Assessment of the Child (Data Collection) Chapter 3

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

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

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

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

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

Information Regarding Lifestyle of the Client School history Social history Personal history Nutrition history

Objective Data Height Weight Blood pressure Temperature Pulse Respiration Assessment of body systems

Observations Made Regarding General Status The child’s overall general appearance Facial expressions Speech Behavior

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

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

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

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

Methods of Measuring a Child’s Temperature Oral 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

Methods of Observing a Child’s Respirations Pulse oximetry Measures the oxygen saturation of arterial hemoglobin Apnea monitor Detects the infant’s respiratory movement

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

Methods of Taking Blood Pressure Readings Auscultation Palpation Doppler Electronic

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