PEDIATRIC HEALTH HISTORY CLASS 8 Focal Points of the Pediatric History The developmental age & level of the child is important, in terms of asking age appropriate questions & in determining the general approach for the interview. The child is part of a family, therefore a “family” approach to communicating with both parents & children is helpful. For infants & young children, the primary source of historical information is the parent, a “third person” type of interview. It is important to involve older children in the history-taking process, and move to a more “first person” type of approach. Even children as young as 3 or 4 years of age can add important information. Treat initial concerns seriously & listen carefully, but also look for issues beyond the chief complaint that might also be important. Increased anxiety of parents/children increases the need for careful teaching & reinforcement of treatment plans. FOCAL POINTS OF PEDIATRIC HISTORY: Biological information CC: Chief complaint or client’s request for care PI: Present Illness or present health status Past Medical History: Prenatal, Natal, Neonatal Illnesses, operations, injuries Immunizations Medications, transfusions Allergies Developmental Data Nutritional Data Family Health History Family Personal/Social History Sexual History ROS: Review of Systems PP: Patient Profile (Summary or Concluding Statement) BIOLOGICAL DATA: Date of Visit Name Nick Name Age Date of Birth Sex Race Language : Spoken Understood Parent’s Name Telephone/Home Work 1
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PEDIATRIC HEALTH HISTORY
CLASS 8
Focal Points of the Pediatric History
The developmental age & level of the child is important, in terms of asking age appropriate questions & in determining the general approach for the interview.
The child is part of a family, therefore a “family” approach to communicating with both parents & children is helpful.
For infants & young children, the primary source of historical information is the parent, a “third person” type of interview.
It is important to involve older children in the history-taking process, and move to a more “first person” type of approach. Even children as young as 3 or 4 years of age can add important information.
Treat initial concerns seriously & listen carefully, but also look for issues beyond the chief complaint that might also be important.
Increased anxiety of parents/children increases the need for careful teaching & reinforcement of treatment plans.
FOCAL POINTS OF PEDIATRIC HISTORY:Biological informationCC: Chief complaint or client’s request for carePI: Present Illness or present health statusPast Medical History:Prenatal, Natal, NeonatalIllnesses, operations, injuriesImmunizationsMedications, transfusionsAllergiesDevelopmental DataNutritional DataFamily Health HistoryFamily Personal/Social HistorySexual HistoryROS: Review of SystemsPP: Patient Profile (Summary or Concluding Statement)
BIOLOGICAL DATA: Date of Visit
Name Nick Name Age Date of Birth Sex
Race Language : Spoken Understood
Parent’s Name Telephone/Home Work
Parent’s Name Telephone/Home Work
Parent’s Occupation/s
Parent’s Occupation/s
Address/Residence
HEALTH INSURANCE/PAYMENT PLAN
GUARDIANSHIP/CUSTODIAL PARENT
Referral Source
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SOURCE OF INFORMATION: INFORMANT: Reliability
CC: Chief Complaint: (Limited to major “chief complain” in client’s words)Confirm with client that CC is the reason for the visit.
