Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Chapter 29 Communication, History, Physical, and Developmental Assessment

2 Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Guidelines for Communication and Interviewing Establishing a setting of of privacy and confidentiality

3 Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Communicating with Families  Communication with parents  Encouraging the parent to talk  Directing the focus  Listening and cultural awareness  Using silence  Being empathetic  Providing anticipatory guidance  Avoiding blocks to communication

4 Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.  Communicating with children should be adapted to development level  Infants…… Cry or bear down  Toddler….No NO NO play play play  PreSchooler “Whats THAT” show & play with equipment  School age “Wait Wait I'm not ready” education  Adolescence direct ? to them instead of parent

5 Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Fig A young child may take the expression “a little stick in the arm” literally.

6 Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Communicating with Families  Communication techniques  Conventional interview methods  Open-ended questions  Word games  Nonverbal techniques  Draw a picture  Play

7 Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. History Taking  Performing health history NeerPerfect  Identifying information  Chief complaint  Present illness  History Birth and dietary Birth and dietary Previous illness, injuries, and operations Previous illness, injuries, and operations Allergies Allergies Medications and immunizations Medications and immunizations Growth and development Growth and development

8 Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. History Taking  Performing health history  Sexual history  Family medical history  Geographic location  Family structure  Assessment  Composition

9 Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. History Taking  Psychosocial history  School adjustment  Unusual habits  Family and home environment  Review of systems  Specific and thorough review of each body system

10 Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nutritional Assessment  Dietary intake  24-hour recall  Clinical examination  Hair, skin, mouth, eyes  Evaluation of nutritional assessment  Malnourished  At risk  Well nourished

11 Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. General Approaches Toward Examining the Child  Head-to-toe sequence for adult  Pediatric assessments age and developmentally appropriate  BE CREATIVE

12 Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Goals of Pediatric Assessment  Minimize stress and anxiety associated with assessment of various body parts  Foster trusting nurse-child-parent relationships  Allow for maximum preparation of child  Preserve security of parent-child relationship  Maximize accuracy of assessment findings

13 Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Doorway Assessment  General appearance color, work of breathing  Skin  Hair, nails, hygiene  Position & Activity  Head and neck  Eyes, ears, nose,  Toys in room

14 Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Tips Pediatric Assessment  Initially use minimal physically contactMinimize stress and anxiety  Foster trusting nurse-child-parent  Allow for maximum preparation of child  Preserve parent-child relationship  Child’s perception of painful procedures  Cooperation usually best with parent’s  Age-appropriate techniques

15 Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.  Infant and toddler vital signs  FIRST Count respirations full minute  SECOND apical heart rate full minute  THIRD blood pressure (BP)  LAST Measure temperature Is patient on Apnea Monitor or Pulse Ox ? Physiologic Measurements

16 Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.  Pediatric BPs  Correct size Cuff selection MOST important WHY ???  Cuff placement  Interpretation of BP measurement

17 Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Temperature in Peds No Rectal Bleeding disorder or Cancer Rectal (RED) insert ½ inch lubricated

18 Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Physical Examination  Growth measurements as needed  Recumbent length for infants up to age 36 months + weight and head circumference

19 Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Fig A, Infant on scale. B, Toddler on scale. Note presence of nurse to prevent falls.

20 Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Fig Measurement of height. Standing height + weight after age 37 months

21 Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Plot on Growth Chart By gender If prematurity note adjusted age 95th percentile considered outside expected parameters for height, weight, head circumference

22 Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Growth  Ethnic differences  Expected growth rates at various ages  Significance of head circumference measurements

23 Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Fig Location of superficial lymph nodes. Arrows indicate directional flow of lymph.  Head & Neck Alerts that need further evaluation Anterior Fontanels close before 12m or delayed closure after 18months Head lag after 6 months old further evaluation Hyperextension of head (opisthotonos) with Pain Any lumps or masses Asymmetry Difficulty or painful ROM Physical Examination Head & Neck Assessment Observe for shape & symmetry Note head control Evaluate ROM Palpate head & neck

24 Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Fig A, Corneal light reflex test demonstrating orthophoric eyes. B, Pseudostrabismus. Inner epicanthal folds cause eyes to appear misaligned; however, corneal light reflexes fall perfectly symmetrically.

25 Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Snell Eye Chart 20 feet away with 1 eye covered

26 Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Fig Ear alignment.

27 Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Fig Positioning for visualizing eardrum in infant (A) and in child older than 3 years of age (B).

28 Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Fig Interior structures of mouth.

29 Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Physical Assessment  Heart  Chest & Lungs  Abdomen  Genitalia  Back and extremities  Neurologic assessment

30 Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Fig Imaginary landmarks of chest. A, Anterior. B, Right lateral. C, Posterior. Infant & Children Variations Observe Abdomen for respirations in infants. Children younger than 6 or 7 years, respiratory movement in abdomen or diaphragmatic

31 Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Fig Direction of heart sounds for anatomic valve sites and areas (circled) for auscultation.

32 Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Fig Location of hernias.

33 Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Fig A, Preventing cremasteric reflex by having child sit in “tailor” position. B, Blocking inguinal canal during palpation of scrotum for descended testes.

34 Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Fig Bowleg. Bowlegged normal for up to 1 year after walking until toddlers development muscle

35 Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Fig Knock-knee.

36 Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Developmental Screen  Screening procedures (Neerperfect)  identify children whose developmental level is below chronologic adjusted age  Since “Education of the Handicapped Act of 1986” there has been greater emphasis on children with disabilities

37 Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Denver Developmental Screening Test II  AKA Denver II  Widely used, standardized measures  Examiners must be specifically trained and certified in use of the tools  Interpretation of test  Referrals to Early Intervention