A nurse is assessing a toddler at a well-child visit At what point in the physical examination

Whether the setting is a hospital or other healthcare facility, it is important to gather information regarding the child’s history and current status.

Collecting Subjective Data

Information spoken by the child or family is called subjective data.

Conducting the Client Interview

Most subjective data are collected through interviewing the family caregiver and the child.

• Why interview? The interview helps establish relationships between the nurse, the child, and the family.
• Listen and communicate. Listening and using appropriate communication techniques help promote a good interview.
• Introduce and explain your purpose. The nurse should be introduced to the child and caregiver and the purpose of the interview stated.
• Establish rapport. A calm, reassuring manner is important to establish trust and comfort; the caregiver and the nurse should be comfortably seated, and the child should be included in the interview process.

Interviewing Family Caregivers

The family caregiver provides most of the information needed in caring for the child, especially the infant or toddler.

• Ask questions and note them. Rather than simply asking the caregiver to fill out a form, the nurse may ask the questions and write down the answers; this process gives the opportunity to observe the reactions of the child and the caregiver as they interact with each other and answer the questions.
• Avoid being judgemental. The nurse must be nonjudgemental, being careful not to indicate disapproval by verbal or nonverbal responses.

Interviewing the Child

It is important that the preschool child and the older child be included in the interview.

• Be age-appropriate. Use age-appropriate toys and questions when talking with the child.
• Establish rapport. Showing interest in the child and in what he or she says helps both the child and caregiver to feel comfortable; by being honest when answering the child’s questions, the nurse establishes trust with the child.
• Listen. The child’s comments should be listened to attentively, and the child should be made to feel important in the interview.

Interviewing the Adolescent

Adolescents can provide information about themselves.

• Interview in private. Interviewing them in private often encourages them to share information that they might not contribute in front of their caregivers.

Obtaining a Client History

When a child is brought to any health care setting, it is important to gather information regarding the child’s current condition, as well as medical history.

• Biographical data. The nurse obtains identifying information about the child, including the child’s name, address, and phone number, as well as information about the caregiver; a questionnaire often is used to gather information, such as the child’s nickname, feeding habits, food likes and dislikes, allergies, sleeping schedule, and toilet-training status.
• Chief Complaint. The reason for the child’s visit to the healthcare setting is called the chief complaint; to best care for the child, it is important to get the complete explanation of what brought the child to the healthcare setting.
• History of present health concern. To help the nurse discover the child’s needs, the nurse elicits information about the current situation, including the child’s symptoms, when they began, how long the symptoms have been present, a description of the symptoms, their intensity and frequency, and treatments to this time.
• Health history. Information about the mother’s pregnancy and prenatal history are included in obtaining a health history for the child; other areas the nurse asks questions about include common childhood, serious, or chronic illnesses; immunizations and health maintenance; feeding and nutrition; as well as hospitalizations and injuries.
• Family health history. The caregiver can usually provide information regarding family health history; the nurse uses this information to do preventive teaching with the child and family.
• Review of systems for current health problem. While the nurse is collecting subjective data, the caregiver or child is asked questions about each body system; the body system involved in the chief complaint is reviewed in detail.
• Allergies, medications, and substance abuse. Allergic reactions to any foods, medications, or any other known allergies should be discussed to prevent the child being given any medications or substances that might cause an allergic reaction; medications the child is taking or has taken, whether prescribed by a care provider or over the counter, are recorded; it is important, especially in the adolescent, to assess the use of substances such as tobacco, alcohol, or illegal drugs.
• Lifestyle. School history includes information regarding the child’s current grade level and academic performance, as well as behavior seen at school; social history offers information about the environment that the child lives in, including the home setting, parents’ occupations, siblings, family pets, religious affiliations, and economic factors; personal history relates to data collected about such things as the child’s hygiene and sleeping and elimination patterns; nutrition history of the child offers information regarding eating habits and preferences, as well as nutrition concerns that might indicate illness.
• Developmental level. Gathering information about the child’s developmental level is done by asking questions directly related to growth and development milestone; knowing normal development patterns will help the nurse determine if there are concerns that should be further assessed regarding the child’s development.

