Beginning the Assessment

Infants (1 to 12 months) primarily communicate through nonverbal vocalization and crying and respond to nonverbal communication behaviors of adults such as holding, rocking, and patting. It is useful to observe the parent’s or caregiver’s interpretation of the infant’s nonverbal cues and the nonverbal communications of the parents. These established communication patterns can aid the nurse in establishing rapport with the infant.

Young infants respond well to gentle physical contact with any adult, but older infants can demonstrate strong separation and stranger anxieties. If it is necessary to handle the older infant, do so firmly. Avoid preparatory gestures such as holding out hands or coaxing the child to come and abrupt movements. Although infants younger than 6 months usually tolerate lying on the examining table, older infants and toddlers are more comfortable when held or sitting in the parent’s or caregiver’s lap. As much as possible, carry out the assessment in a way that allows the infant to either keep the parent in view or to be held by the parent. Infants should be allowed security objects such as blankets and pacifiers, if they have them. The use of a high-pitched, soft voice and smile will also assist in gaining the infant’s cooperation.

Toddlers (12 months to 3 years) have not yet acquired the ability to effectively communicate verbally. Their communication is rich with expressive nonverbal gestures and simple verbal communications. Pushing the examiner’s hand away and crying can be an eloquent expression of fear, anxiety, or lack of knowledge. Toddlers accept the verbal communications of others literally, so that saying, “I can see all the way to your tummy button when you open your mouth” will mean just that to toddlers. Toddlers have the beginnings of memory and imagination, but they are unable to understand abstractions and become frustrated and frightened by phrases that seem ordinary to adults. Perceptions of threat are amplified by inaccurate understandings of the situation and limited knowledge of the resources that are available.

Communication with toddlers requires that the nurse use short, concrete terms. Explanations and descriptions need to be repeated several times. Visual aids such as puppets and dolls assist explanations. Children of this age attribute magical qualities to inanimate objects, so it is useful to allow them to handle instruments and to tell them exactly, in concrete terms, what the instrument does and how it feels. The use of comfort objects and access to the parent should be encouraged throughout the assessment, as they are for the infant.

Although preschoolers (3 to 6 years) generally use more sophisticated verbal communications, their reasoning is intuitive. Therefore many of the guidelines for communicating with toddlers apply to preschoolers as well. Because of the preschooler’s increased verbal communication abilities, the nurse can successfully indicate to the child how and when cooperation is desired. The older preschooler, in particular, likes to conform, knows most external body parts, and might be interested in the purpose of various parts of the assessment. Allowing the preschooler to handle the equipment eases fears and helps answer questions about how the equipment is used.

Preschool-age children are often very modest. They should be exposed minimally during examination and requested to undress themselves. They need to know exactly what is being examined and benefit from opportunities for questions. Parental proximity is still important for this age group.

School-age children (6 to 12 years) think in concrete terms but at a more sophisticated level. Generally they have had enough contact with health care personnel that they can rely on past experiences to guide them. Depending on the quality of their past experiences, they might appear shy or reticent during health assessment. Children might fear injury or embarrassment. Allowing time for composure and privacy (perhaps even from parents) aids in communication. Reassurance and third-person speech are helpful in eliciting worries and anxieties and in allowing the child to express fear or pain.

The purpose of the health assessment should be related to the child’s condition. It is useful to determine what the child already knows about the health contact and to proceed from there. Simple medical diagrams and teaching dolls are useful in explaining the assessment process. Specific information should be given about body parts affected by the assessment.

Children of this age are often curious about the function of equipment and its usefulness. An appropriate response to “How can you tell what my temperature is from the thermometer?” might be “Your body heat is picked up by a special sensor. The sensor reads your temperature as a number. I can then tell from the number how warm you are.”

Adolescents (12 years and older) use sophisticated verbal communication, although their behavior might not necessarily indicate an advanced level of communication, cognition, or maturity. Adolescents sometimes respond to verbal approaches with monosyllables, reticence, anger, or other behaviors, and the nurse might have to do more talking than is usual at the beginning of the interaction. The nurse must avoid the tendency to respond to less than desirable social behaviors with prying, confrontation, continuous questioning, or judgmental attitudes. Easing into the initial contact with discussion of friends, hobbies, school, and family can give the apprehensive adolescent time for self-composure. Disclosure might occur more easily when the adolescent and nurse are engaged in joint activity.

