Chapter 28: Assessment of the Child (Data Collection)

Collecting Subjective Data

  • Definition: Information verbally shared by the child or family during the health interview.

  • Purpose & Significance
    • Establishes rapport, clarifies chief concerns, guides the focus of objective assessment.
    • Most data come from caregiver for infants/toddlers; include child whenever developmentally appropriate.

Conducting the Client Interview

Universal Principles

  • Introduce yourself, state purpose, maintain confidentiality.

  • Use focused, age-appropriate, non-leading questions; allow silence for thoughtful replies.

  • Remain non-judgmental; avoid verbal or non-verbal signals of disapproval.

Interviewing Specific Age-Groups

  • Caregivers (all ages): Primary historians; encourage expression of worries or anxieties.

  • Preschool & School-Age Children: Involve directly; use concrete language; be honest; listen attentively.

  • Adolescents: Offer private interview time; respect autonomy; reinforce confidentiality limits (e.g., self-harm).

Components of a Pediatric History

  1. Biographical Data
    • Child’s full name, address, phone, DOB, caregiver contact, legal custodial status.
    • Forms part of the legal record ⇒ safeguard privacy.

  2. Chief Complaint (CC)
    • Exact reason for visit stated in caregiver’s/child’s own words.

  3. History of Present Illness/Health Concern (HPI)
    • Onset, chronology, duration, location, quality, intensity, frequency, aggravating/relieving factors, prior treatments.
    • Use mnemonic “OLD CARTS.”

  4. Past Health History
    • Prenatal & perinatal details (maternal illness, medications, substance use).
    • Birth details: GA, delivery type, Apgar, birth weight.
    • Childhood illnesses (common, serious, chronic), hospitalizations, surgeries, injuries.
    • Immunization status & routine health maintenance.
    • Feeding & nutrition history (breast/formula, intro of solids, current diet).

  5. Family Health History
    • Genograms help reveal hereditary or environmental risks (e.g., \text{asthma}, \text{DM}, HTN).
    • Use findings for preventive teaching.

  6. Review of Systems (ROS)
    • System-by-system screening of current symptoms; probe CC-related systems deeply.

  7. Allergies/Medications/Substance Use
    • Document drug, food, environmental allergies & reactions.
    • List ALL meds (RX, OTC, supplements) with dose, route, schedule.
    • Screen for tobacco, alcohol, illicit drugs—be alert to “trigger” disclosure cues.

  8. Lifestyle & Social History
    • School performance, extracurriculars, peer relations, home environment, screen time.
    • Nutrition recall, sleep pattern, physical activity.

  9. Developmental History
    • Milestone attainment (gross/fine motor, language, social), regressions, concerns.

Collecting Objective Data

  • Definition: Information obtained via direct observation, measurement, or diagnostic tools.

  • General Exam Strategy
    • Tailor to child’s developmental stage.
    • Warm room, distraction/toys, exam on parent’s lap PRN.
    • Perform invasive/traumatic steps (ears, nose, throat) LAST.

General Appearance & Behavior

  • Compare apparent vs. stated age; note grooming, hygiene, nutritional status.

  • Observe caregiver–child interaction, speech, facial affect.

  • Psychological/Behavioral cues: Document deviations from baseline (lethargy, inconsolable crying, withdrawal).

Infant Behavioral Observation (Table 28-2 Highlights)

Domain

Healthy

Ill/Pain

Key Red Flags

Activity

Constant, curious

Lethargic, little interest

Abrupt ↓ activity

Muscular Tension

Tense, vigorous kicks

Limbs lax, head lag prone

Persistent hypotonia

Reaction Constancy

Developmentally steady

Regression, apathetic

New loss of skill

Cry

Strong, vigorous

Weak, high-pitched, or shrill (↑ICP)

Absent or inconsolable

Skin Color

Reddish-pink mucosa

Pallor, cyanosis (nail beds/tongue)

Sudden color change

Appetite

Impatient to feed

Indifferent, vomiting, regurgitation

Persistent refusal

Bizarre Behavior

—

Clinging, extreme passivity

Change from norm

“Any single manifestation may be insignificant; CONSTANCY & CHANGE matter.”

Anthropometric Measurements

Height & Weight

  • Record at every visit.

  • Hospitalized infants: weigh daily same time, same clothing; keep hand poised to prevent falls.

  • Equipment: measuring board (infant/toddler), standing scale & stadiometer once child can stand independently.

Head & Chest Circumference

  • Measure head at each visit until 3\text{ yr} or with neurological concern.
    • Tape wraps just above eyebrows & occipital prominence.

  • Normal: By late infancy/early childhood, chest circumference exceeds head by 2\text{–}3\text{ in}.

Vital Signs

Method

Age/Indication

Normal Range/Notes

Temperature

Oral

>4\text{–}6\,yr, cooperative

(97.6 – 99.3)^{\circ}\text{F} (36.4 – 37.4)^{\circ}\text{C}

Tympanic

All ages, esp. sleeping infant

Quick, minimal disturbance

Temporal

Newer, forehead scan

Infrared sensor across skin

Rectal

Last resort; avoid in diarrhea, rectal anomalies

T{rectal} = T{oral} + 0.5 – 1^{\circ}\text{F}

Axillary

Newborns/when rectal contra.

T{axillary} = T{oral} − 0.5 – 1^{\circ}\text{F}

  • Electronic Thermometers: Choose correct probe (red = rectal, blue = oral).

