering the childs
  questions, the nurse establishes trust.
• Using stories or books written at a childs level
  helps with understanding what the child is
  thinking or feeling.
• The child should be made to feel important in the
  interview.

8
Interviewing the Adolescent

• Adolescents should be interviewed in private
  which often encourages them to share information
  that they might not contribute in front of their
  caregivers.

9
Obtaining a Client History

• It is important to gather information regarding
  the childs current condition as well as past
  medical history.
• This information is used to develop a plan of
  care.

10
Obtaining a Client History

• In obtaining information, the nurse is developing
  a relationship as well as noting what the child
  and family know and understand about the childs
  health.
• Observations of the caregiver-child relationship
  can also provide important information.

11
Biographical Data

• The nurse collects the childs name, address, and
  phone number as well as information regarding the
  caregiver.
• This is confidential.

12
Biographical Data

• A questionaire if often used to gather
  information such as the childs nickname, feeding
  habits, food likes and dislikes, allergies,
  sleeping schedule, and toilet training status.
• Figure 3-2 pg. 44-45 provides an example of an
  assessment form that may be used to collect
  information.

13
Chief Complaint

• The reason for the childs visit to the health
  care setting is called the chief complaint.
• The caregivers primary concern.
• It is important to get the most complete
  explanation of what brought the child to the
  health care setting.

14
History of Present Health Concern

• The nurse elicits information about the current
  situation, including the childs symptoms, when
  they began, how long the symptoms have been
  present, a description of the symptoms, their
  intensity and frequency, and treatments up to
  this time.
• The nurse should ask the questions in a way that
  encourages the caregiver to be specific.

15
Past Health History

• Prenatal history are included in obtaining a past
  health history.
• The childs mother is usually the best source of
  this information.
• Other areas include common childhood, serious,
  or chronic illnesses immunizations and health
  maintenance feeding and nutrition as well as
  hospitalizations and injuries.

16
Family Health History

• The caregiver can usually provide information
  regarding family health history.
• The nurse uses this information to do
  preventative teaching.

17
Review of Systems for Current Health Problem

• While the nurse is collecting subjective data,
  the caregiver or child is asked questions about
  each body system.
• Information is gathered that helps to focus the
  physical exam as well as to get an overall
  picture of the childs current status.
• The nurse needs to include the areas listed in
  Table 3-1 Pg. 46. Look at on your Own!!

18
Allergies, Medications, Substance Abuse

• Allergic reactions to any foods, medications, or
  any other known allergies should be discussed to
  prevent the child being given any medications or
  substances that might cause an allergic reaction.

19
Allergies, Medications, Substance Abuse

• Medications prescribed or over the counter are
  recorded.
• This information will help avoid the possibility
  of overmedicating or causing drug interactions.
• It is important, especially in the adolescent, to
  assess the use of substances such as tobacco,
  alcohol or illegal drugs.

20
Lifestyle

• School historycurrent grade level and academic
  performance as well as behavior.
• Interactions give insight into areas of concern
  for the child that might affect the childs
  health.
• Social historyoffers information about the
  environment that the child lives in.

21
Lifestyle

• Personal historydata collected about the childs
  hygiene and sleeping and elimination patterns.
  Activities, exercise, special interest, favorite
  toy, any behaviors such as thumb sucking, nail
  biting, or temper tantrums are discussed.
• Nutrition historyinformation regarding eating
  habits and preferences as well as nutritional
  concerns.

22
Developmental Level

• Knowing normal development patterns will help the
  nurse determine if there are concerns that should
  be further assessed regarding the childs
  development.

23
Collecting Objective Data

• Collection of objective data include height,
  weight, blood pressure, temperature, pulse, and
  respirations.
• Exam for a child is not done in a head-to-toe
  manner as in adults bur rather in an order that
  takes the childs age and developmental needs
  into consideration.

24
Collecting Objective Data

• The caregiver may be involved in helping with the
  data collection.
• The nurse carefully documents any finding that is
  not within normal limits and describes in detail
  any unusual findings.
• Special attention to any symptoms that the
  caregiver has identified.
• All the information gathered is used to plan the
  childs care.

25
General Status

• The nurse uses knowledge of normal growth and
  development to note if the child appears to fit
  the stated age.
• Interactions with caregivers and siblings provide
  the nurse with information about these
  relationships.
• Overall general appearance, facial expressions,
  speech and behavior is noted.

26
Observing General Appearance

• Observing physical appearance and condition can
  give clues to the childs overall health.
• The infant or childs face and body should be
  symmetrical.
• Observe for nutritional status, hygiene, mental
  alertness and body posture and movements.
• Examine the skin for color, lesions, bruises,
  scars, and birthmarks.
• Observe hair texture, thickness and distribution.