PI: OR CURRENT HEALTH STATUS: (Direct questions, focus on specific details, do not necessarily limit questioning to just chief complaint, as there may be other health issues of importance). Then select one of three types of histories:
1. INITIAL WELL CHILD: Complete history
2. INTERVAL WILL CHILD: Factors of significance since last visit
3. ILL CHILD: Details of illness/problem
ILL CHILD: ONSET
When was child last well? Health prior to illness?How or when did disturbance begin?Progress of disease/illness:
chronological order of eventsspecific signs and symptomsduration, characteristics, locationabrupt/gradual, related activityaggravating/alleviating factors: medication, treatment
Weight gainDuration of pregnancyAttitudes toward pregnancyMedications/drugs/OTC/recreational/herbs/alternative treat therapiesSmokingNutrition
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NATAL HISTORY (BIRTH):Gestational age (pregnancy duration)Birth weight, lengthDuration of laborType of delivery (vaginal cephalic/breech, cesarean, instruments, etc.)Sedation/anesthesiaCondition of infant at birthOnset of respirations - first cryResuscitation
NEONATAL HISTORY (NEWBORN):Ask about newborn APGAR Score, illustrated below: APGAR assessment scores (rated from 1 – 10) are recorded at 1 & 5 minutes after delivery. The 5 minutes scores indicate infant’s risk for neurologic sequelae: Low risk score: 8 – 10 Moderate risk score: 5 – 7 High risk score: 4 or lower
APGAR: 0 - 10 0 1 2
A appearance blue pink/blue pinkP pulse/heart rate 0 100 - 100 +G grimace 0 grimace cryA activity limp flexion activeR Respirations 0 slow, irreg. good cry_______________________________________________________________________________
Color - good, pallor, cyanosis, jaundiceHyperbilirubinemiaCry, breathing problemsTremor, convulsionsFeeding, sucking problemsCongenial anomaliesBirth injury, paralysisRashes, feverHemorrhageSpecial care nurseryAge at discharge
PAST ILLNESSES : Age & Date: Sequelae or complicationsInfectionsContagious diseasesMedical IllnessesInjuries, accidents, poisoningsHospitalizationsOperations
ALLERGIES: MUST include “kind of” reactionEnvironmentalFoodDrugOther
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IMMUNIZATIONS: 1999 SCHEDULE FOR ACTIVE Dates, Reactions IMMUNIZATION OF NORMALDesensitization procedures (MMR/egg allergy) INFANTS AND CHILDREN BY
12-15 months Hib, MMR. TB (Tuberculin Testing) begin with 15-18 months DTaP/DTP, VAR15 month immunizations recommended, 4-6 years DTaP/ DTP, OPV/IPV, MMRnot earlier than 12 months 11-12 years Td (if 5 year interval)
11-16 years Td, & repeat q 10 yearsVAR (Varicella)---can be administeredto susceptible children any time UNDER 7 YEARS, NOT IMMUNIZED INafter 12 months: unvaccinated with no HX FIRST YEARchickenpox should be vaccinated @ 11-12 yrs.If older than 13 yrs, 2 doses, 4 weeks apart 1st visit DTaP/DtaP, Hib, HBV,OPV/IPV, MMR
Intervals after :Rv (Rotavirus) 3 doses only. Begin @ 6 weeks, 1 month DTaP/DTP, HBV, VARMinimum interval 3 weeks. Do not initiate 2 months DTaP/DTP, Hib, OPV/IPVAfter 7 months of age. Must complete by <8 months DTaP/DTP, HBV, OPV/IPV12 months of age 4-6 yr DTaP/DTP, OPV/IPV, MMR
11-12 years Td (if 5 year interval)11-16 years Td , & repeat q 10 years
7 YEARS & OLDER1st visit HBV, OPV/IPV MMR, TdIntervals after:2 months HBV, OPV/IPV, MMR, Td8-14 months HBV, OPV/IPV, Td11-16 years Td (if 5 year interval) & repeat q 10 years
AAP - American Academy of Pediatrics http://www.aap.org/family/parents/immunize.htm CDC , ACIP - Centers for Disease Control, Advisory Committee on Immunization Practices
http://www.cdc.gov/nip/publications
CURRENT MEDICATIONS:Prescription, OTC,herbs, complimentary therapiesCurrent & past treatment
DEVELOPMENTAL HISTORY (standard historical questions to ask)Raised headSmiledRolled overSat aloneWalked aloneTalked -- meaningful words, simple phrasesDressed without help
EXAMPLES OF HABITS & ISSUES RELATED TO SPECIFIC AGE GROUPS
Early Infancy: eating, sleeping, elimination, colic, fussiness, body contact, predictability of patterns, temperament
Toddler: fear of strangers, sleeping, eating (weaning, table foods), increased mobility, safety
Pre-School: peer & social adjustment, discipline, genital curiosity, imagination, language development
School: school performance, peer socialization & friends, hobbies, interests, development of responsibility, independence (experimentation with smoking, drinking, drugs, sexual activity)
Adolescent: dealing with physical changes & sexual development, independence & emancipation from family, career goals, peer pressures (smoking, drinking, drugs, sexual activity), unusual behaviors or indications of depression (more common symptoms in girls may be body-image distortion, loss of appetite/weight & lack of satisfaction; more common symptoms in boys may include irritability, social withdrawal & drop in school performance)Major areas of functioning: school, home, peersOther assessment methods include: HEADS (Home, Education, Activities, Drugs, Sex, Suicide), or GAPS, Guidelines for Adolescent Preventive Services (American Medical Association).
