Chapter 28: Assessment of the Child (Data Collection)

Vocabulary-style flashcards covering subjective data collection, objective data collection, interviewing, history taking, physical examination, and vital signs in pediatric assessment.

Subjective data

Information spoken by the child or family in a client interview.

Objective data

Information collected via direct observation and measurement.

Client interview

Process of obtaining subjective data through interviewing the family caregiver and child, using nonleading questions to establish rapport.

Chief complaint

Reason for the child’s visit; caregiver’s primary concern.

History of present health concern

Details about the current situation: beginning, duration, description, intensity, frequency, and treatments used.

Health history

Mother’s pregnancy and prenatal history; common childhood illnesses; immunizations; feeding and nutrition; hospitalizations and injuries.

Immunizations and health maintenance

Immunization status and ongoing health maintenance for the child.

Feeding and nutrition

History related to feeding patterns and nutritional intake.

Hospitalizations and injuries

Past hospitalizations and injuries the child has experienced.

Family health history

Diseases and conditions within the family; caregiver can provide information; used for preventive teaching.

Review of systems

Questions about each body system, including allergies, medications, and substance use.

Lifestyle

School history, social history, personal history, and nutrition history.

Developmental level

Questions directly related to milestones to assess growth and development.

Biographical data

Identifying information about the child and caregiver; part of the legal record and confidential.

Confidentiality

Protection of the child’s and family’s information; records are treated as confidential.

Interviewing family caregivers

Caregivers provide most information; interview should be nonjudgmental and acknowledge concerns.

Interviewing the child

Include preschool and older children; use age-appropriate questions; be honest and attentive.

Adolescent privacy

Adolescents should be interviewed privately to encourage honest disclosure.

General appearance

Observation of nutritional status, hygiene, mental alertness, posture, skin, and hair.

Psychological status and behavior

Observation of behavior, emotional and intellectual responses; note signs of illness.

Infant pain indicators

Behaviors signaling pain in infants, e.g., crying when held, head turning, ear pulling.

Observation of infant behavior vs illness

Constancy of behavior matters; change from baseline may indicate illness.

Height and weight measurement

Measured at each visit using consistent clothing and time; use appropriate equipment; safety precautions.

Head circumference

Measured routinely up to age 3 or with neurologic concerns; taken around the largest part of the head.

Temperature ranges (normal)

Oral/tympanic/temporal 97.6°F–99.3°F (36.4°C–37.4°C); Rectal 0.5–1°F higher; Axillary 0.5–1°F lower.

Oral temperature suitability

Oral temperatures are used only in children >4–6 years who are cooperative.

Tympanic temperature

Often obtained without waking a sleeping child.

Temporal temperature

Infrared sensor scanned across the skin on the forehead.

Rectal temperature considerations

Used when other methods are not possible; lubricate; insert 1/4–1/2 inch; position properly; notify physician if resistance.

Axillary temperature

Used for newborns/infants; place probe well into the armpit; skin-to-skin contact preferred.

Apical pulse

Preferred method for infants and young children; place stethoscope between the left nipple and sternum.

Radial pulse

Used in older children if pulse quality or rhythm is abnormal; count for a full minute.

Pulse oximetry

Measures arterial oxygen saturation; check site every 2 hours; change site every 4 hours.

Apnea monitor

Detects infant’s respiratory movement; often used in home settings.

Blood pressure (BP) in children

BP monitoring is routine for children ≥3 years; cuff size matters; normal values rise with age.

Point of maximum impulse (PMI)

The felt location of the maximal cardiac impulse; assess rhythm and rate.

Four abdominal quadrants

LUQ, LLQ, RUQ, RLQ used to describe abdominal findings.

Genitalia and rectum examination considerations

Respect privacy, consider age/development, observe for sores/lesions, palpate testes, assess for signs of abuse.

Back and extremities examination

Assess symmetry, gait, posture, ROM, strength; check hips and skin folds.

Neurologic examination

Most complex part of the exam; establish a baseline; assess reflexes, cranial nerves, and, if needed, Glasgow coma scale.