27
Noting Psychological Status and Behavior

• Carefully observing the childs behavior and
  recording those observations provide vital clues
  to a childs condition.
• Characteristic behaviors of the healthy infant or
  older child compared with behaviors that may
  indicate signs of illness are shown in Table 3-2
  pg. 48.

28
Measuring Height and Weight

• Height and weight should be measured and recorded
  each time the child has a routine physical exam
  as well as at other health care visits.
• Must be charted and compared with norms for the
  childs age. (Appendix F)

29
Measuring Height and Weight

• Plotting on a growth chart gives a good
  indication of the childs health status.
• Charts are indicators, the size of other family
  members, the childs illnesses, general
  nutritional status, and developmental milestones
  also must be considered.

30
Measuring Height and Weight

• 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.
  
• An infant is weighed nude with no shirt or diaper
  lying on an infant scale.
• The nurse must keep a hand within 1 inch of the
  infant at all times to be ready to protect the
  infant from injury.

31
Measuring Height and Weight

• The scale is covered with a fresh paper towel or
  clean sheet of paper as a means of infection
  control.
• A child who can stand alone steadily is weighed
  on platform-type scales.
• The child should be weighed without shoes.
• Weights are recorded in grams and kilograms or
  pounds and ounces.

32
Measuring Height and Weight

• The standing scales have a useful, adjustable
  measuring device for height measurement.
• An infant is measured while laying on a flat
  surface with knees held flat to the table.
• Height is recorded in centimeters or inches
  according to the practice of the health care
  facility.

33
Measuring Head Circumference

• The head circumference is measured routinely in
  children up to the age of 2 or 3 or in any child
  with a neurologic concern.
• A paper or metal tape measure is place around the
  largest part of the head just above the eyebrows
  and around the largest part of the head just
  above the eyebrows and around the most prominent
  part of the back of the head. (Fig. 3-4, pg. 50)
• The measurement is recorded and plotted on a
  growth chart.

34
Vital Signs

• V/S are taken at each visit and compared to the
  normal values for children of the same age as
  well as to that childs previous recordings.
• It will usually be less traumatic for the infant
  the nurse counts the respirations before the
  child is disturbed, then takes the pulse and the
  temperature.

35
Temperature

• Measuring a childs temperature is set by the
  policy of the health care setting.
• Can be measured by oral, rectal, axillary, or
  tympanic method.
• Recorded in Celsius or Fahrenheit according to
  policy.

36
Temperature

• A normal oral temp range is 36.4 to 37.4 C (97.6
  to 99.3 F)
• A rectal temp is usually 0.5 to 1 degree higher
  than the oral measurement.
• An axillary temp usually measures 0.5 to 1 degree
  lower than the oral measurement.
• A tympanic is the same range as the oral method.

37
Temperature

• Any deviation should be reported.
• It is important to record the method of temp
  measurement as well as the measure temperature.
• In pediatrics, oral temps usually are taken only
  on children older than 4-6 years of age who are
  conscious and cooperative.
• The child should not be left unattended while any
  temp. is being taken.

38
Temperature

• Tympanic thermometer records the temp. rapidly
  (about 2 seconds), is noninvasive, and causes
  little disturbance.

39
Temperature

• Rectal temps are measure in infants and children
  younger than 4 to 6 years of age.
• They are not desirable in the newborn because of
  the danger of irritation to the rectal mucosa.
• The bulb end should be lubricated with a
  water-soluble lubricant.
• Placed in the prone position, the buttocks are
  gently separated and the thermometer is inserted
  gently about ¼ to ½ inch.

40
Temperature

• The nurse must keep one hand on the childs
  buttocks and the other on the thermometer during
  the entire time the rectal thermometer is in
  place.
• Mercury thermometers have been replaced by
  mercury-free glass thermometers.
• An electronic thermometer is removed as soon as
  it signals a recorded temp.

41
Temperature

• Axillary temps are taken on newborns and on
  infants and children with diarrhea or when a
  rectal temp is contraindicated.
• Insert the thermometer bulb well into the armpit
  and bring the childs arm down close to the body.
• Must be skin-to-skin contact with no clothing in
  the way.
• Left in place until the electronic thermometer
  signals.

42
Pulse

• An apical pulse rate is preferred in an infant or
  young child.
• Accomplish this while the child is quiet.
• Should be counted before the child is disturbed
  for other procedures.