  • Never leave child unattended with thermometer in mouth.

Pulse

  • Apical: Preferred for infants & young children; locate midway between L nipple & sternum; count 1 full min when calm.

  • Radial: Acceptable in older child; if irregular, count apical full minute.

  • Cardiac Monitor: Skin prep with alcohol, check electrodes q2h; alarms ON with min/max limits; respond to alarms immediately.

Respirations

  • Observe before disturbing child; count 1 full min.

  • Infants = abdominal (diaphragmatic) breathers.

  • Document retractions—substernal, subcostal, intercostal, suprasternal, supraclavicular ⇒ signal distress.

  • Pulse Oximetry: Check probe site q2h, rotate q4h (foot, toe, finger).

  • Apnea Monitor (home/hospital): Electrodes over maximal respiratory motion; set alarm limits; family teaching essential.

Blood Pressure

  • Routine for children \ge 3\,yr; choose cuff width = \approx 40\% of arm circumference, bladder length \approx 80\% of limb.

  • Values rise steadily from infancy through adolescence—reference percentile tables.

Head & Neck Examination

  • Head: Shape, plagiocephaly, fontanels (anterior closes by 12\text{–}18\,mo).

  • Eyes: Position, symmetry, pupillary reaction \text{(PERRLA)}, extra-ocular movements, accommodation.

  • Ears: Alignment (top of pinna in line with outer canthus). Low-set ears ⇒ possible genetic/intellectual disorders. Assess conversational response; unclear or loud speech suggests hearing deficit.

  • Nose/Mouth/Throat: Midline nose, patency, absence of flaring or drainage. Use tongue blade (not gloved finger) for toddlers. Inspect mucosa, dentition, swallowing.

Chest & Lungs

  • Measure chest circumference at nipple line when indicated.

  • Observe thoracic shape & symmetry; note retractions, paradoxical movement.

  • Auscultate breath sounds—compare sides; wheezes, rales, diminished areas.

  • Document cough quality (dry, productive, “bark”), sputum description.

  • In older female children, note Tanner breast staging.

Cardiovascular

  • Locate Point of Maximum Impulse (PMI) (4th ICS LMCL in <7 yr; 5th ICS MCL in >7 yr).

  • Assess rate, rhythm, extra sounds (S₃, S₄, murmurs), thrills, heaves.

Abdomen

  • Inspect contour (flat, scaphoid, distended), auscultate before palpation.

  • Use four-quadrant method: \text{RUQ, RLQ, LUQ, LLQ}.

  • Palpate for masses, organomegaly, tenderness; observe umbilicus in infants.

Genital & Rectal Area

  • Ensure privacy; engage caregiver/child in explaining procedure.

  • Inspect for lesions, discharge; palpate testes (should descend by \approx6\,mo).

  • Abnormal findings may indicate infection, congenital issues, or abuse.

Back & Extremities

  • Inspect spine for scoliosis/kyphosis/lordosis; observe gait & posture.

  • Assess ROM of all joints, muscle tone, symmetry, limb length.

  • In infants, examine hip stability (Ortolani/Barlow tests), symmetrical thigh folds.

Neurologic Assessment

  • Establish baseline & monitor trends, esp. post-injury.

  • Reflexes: Primitive (Moro, rooting) vs. protective/postural; note persistence or absence.

  • Cranial Nerves: Age-adjusted testing (e.g., tracking, facial symmetry, shoulder shrug).

  • Glasgow Coma Scale (Pediatric adaptation): Eye 4, Verbal 5, Motor 6; normal \text{= 15}, reassess q1–2h if indicated.

Assisting With Common Diagnostic Tests

  • Purpose: Clarify subjective/objective findings, define pathology. Tests include labs (CBC, BMP), imaging (X-ray, US, CT, MRI), cardiac (ECG, echocardiogram), pulmonary (PFTs), neurologic (EEG, LP), etc.

  • Nursing role: Explain procedure, obtain consent, prep child/family, ensure comfort & safety, collect specimens, label accurately, monitor post-procedure.

Ethical & Practical Considerations

  • Confidentiality vs. mandatory reporting (abuse, self-harm).

  • Culturally sensitive communication; interpreters when language barrier present.

  • Always document objectively—quote caregiver when possible, avoid judgmental terms.

Real-World Connections

  • Accurate subjective/objective data underpin diagnosis, influence resource allocation (e.g., early intervention for developmental delays).

  • Trends in growth/vitals help detect chronic issues (failure to thrive, hypertension epidemic in youth).

  • Pain misinterpretation in infants can delay treatment—highlighting importance of behavioral cues.

Quick Reference ‑ Key Numbers & Ranges

\begin{aligned}
\text{Oral T} &: 97.6^{\circ}\text{F} – 99.3^{\circ}\text{F} \, (36.4^{\circ}\text{C} – 37.4^{\circ}\text{C}) \
T{rectal} &= T{oral} + 0.5^{\circ}\text{F} – 1^{\circ}\text{F} \
T{axillary} &= T{oral} − 0.5^{\circ}\text{F} – 1^{\circ}\text{F} \
\text{Chest – Head} &= 2\text{–}3\text{ in (childhood)} \
\text{GCS Normal} &= 15 \
\end{aligned}

These notes consolidate every critical element from Chapter 28 (Assessment of the Child) into a structured study guide suitable for exam preparation or clinical reference.