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COMMUNICATION AND HEALTH
ASSESSMENT
CHILD AND FAMILY
COMMUNICATING WITH PARENTS
Encouraging parents to talk Use open ended questions Let them express what they see as concerns
Direct the focus of interview – redirect Active Listening most important; watch nonverbals,
pick up on unspoken messages, reliability. Check your own attitudes & feelings so not
judgmental Be culturally sensitive Review Guidelines for use of an interpreter (p. 121-2)
PRINCIPLES OF COMMUNICATION
Avoid analogies and metaphors Give instructions clearly Give instructions in a positive manner Avoid long sentences, medical jargon; think
about “scary” words Give older child opportunity to talk without
parents present Excellent resource for communication tech.
Hockenberry et al, pp pp125-126, Box 6-4
COMMUNICATING WITH CHILDREN
Always get to their eye level Allow child to observe from a safe position If has a doll or stuffed animal talk to it first –
transitional object Be consistent: don’t smile when doing painful things Remember play is a universal language Communication is based on
developmental level Avoid sudden or rapid advances or
extended eye contact with young children
Preparation of Child for PE
Sequence of exam adapted to developmental needs of child
Need to be adaptable – flexible!! Involve parents – get best cooperation with
the very young Infants: b/4 sits alone can lie
on table; after ~6 mos let sit on parent’s lap. While quiet do heart & lungs; nonthreatenning areas 1st – eyes, ears, mouth last
Preparation for PE continued
Toddlers: minimal contact 1st; allow to inspect equip; use puppet or stuffed animal; focus on child; sequence same as infant
Preschool: similar to toddler School age: respect privacy;
explain procedures; concern is body integrity; head→toe; genitalia last
Adolescents: allow exam alone; explain findings; stress confidentiality
Great guidelines in book, pp. 139-140
Health History Components 10 Components
Identifying Information Chief Complaint Present Illness Past History Family Medical History Psychosocial History Sexual History Family History Nutritional Assessment Review of Systems
Health History Past History:
Birth hx, perinatal hx – explain relevance Allergies – very important, p. 128 “guidelines for taking a hx” Current medications; OTC, vitamins, & herbs Immunizations and any reactions Growth and development – major milestones Habits: sleep & activities; smoking, drug/OH use Pain Assessment: More in chapter 7 (we will discuss later) Psychosocial History – info re: child’s self concept; school
adjustment; coping skills Family history
PHYSICAL EXAM
Growth measurements Weight Height Head Circumference (til 36 mos) Skinfold Thickness (measures body fat) Arm circumference (indirect measure of muscle
mass) Chest circumference (infancy only)
Physical Examination
Growth measurements Recumbent length for infants up to age 36
months + weight and head circumference Standing height + weight after age 37 months Plot on growth chart
By gender and prematurity if appropriate Less than 5th or greater than 95th percentile
considered outside expected parameters for height, weight, head circumference
GROWTH CHARTS
Plot: height, weight, head circumference Now includes BMI for age
www.cdc.gov/nccdphp/dnpa/bmi/index.htm
Available on line at www.cdc.gov/growthcharts See appendix B in textbook Concerns regarding growth
Ht and wt percentiles are widely disparate Sudden increase or decrease in previously steady growth
pattern Fail to show expected growth rates in ht & wt
VITAL SIGNS
Resp & pulse first – BEFORE child is disturbed – 1 full minute
Temperature – use method according to agency protocol (p 145-148)
Take BP if > 3 yrs; prep them on how it may feel (a little squeeze); use proper size or larger
Exercise, crying, stress, envir. conditions affects VS
Physical Assessment
General appearance Skin Hair, nails, hygiene Lymph nodes Head and neck EENT
Head
Check shape & symmetry Occiput flat – lying on back continually?? Premature closure of sutures Head lag – none by 6 mos at the latest Post. Font closes by 2 mos Ant. Font closes by 18 mos Face – check for symmetry Check ROM: torticollis, opisthotonos
Cranial Deformities
Normal closure of sutures is regular and predictable
Early closure → altered skull growth to accommodate nl brain growth
Small head w/nl shape = deficient brain growth & early closure is secondary
May notice deformity at birth or may be apparent only as child gets older
www.faces-cranio.org
Cranial Deformities
Microcephaly: primary or secondary Occipital Frontal Head Circumference > 2 SD below mean
for age & sex
Craniosynostosis: premature closure at birth of 1 or more cranial sutures; early ID imp.; persistent cranial molding wks after birth molding would have resolved
Plagiocephaly: infant head molded by continued pressure against a surface; ↑d with supine sleeping to prevent SIDS; also result of congenital torticollis which occurs in utero