43
Pulse

• The stethoscope is placed between the childs
  left nipple and sternum.
• A pulse that is unusual in quality, rate, or
  rhythm, should be counted for a full minute.
• Any rate that deviates from the normal rate
  should be reported.
• Pulse oximetry-measures the oxygen saturation of
  arterial hemoglobin. Probe may be taped to toe,
  finger, earlobe. Site changed every 4 hours.

44
Pulse

• Pulse rates vary with age
• Neonate (birth to 30 days old) -- 100 to 180 bpm
• 14 to 18 year-old 50 to 95 bpm

45
Pulse

• Cardiac monitors are used to detect changes in
  cardiac function.
• The skin is cleansed with alcohol to remove oil,
  dirt, lotions, and powder.
• Alarms are set to maximum and minimum settings
  above and below the childs resting heart rate.
• The electrode sites must be checked every 2 hours
  to detect any skin redness or irritation, and
  secured probe sites.
• Cardiac status must be checked when the alarm
  sounds.

46
Respirations

• Respirations of an infant or young child also
  must be counted during a quiet time.
• Infants are abdominal breathers.
• Must be counted for a full minute because of
  normal irregularity.

47
Respirations

• The chest is observed for retractions that
  indicate respiratory distress.
• Retractions are noted as substernal (below the
  sternum), subcostal (below the ribs), intercostal
  (between the ribs), suprasternal (above the
  sternum) or supraclavicular (above the clavicle).
  
• See Fig. 3-7 pg. 52

48
Respirations

• Pulse Oximetrymeasures the oxygen saturation of
  arterial hemoglobin.
• The probe can be taped to the toe or finger or
  clipped on the earlobe.
• The site is changed at least every 4 hours to
  prevent skin irritation.
• In an infant, the foot may be used.
• The site should be checked every 2 hours to
  ensure that the probe is secure and tissue
  perfusion is adequate.
• Alarms can be set and the nurse must check that
  alarms are accurately set and have not been
  inadvertently changed.

49
Respirations

• Apnea Monitordetects the infants respiratory
  movement.
• Electrodes or a belt are placed on the infants
  chest where the greatest amount of movement is
  detected.
• An alarm is set to sound when the infant does not
  breathe for a predetermined number of seconds.

50
Respirations

• These monitors can be used in a hospital setting,
  and often are used in the home for an infant who
  is at risk for apnea or who has a tracheostomy.
• Caregivers are taught to stimulate the infant and
  to perform CPR if necessary.

51
Blood Pressure

• For children 3 years of age and older, BP
  monitoring is part of routine and ongoing data
  collection.
• Children of any age should have a baseline BP
  taken.
• Methods for measuring pedi b/p page 55.

52
Blood Pressure

• Referring to the BP cuff as giving your arm a
  hug will help.
• First taking a BP on a stuffed animal or doll
  will show the procedure is not to be feared.
• Obtaining a BP measurement in an infant or small
  child is difficult, but equipment of the proper
  size helps ease the problem.
• The cuff should be wide enough to cover about 2/3
  of the upper arm and long enough to encircle the
  upper arm without overlapping.
• Normal BP values gradually increase from infancy
  through adolescence. (Table 3-4 pg. 54)

53
Head and Neck

• The heads general shape and movement should be
  observed.
• Symmetry or a balance is noted in the features of
  the face and in the head.
• Observe the childs ability to control the head.

54
Head and Neck

• Ask the older child to move her or his head in
  all directions.
• In the infant the nurse gently moves the head to
  observe for any stiffness in the neck.
• The nurse feels the skull to determine if the
  fontanels are open or closed and to check for any
  swelling or depression.

55
Eyes

• Observe for symmetry-- and location in
  relationship to the nose.
• Note any redness, evidence of rubbing, or
  drainage.
• Ask the older child to follow a light to observe
  her or his ability to focus.
• An infant will also follow a light.

56
Eyes

• Observe pupils for equality, roundness, and
  reaction to light.
• Vision screening is done in the school or clinic
  settings.

57
Ears

• The alignment of the ears is noted by drawing an
  imaginary line from the outside corner of the eye
  to the prominent part of the childs skull.
• The top of the ear, known as the pinna, should
  cross this line.(Fig. 3-11 pg. 55).
• Ears that are set low often indicate mental
  retardation.

58
Ears

• Note the childs ability to hear during normal
  conversation.
• A child who speaks loudly or responds
  inappropriately may have hearing difficulties.
• Note any drainage or swelling.

59
Nose, Mouth, Throat

• The nose is in the middle of the face.
• Should be symmetrical.
• Flaring of the nostrils might indicate
  respiratory distress and should be reported
  immediately.
• Observe for swelling, drainage, or bleeding.