It is helpful to ask the adolescent what he or she knows about the health contact and to explain the rationale for the health assessment. Adolescents might be concerned about privacy and confidentiality, and opportunity should be provided for completing some or all of the assessment without the presence of the parent. The female nurse needs to be sensitive to the potential of embarrassment for male adolescents at being examined by a female and provide draping and minimal touching. The parameters of confidentiality should be explained; specifically, it should be explained that disclosure is confidential unless intervention is necessary. Adolescents tend to be preoccupied with body image and function, and when appropriate they should be given feedback from the assessment. Diagrams and models can enhance feedback. Although adolescents have a high level of comprehension and vocabulary, they might not consistently function at higher levels of cognition, and the nurse must avoid the tendency to become too abstract, too detailed, and too technical. The self-conscious adolescent might be reluctant to ask for clarification of an explanation that has not been understood.

Parents are often an integral part of the health assessment of an infant or child. Parents are the primary source of information about the young child. The information that parents give can be considered reliable in most instances because of close contact with their children.

Broad questions are useful, especially in eliciting responses in sensitive areas, because the parent can assume control over the direction of the response: “Tell me what Jason did at 2 years” is less threatening than “Did Jason talk when he was 2?” or “Did you have trouble disciplining Jason when he was 2?” More focused and closed questions should be saved for later in the assessment process when specific information is desired.

Silence and listening are essential to reassure parents that what they are about to say is worthwhile. In a supportive, attentive atmosphere, parents often communicate information and feelings that might have little to do with the current problem but are significant in the overall care of the child.

The parents are members of the health team. If they believe the child has a problem, their concern must be treated seriously. The parents and the nurse must agree that the problem exists. Once agreement exists, the nurse can ask how the parents have tried to solve the problem. This approach reinforces the worth of the parents’ solutions. Having accomplished this, the nurse can help the parents to find alternative solutions for the problem. Occasionally parents will select alternatives that are not preferred. If the alternative will not harm the child, it is best to allow the parents to carry out their plan.

The nurse must avoid the temptation to inundate the parents with anticipatory guidance. Parents need recognition, praise, and reassurance for their strengths. Too much information and advice can intimidate parents and effectively shut down communication.

In communicating with parents and children from diverse cultures, it is critical to recognize that communication patterns, childrearing practices, and health practices might differ from those of the nurse (Table 1-1). Knowledge of these differences will assist in developing hypotheses about the family and in acquiring sensitivity to differences; however, the nurse must observe the family carefully for cues to family practices and relationships with children and each other. Further, the nurse must avoid the trap of assuming that because the family belongs to a specific ethnic or cultural group, they will behave and hold beliefs similar to those of the group as a whole.

When communicating with families from diverse cultures, watch their interactions with others (e.g., note whether eye contact is established and with whom) and observe what distance is generally assumed in communication. This will assist in determining what body gestures are appropriate; however, if unsure, ask. When addressing the family, it is important to learn and to use culturally appropriate forms of address. If the family has limited language comprehension, speak slowly and carefully, avoiding the tendency to speak loudly. If unsure as to what has been said, ask for clarification; if unsure whether information has been understood, repeat important points. If possible, use wording written in the family’s own language and if necessary, use an interpreter. As with all families, convey caring and use active listening.

The health interview provides an ideal opportunity to establish communication and rapport and usually is the first step in an assessment. The interview should be conducted in a room that is private, bright, and nonthreatening. Toys and drawing materials are useful for distracting the young child, so that the parent can give the interviewer full attention.

Before beginning the health interview, nurses must introduce themselves and ask the names of family members. Family members are then addressed by name. Unless an infant, the child is usually included in the interview; the extent of involvement varies with age and culture.

Nurses must clarify their roles in the assessment process because in some health settings many health practitioners see the child. The purposes of the health interview and physical assessment are clarified because parents might wonder about the relevance of the information they are about to give. Parents, and the child, as appropriate, are also told who has access to the information and are assured about the limits of access. After the parameters of the interview and physical assessment have been set, the parents are better able to decide how and what they want to communicate.