Chapter 29 Communication, History, and Physical Assessment All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier.

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Presentation transcript:

Chapter 29 Communication, History, and Physical Assessment All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

 Establishing a setting  Appropriate introduction  Assurance of privacy and confidentiality  Computer privacy and applications in nursing  Telephone triage and counseling Guidelines for Communication and Interviewing 2 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

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 Communicating with parents  Encouraging the parents to talk  Directing the focus  Listening and cultural awareness  Using silence  Being empathetic  Providing anticipatory guidance  Avoiding blocks to communication  Communicating through an interpreter Communicating with Families 4 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

 Communicating with children  Communication related to development of thought processes  Infancy  Early childhood  School years  Adolescence Communicating with Families (Cont.) 5 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

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 Communication techniques  A variety of techniques  Open-ended questions  Word games  Nonverbal techniques  Play Communicating with Families (Cont.) 8 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

 Performing a health history  Identifying information Informant, most likely the parent  Chief complaint  Present illness Analyzing a symptom or symptoms History Taking 9 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

 History  Birth history  Dietary history  Previous illness, injuries, and operations  Allergies  Medications  Immunizations  Growth and development  Habits History Taking (Cont.) 10 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

 Performing a health history  Sexual history  Family medical history  Geographic location  Family structure  Assessment  Composition History Taking (Cont.) 11 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

 Psychosocial history  School adjustment  Unusual habits  Parent-child relationships  Review of systems  Specific and thorough review of each body system History Taking (Cont.) 12 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

 Dietary intake  Clinical examination of nutrition  Hair, skin, mouth, eyes  Evaluation of nutritional assessment  Malnourished  At risk  Well nourished  Overweight or obese Nutritional Assessment 13 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

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 Sequence of the examination  Head-to-toe sequence for assessing adult clients  Sequence for pediatric assessments generally altered to accommodate child’s developmental needs  Use chronological age as the main criteria General Approaches Toward Examining the Child 15 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

 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 Goals of Pediatric Assessment 16 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

 Child’s perception of painful procedures  Cooperation usually enhanced with parent’s presence  Age-appropriate techniques  Positioning and preparation Preparation of the Child 17 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

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 Growth measurements  Growth charts  Length  Height  Weight  Skin full thickness and arm circumference  Head circumference Physical Examination 20 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

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 Physical states of vital function  Temperature Electronic intermittent thermometer Infrared thermometer Electronic continuous thermometer  Pulse  Respirations Physiologic Measurements 26 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

 Pediatric blood pressure (BP)  Measurement devices  Selection of cuff  Cuff placement  BP measurement and interpretation  Orthostatic hypotension Physiologic Measurements (Cont.) 27 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

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 General appearance  Skin  Hair, nails, hygiene  Lymph nodes  Head and neck  Eyes, ears, nose, and throat Physical Assessment 30 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

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 Chest  Lungs  Heart  Abdomen  Genitalia and anus  Back and extremities  Neurologic assessment Physical Assessment (Cont.) 45 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

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 Which approach would be best to use to ensure a positive response from a toddler?  Assume an eye-level position and talk quietly.  Call the toddler’s name while picking him or her up.  Call the toddler’s name and say, “I’m your nurse.”  Stand by the toddler, addressing him or her by name. Question 67 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.