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