Collecting Objective Data

Objective data in nursing is part of the health assessment that involves the collection of information through observations. The collection of objective data includes the nurse doing a baseline measurement of the child’s height, weight, blood pressure, temperature, pulse, and respiration.

General Status

The nurse uses knowledge of normal growth and development to note if the child appears to fit the characteristics of the stated age.

• Observing general appearance. The infant or child’s face should be symmetrical; observe for nutritional status, hygiene, mental alertness, and body posture and movements; examine the skin for color, lesions, bruises, scars, and birthmarks; observe hair texture, thickness, and distribution.
• Noting psychological status and behavior. Observation of behavior should include factors that influenced the behavior and how often the behavior is repeated; physical behavior, as well as emotional and intellectual responses, should be noted; also consider the child’s age and developmental level, the abnormal environment of the healthcare facility, and if the child has been hospitalized previously or otherwise separated from family caregivers.

Measuring Height and Weight

The child’s height and weight are helpful indicators of growth and development.

• When to measure. Height and weight should be measured and recorded each time the child has a routine physical examination, as well as at other health care visits.
• How to measure weight. 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 infant is weighed nude, lying on an infant scale, or when the infant is big enough to sit, the child can be weighed while sitting.
• How to measure height. The child who can stand usually is measured for height at the same time; to measure the height of a child who is not able to stand alone steadily, usually under the age of about 2, place the child flat, with knees held flat, on an examining table; measure the child’s height by straightening the child’s body and measuring from the top of the head to the bottom of the foot.

Measuring Head Circumference

The head circumference us measured routinely in children to the age 2 or 3 years or in any child with a neurologic concern.

• How to measure. A paper or plastic tape measure is placed around the largest part of the head just above the eyebrows and around the most prominent part of the back of the head.
• Record and plot. This measurement is recorded and plotted on a growth chart to monitor the growth of the child’s head.

Vital Signs

Vital signs, including temperature, pulse, respirations, and blood pressure, are taken at each visit and compared with the normal values for children at the same age.

• The temperature can be measured by the oral, rectal, axillary, or tympanic method; temperatures are recorded in Celsius or Fahrenheit, according to the policy of the health care facility.
• A normal oral temperature range is 36.4 degrees Celsius to 37.4 degrees Celsius (97.6 degrees Fahrenheit to 99.3 degrees Fahrenheit.
• A rectal temperature is usually 0.5 to 1.0 degrees higher than the oral measurement.
• An axillary temperature usually measures 0.5 degrees to 1.0 degrees lower than the oral measurement.

• The apical pulse should be counted before the child is disturbed for other procedures. The stethoscope is placed between the child’s left nipple and sternum.
• A radial pulse may be taken on an older child
• A pulse that is unusual in quality, rate, or rhythm should be counted for a full minute and should be compared on the opposite site.
• Pulse rates vary with age: from 100 to 180 beats per minute for a neonate to 50 to 95 beats per minute for the 14-to 18-year-old adolescent.

• The child can be observed while lying or sitting quietly; infants are abdominal breathers; therefore the movement of the infant’s abdomen is observed to count respirations;
• The older child’s chest can be observed how an adult’s would be.
• The infant’s respirations must be counted for a full minute because of normal irregularity.
• Retractions are noted as substernal, subcostal, intercostal, suprasternal, or supraclavicular.

• For children 3 years of age and older, blood pressure monitoring is part of routine and ongoing data collection;
• Taking the blood pressure on a stuffed animal or doll will show the child the procedure is not to be feared.
• The most common sites used to obtain a blood pressure reading in children are the upper arm, lower arm or forearm, thigh, and calf or ankle;
• The blood pressure is taken by auscultation, palpation, or Doppler or electronic method.

Physical Examination

Data are also collected by examining the body systems of the child.

Symmetry or a balance is noted in the features of the face and in the head.