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NUTRITION:
A 24 hour recall diet history is recommended for nutritional assessment Compare general intake/output & weight gain/loss Nutritional intake varies with each age group Appetite & eating behaviors change with age Using the food pyramid as a guideline may be helpful
The following guidelines may be helpful in eliciting & evaluating dietary histories in infants & children;
During infancy the focus is related to breast or formula feeding, supplements (iron, fluoride, vitamins),& introduction of solid foods.
Young children tend to be irregular, sporadic eaters, so food variety (food groups) consumed over longer time periods, such as a week rather than a day, may be more indicative of over-all nutritional intake. Offer small portions.
School-aged children tend to be “picky eaters, and do not like mixtures (casseroles) or things to “touch” on the plate
. Adolescents tend to be “fast food” and “snack” eaters, so quality of snacks becomes import to nutrition
intake.
INFANT GUIDELINES:
Higher protein & fat content needed in diet
Breast milk/formula recommended for first year
Whole milk no recommended until after 12 months of age year
Low fat or skim milk not recommended until 2 years of age
Breast Feeding:Neonate q. 2-3 hrsOlder infant 4-6 X/day
Vitamin, iron & flouride supplement variesBreastfed infant not exposed to sunlight may be deficient in vitamin DIron in breast milk is low, but highly bioavailableFluoride is not present in adeqate amounts in breast milk
Formula feeding:Most commerical formulas contain vitamins & ironFormulas come in 3 forms & correct preparation should be reviewed1. Ready-to-feed: expensive, convenient, good for travel2. Liquid concentrate: to be mixed in 1:1 concentration with water3. Powdered concentrate: most preparations are mixed 1 scoop (provided) to 2 oz. H20
(check specific instructions)Formula IntakeVolumes: Age in months # oz # feedings/day
1 4 63 5 56 6 512 4.5 4
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Fluoride: Optimum fluoridation of water is 1 part per million (0.7 - 1.2)Supplement dosage in mg/day, according to fluoride in water
Solid foods: Begin 6-12 months, 1-2 spoonfuls to 1/4 cup servingsFinger foods 6-7 months: chopped table foods & cup drinking 8/9 - 12 monthsOrder: Cereals (good iron source), vegetables, fruits, meat/fish/poultry
Delay egg whites until 12 months Breast/formula feedings reduce after solid foods: less than 1 quart/day
Family members with patient’s illness Parents: Age, health status, cause of death if deceased Siblings: # of siblings, age, sex, health status Deaths: Age, cause, family relationship, miscarriages/abortions Health of other close contacts
FOOD GROUP MAJOR NUTRIENT SERVINGS/DAY & SERVING SIZES Milk Protein 2-3 servings for child1/2 cup whole milk = Calcium 4 servings for adolescent 3/4 oz cheese Riboflavin (B2) Usual serving size: 1/2 cup yogurt, pudding Toddler/preschool--1/2 - 3/4 cup 1 cup cottage cheese School age & older - 1 cup_____________________________________________________________________________________MEAT Protein 2 for child & adolescent1 oz meat = Niacin Usual serving size: 1 egg Iron Toddler/preschool - 1 egg or 1 -2 oz meat 1 oz cheese Thiamin (B1) School age & older - 1 egg or 3 oz meat 2 TBS peanut butter_____________________________________________________________________________________VEGETABLES/FRUIT Vitamin A 4 for child & adolescentCitrus equivalents Vitamin C 1 citrus daily 1 orange or 1 tomato Fiber 1 yellow or dark green veg. 3-4 times/week 1/2 cup orange or grapefruit Usual serving size: 3/4 cup strawberries Toddler/preschool - 2-4 TBS to 1/4 -1/2 cup