Eyes
Inspect externally: position, epicanthal folds, placement, swelling, discharge
Visual acuity: 3-4 mos can fixate on 1 visual field with both eyes – binocularity
Corneal light reflex/cover test used to check for strabismus (cross eye); if not corrected by age 4-6 can lose vision: amblyopia
Snellen chart Color vision testing (2nd grade in IL)
Ears Last thing to do in exam with
infants and young children Infants & Toddlers, pull pinna down and
back before inserting otoscope or administering otic meds
Child > 3, pull up and back to view tympanic membrane with otoscope or to give otic meds
Check for cerumen, foreign bodies, discharge Check external structures; placement &
position; skin condition
Nose, Mouth, Throat
Nose: structure, patency, discharge, tenderness, color or swelling of turbinates
Check for foreign objects Percuss and palpate sinuses if > 3yr Flaring nares → resp. distress Mouth – deciduous teeth erupt by about 6
mos. and all 20 appear by 30mos. Tonsils may normally be very large & then
atrophy by adolescence
Chest, Lungs, Heart Perform early in exam while quiet!! Inspect, palpate, percuss, auscultate Breath sounds louder/harsher in the young Diaphragmatic under age 6-7; older child, esp
females, resp are thoracic Inspect breasts: breast development 10-14 yrs. -
teach self breast exam males gynecomastia
Apical pulse: LMCL 4th ICS < 7 yrs. LMCL 5th ICS > 7 yrs
Heart Sounds are louder, higher pitched and
shorter in infants & children To distinguish between S1 and S2,
simultaneously palpate the carotid pulse with the index and middle fingers & listen. S1 is synchronous with the carotid pulse.
Physiologic splitting – significant nl finding S2 widens during inspiration Fixed split S2: doesn’t change w/inspiration; Dx of
atrial septal defect S3 – vibrations heard during ventricular filling nl in
some kids, abnl in older adults S4 – recoil vibration bet. atria & vent following
atrial contraction @ end of diastole → abnormal
Heart
Murmurs: Innocent: no abnormality Functional: no anatomic cardiac defect but
physiologic abnormality such as anemia is present
Organic: cardiac defect with or without physiologic abnormality exists
**HR ↑s 8-10 beats for each degree temp. elevation
Abdomen
Always: Inspect, Auscultate, percuss, then palpate
Umbilicus – pink w/o discharge Umbilical hernia common esp. in African-
American young children Palpate for inguinal or femoral hernias May need to have them “help” with palpation
if tickle easily
GENITALIA
Uneventful for infants & toddlers Anxiety ↑s from preschool age on Excellent time to integrate teaching & elicit
questions of concern re: body functioning or sexual activity
Assess 2º sexual characteristics w/Tanner Stages (pp. 742 -744)
Limited to inspection and palpation of ext structures Female internal exam not done until sexually active
or about age 18 unless indicated
Genitalia cont.
Males: inspect penis & urinary meatus Foreskin retractable by 3 mos Inspect, palpate scrotum, testes – failure of 1
or both to descend: cryptorchidism Block cremasteric reflex: have sit in “taylor”
position, warm hands, and/or place thumb & index finger over upper part of scrotal sac
along inguinal canal blocking ascent of testes Inspect anal area: sphinter tone,small cuts or
tears, pinworms, diaper rash
Spine & Extremities
Inspect curvature; assess mobility Check for tufts of hair; pilonidal cyst Inspect extremities for symmetry of length & size Assess gait: pigeon toe most common Toe walking lasting > 3 mos. → refer Bowleg (genu varum): nl w/toddlers 1st walking;
unilateral & present past 2-3 yrs → refer Knock-knee (genu valgum): nl bet. 2-7 yrs;
excessive, asymmetric or persists →refer
Neurological
Integrate into PE as much as possible Child >2 same as adult – cranial nerves and
deep tendon reflexes Denver II excellent screening tool: fine &
gross motor; personal social; language Presence of reflexes when should be gone in
an infant indicates CNS problem, i.e. Babinski gone by ~ 1 yr
Soft Signs
Gray area – normal in young child but usually disappear as mature – when they persist their significance is controversial:
Short attention span, unusual body movement, poor coordination & sense of position, hyperactivity, hypoactivity, impulsiveness, labile emotions, distractibility, no established handedness, language & articulation problems, perceptual deficits, learning disabilities
Developmental Theorists Freud: Psychosexual Erikson: psychosocial
Trust vs mistrust (infancy) Autonomy vs shame & doubt (1-3 yrs) Initiative vs guilt (3-6 yrs) Industry vs inferiority (6-12 yrs) Identity vs identity confusion (12-19 yrs)
Piaget: cognitive (4 major stages) Sensorimotor (birth to 2 yrs) Preoperational (2 to 7 yrs) Concrete operations (7 to 11 yrs) Formal operations (11 to 15 yrs)
Kohlberg: Moral development Fowler: Spiritual development