• Assess the range of motion. Observe the child’s ability to control the head and the range of motion; to see full range of motion, ask the older child to move her or his head in all directions; in the infant, the nurse gently moves the head to observe for any stiffness in the neck.
• Assess the fontanels. The nurse feels the skull to determine if the fontanels are open or closed and to check for any swelling or depression.
• Assess the eyes. Observe the eyes for symmetry and location in relationship to the nose; note any redness, evidence of rubbing, or drainage; ask the older child to follow a light to observe her or his ability to focus; an infant will also follow a light with his or her eyes; Observe pupils for equality, roundness, and reaction to light.
• Assess the ears. The alignment of the ears is noted by drawing an imaginary line from the outside corner of the eye to the prominent part of the child’s skull; the top of the ear, known as the pinna, should cross this line; note the child’s ability to hear during normal conversation; a child who speaks loudly, responds inappropriately, or does not speak clearly may have hearing difficulties that should be explored.
• Asses the nose, mouth, and throat. The nose is in the middle of the face; if an imaginary line were drawn down the middle, both sides of nose should be symmetrical; observe for swelling, drainage, or bleeding; to observe the mouth and throat, have the older child hold his or her mouth wide open and move the tongue from side to side; with the infant or toddler, use a tongue blade to see the mouth and throat; observe the mucous membranes for color, moisture, and any patchy areas that might indicate infection; observe the number and condition of the child’s teeth.

Chest measurements are done on infants and children to determine normal growth rate.

• How to measure the chest. Take the measurement at the nipple level with a tape measure; observe for chest size, shape, movement of the chest with breathing, and any retractions.
• Adolescents. In the older school-age child or adolescent, note evidence of breast development.
• Assess respiratory characteristics. Evaluate respiratory rate, rhythm, and depth; report any noisy or grunting respirations.
• How to assess breath sounds. Using a stethoscope, the nurse listens to breath sounds in each lobe of the lung, anterior and posterior, while the child inhales and exhales; describe, document, and report absent or diminished breath sounds, as well as unusual sounds such as crackling or wheezing.

In some infants and children, a pulsation can be seen in the chest that indicates the heart beat, which is called the point of maximum impulse.

• Assessing heart rate and rhythm. The nurse listens for the rhythm of the heart sounds and counts the rate for  1 full minute.
• Assessing for heart abnormalities. Abnormal or unusual heart sounds might indicate the child has a heart murmur, heart condition, or other abnormality that should be reported.
• Assess the heart function’s effectiveness. To determine the heart function’s effectiveness, the nurse assesses the pulses in various parts of the body.

The abdomen may protrude slightly in infants and small children.

• Dividing the abdomen. To describe the abdomen, divide the area into four sections and label sections with the terms left upper quadrant (LUQ), left lower quadrant (LLQ), right lower quadrant (RLQ), and right upper quadrant (RUQ).
• Assess bowel sounds. Using a stethoscope, the nurse listens for bowel sounds or evidence of peristalsis in each section of the abdomen and records what is heard.

When inspecting the genitalia and rectum, it is important to respect the child’s privacy and take into account the child’s age and stage of growth and development.

• Inspect the genitalia and rectum. While wearing gloves, the nurse inspects the genitalia and rectum; observe the area for any sores or lesions, swelling, or discharge.
• Assess the testes. In male children the testes descend at varying times during childhood; if the testes cannot be palpated, this information should be reported.

The back and extremities should also be assessed for abnormalities.

• Assess the back. The back should be observed for symmetry and for curvature of the spine; in infants the spine is rounded and flexible; as the child grows and develops motor skills, the spine further develops.
• Assess gait and posture. Note gait and posture when the child enters or is walking in the room.
• Assess the extremities. The extremities should be warm, have good color, and be symmetrical; by observing the child’s movements during the exam, the nurse notes range of motion, movement of the joints, and muscle strength.

Assessing the neurologic status of the infant and child is the most complex aspect of the physical exam.

• Neurologic exam. The practitioner in the health care setting assesses the neurologic status of the child by doing a complete neurologic exam; this exam includes detailed examination of the reflex responses, as well as the functioning of each of the cranial nerves.
• Neurologic assessment tools. The nurse uses a neurologic assessment tool such as the Glasgow coma scale; the use of s standard scale for monitoring permits the comparison of results from one time to another and from one examiner to another; using this tool, the nurse monitors various aspects of the child’s neurologic functioning.