60
Nose, Mouth, Throat

• To observe the mouth and throat, have the older
  child hold her or his mouth wide open and move
  the tongue from side to side.
• With the infant or toddler, use a tongue blade to
  see the mouth and throat.
• Observe the mucous membranes for color, moisture,
  and any patchy areas that might indicate
  infection.

61
Nose, Mouth, Throat

• Observe the number and condition of the childs
  teeth.
• The lips should be moist and pink.
• Note any difficulty swallowing.

62
Chest and Lungs

• Chest measurement are done on infants and
  children to determine normal growth rate.
• Measurement at the nipple level.
• Observe the chest for size, shape, movement of
  the chest with breathing, and any retractions.

63
Chest and Lungs

• In the older school-age child or adolescent, note
  evidence of breast development.
• Evaluate respiratory rate, rhythm, and depth.
• Report any noisy or grunting respirations.
• Using a stethoscope, listen to breath sounds in
  each lobe of the lung, anterior and posterior,
  while the child inhales and exhales.

64
Chest and Lungs

• Describe, document, and report absent or
  diminished breath sounds as well as unusual
  sounds such as crackling or wheezing.
• If the child is coughing or bringing up sputum,
  record the frequency, color and consistency of
  sputum.

65
Heart

• In some infants and children, a pulsation can be
  seen in the chest that indicates the heartbeat.
• This point is called the point of maximum impulse
  (PMI).
• This point is where the heartbeat can be heard
  the best with a stethoscope.
• The nurse listens for the rhythm of the heart
  sounds and counts the rate for one full minute.

66
Heart

• Abnormal or unusual heart sounds or irregular
  rhythms might indicate the child has a heart
  murmur, heart condition, or other abnormality
  that should be reported.
• The nurse assess the pulses in various parts of
  the body. Fig. 3-12 pg. 56

67
Abdomen

• The abdomen may protrude slightly in infants and
  small children.
• To describe the abdomen, divide the area into 4
  sections and label sections with the terms left
  upper quadrant (LUQ), left lower quadrant (LLQ),
  right upper quadrant (RUQ), and right lower
  quadrant (RLQ).

68
Abdomen

• Using a stethoscope, listen for bowel sounds or
  evidence of peristalsis in each section of the
  abdomen and record what is heard.
• The umbilicus is observed for cleanliness and any
  abnormalities.
• Infants and young children sometimes have
  protrusions in the umbilicus or inguinal canal
  that are called hernias.

69
Genitalia and Rectum

• Very important to respect the childs privacy and
  take into account the childs age and the stage
  of growth and development.
• Keeping the child covered is important.
• While wearing gloves, the nurse inspects the
  genitalia and rectum.
• Observe for any sores or lesions, swelling, or
  discharge.

70
Genitalia and Rectum

• In male children the testes descend at varying
  times.
• If the testes cannot be palpated, this
  information should be reported.
• Nurses should be aware that any unusual findings
  might indicate child abuse and should be further
  investigated.

71
Back and Extremities

• The back should be observed for symmetry and for
  curvature of the spine.
• In infants the spine is rounded and flexible.
• Screening is done in school for school age
  children to detect abnormal curvatures of the
  spine such as scoliosis.
• Note gait and posture.

72
Back and Extremities

• The extremities should be warm, have good color,
  and be symmetrical.
• Note range of motion, movement of the joints and
  muscle strength.
• In infants, examine the hips and report any
  dislocation or asymmetry of gluteal skin
  foldswhich could indicate a congenital hip
  dislocation.

73
Neurologic

• All the body systems function in relationship to
  the nervous system.
• A complete neurological exam should be
  doneincludes reflex responses, as well as the
  functioning of each of the cranial nerves.

74
Neurologic

• The Practitioner will perform a neurologic exam
  on children following a head injury, seizure, or
  on children who have metabolic conditions such as
  diabetes mellitus, drug ingestion, severe
  hemorrhage, or dehydration, where the childs
  neurologic status might be affected.

75
Neurologic

• A neurologic assessment is done to determine the
  level of the childs neurologic functioning.
• A neurologic assessment tool such as the Glasgow
  coma scale Pg. 57 is commonly used.
• If hospitalized with a neurologic concern, the
  neurologic status is monitored closely every 1 to
  2 hours to observe for significant changes.

76
Assisting with Common Diagnostic Tests

• Diagnostic tests help determine more clearly the
  nature of the childs concern
• The role of the nurse in assisting with common
  diagnostic tests is discussed in chapter 5.