School age & older - 1/2 cup_____________________________________________________________________________________BREADS & CEREALS. Carbohydrate 4 for child & adolescent1 slice enriched bread = Thiamin (B1) Usual serving size: 3/4 cup dry cereal Iron Toddler/preschool - 1/2 slice, 1/2 cup 1/2 cup cooked pasta/rice/cereal Niacin School age & older - 1 slide, 1/2 cup 1/2 hamburger bun 1 small muffin/biscuit
GENOGRAM TO GRANDPARENTSFamily tree or family diagram is a visual presentaton of the family history
FAMILY SOCIAL HISTORY
Internal Family Structure
Composition: Members living in home, nuclear, blended, single parent, extended family Family interactions: Family development, function, communication, problem-solving –
Happy, emotional, verbal, cooperative, antagonistic, chaotic… Social background: Culture, ethnicity, religion, ethics & values Home conditions: Housing, environment, adequacy, safety, milk & water supplies
External Family Structure
Social background: Culture, ethnicity, church/religion, ethics & values Socioeconomic: Finances, who works, education, occupations, assistance programs Outside help: Child care: baby-sitters, day-care, preschool, latch-key, teen center School: Members in school, grades, relationships, transportation, special
educational needs Other: Community groups, military, travel
ECOMAP Visual presentation of family’s support system, can be used to show: Internal family attachments (attachment diagram) or External family support or attachments
ROS: REVIEW OF SYSTEMS:
GENERAL: Unusual weight changes (previous trending/graphs), pattern of growth, fatigue, skin color /texture changes, temperature, chills, sensitivity, mentality, time & pattern of pubescence: changes in behavior (crying, irritability, nervousness, withdrawal, sleep patterns).
SPECIAL SENSES: Vision, Smell, Taste, Touch, Hearing
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SKIN: Birthmarks, rashes, acne, pigmentation--color changes--jaundice, cyanosis, pallor,changes in body hair, nails, nutrition, circulatory, or hydration status
HEENT: Head size, & shape, (fontanels/sutures), head injuries, headaches, loss of consciousness
EYES: Strabismus, vision, glasses, red eyes/infection, painful eyes, photophobia, double vision, surgery(myringotomy with tubes), dizziness, vertigo
GASTROINTESTINAL: Nausea, vomiting, diarrhea, constipation, type of stools, blood in stools, abdominal pain/discomfort, jaundice, dietary history may be applicable
GENITOURINARY: Enuresis, dysuria, frequency, polyuria, pyuria, hematuria (dark urine/”cola colored”), character of stream, flank pain, vaginal discharge, menstrual history, bladder
control, abnormalities of penis or testes, STDs, sexual activity
MUSCULOSKELETAL: Weakness, clumsiness, ataxia, lack of coordination, unusual movements, back or joint stiffness, muscle or joint pains, cramps, abnormal gait,
deformities, fractures, serious sprains, pain, swelling, muscle weakness or wasting (Gower’s sign), limitation of movement, activity level, exercise tolerance
NEUROLOGIC: Seizures, tremors, dizziness, tingling, sensory changes or paresthesias, loss of feeling, syncope, loss of memory, headaches, general affect, fears, nightmares, speech
problems, unusual habits, changes in gait or coordination
ENDOCRINE: Disturbances in growth, excessive thirst or appetite, goiter, thyroid disease, changes in hair, nails, lethargic baby with course cry
