This text focuses on health assessment of the child, beginning with the 1-month-old infant and ending with the teenager in late adolescence. Although the physical assessment process is broken down into evaluations of the various body systems, the nurse need not adopt a fragmented approach to physical assessment. In fact, physical assessment is continuous and occurs during the health interview, when the nurse is also able to observe the infant, child, or adolescent.
Assessment is facilitated for the child, parent (if present), and examiner if a rapport is established early. It might not be possible to erase all of a child’s apprehension or discomfort, but creating an atmosphere of trust and communication can help make the assessment a more positive experience.
Guidelines for Communicating with Children
▪ Take time to become acquainted with the child and parents.
▪ Set up a physical environment that is appropriately warm, cheerful, and private. If possible, select an environment that is decorated in an age-appropriate manner; for example, adolescents might not appreciate Snow White pictures.
▪ Ask the parents how the child usually copes with new or stressful situations or what previous experiences the child has had with health care or caregivers. Knowing how the child might react enables the nurse to plan specific interventions to facilitate communication.
▪ Ask the parents what they have told the child about the health care encounter. The preparation children receive, especially males, is often inadequate or inappropriate. In such a case, more time might be necessary to prepare the child before beginning any aspect of the health assessment requiring active participation.
▪ Observe the child’s behavior for clues to readiness. A child who is ready to participate in assessment will ask questions, make eye contact, describe past experiences, touch equipment, or detach willingly from the parent.
▪ If a child is having difficulty accepting the assessment:
Talk to the parent, ignoring the child.
Compliment the child.
Play a game (such as peek-a-boo) or tell a story.
Use the third-person linguistic form: “Sometimes a guy can get really scared when his blood pressure is taken.”
Sequence the assessment from that causing least discomfort to that causing most discomfort.
Start from toe to head.
Undress the child gradually or allow the child to undress gradually.
Briefly perform the technique on the parent first.
▪ Encourage the child to ask questions during the assessment, but do not pressure to do so. This allows the child some control over the situation.
▪ Explain the assessment process in terms consistent with the child’s developmental level.
▪ Use concrete terms rather than technical information, particularly with young children: “I can hear you breathing in and out,” not “I am auscultating your chest.” “Do your ears ever hurt?” not “Have you had otitis media?”
▪ Present small amounts of information at a time. A rule of thumb is that no more than three items should be presented at once.
▪ Do not make rushed movements.
▪ Make expectations known clearly and simply: “I want you to be very still.”
▪ Do not offer choice where there is none.
▪ Offer honest praise: “I know that hurt. You held your tummy very still.” A positive experience helps build coping skills and self-esteem.
▪ If using an interpreter, it is critical to explain the purpose of the assessment and to introduce the interpreter to the family. Avoid medical jargon as much as possible, and ask one question at a time.
▪ When examining more than one child, usually begin with the oldest or most cooperative child.
Communicating with Infants
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.
Communicating with Toddlers
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.
Communicating with Preschool-Age Children
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.
Communicating with School-Age Children
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.”
Communicating with Adolescents
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.
Communicating with Parents
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.
Communicating with Parents and Children from Diverse Cultures
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.
| Ethnic Group | Family Structure | Child Rearing | Traditional Health Care Beliefs/Practices | Relationship with Professionals | Prevalent Health Concerns |
|---|---|---|---|---|---|
| Asian Indians |
Family most important social unit.
Extended family tend to live in one household.
Lifestyle collectivistic rather than individualistic.
Earnings shared in the extended family.
Head of household is the most established and financially secure male; head of household makes most decisions but consults close relatives on matters of importance.
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Children relatively more controlled and protected than North American children.
Compliance achieved through threats, treats, and occasional spanking.
Independence not encouraged.
No fixed schedule for young children.
Male children are preferred and have special roles.
Education highly valued.
Careers and marriage partners selected for children although this is changing.
|
Illnesses result from imbalance in body humors (bile, wind, phlegm).
Dietary imbalance most common cause of sickness.
Hot/cold classification used for foods, depending on how they affect the body.
Food is to be eaten in a quiet room and with warm water.
Bathing, massage, ritual oils, herbs, and foods are used to treat ailments.
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Physician expected to have all the answers, make all decisions, and go beyond questions.
Medication is expected.
Formal dress expected of caregivers.
Females tend to be uncomfortable with male caregivers.
Health decisions about children made by senior family members.
Care of ill family members is responsibility of wife, grandparents.
Leisurely style of communication preferred. Small talk significant; rushing considered rude; a direct “no” is impolite.
|
Tuberculosis
Parasites
Hepatitis
Malaria
Cardiac disease
|
| Blacks |
Strong kinship ties and interactions with extended family.
Kinship network not necessarily limited to blood lines; unrelated persons found in same household.
Rigid sex Roles deemphasized. Men and women share in household and family responsibilities. Turn to neighbors, or minister in time of crisis.
Discussion of family Concerns outside of family is major breach of family ethics.
|
High emphasis on peoplehood or collective consciousness.
Strong emphasis on ambition and work.
|
Self-care, folk medicine important.
Tend to seek help from “old lady,” priest, root doctor, spiritualist, or minister when ill.
Prayer important to healing and treatment.
Illness seen as “will of God.” Might believe in voodoo and religious healing.
Might wear copper and silver bracelets to prevent illness.
Prevention important through cleanliness, laxatives, rest, and diet.
|
Sensitive to any evidence of discrimination.
Might disguise health concern initially to “test” health care professional’s ability to see real problem.
Nonverbal behavior important in interactions.
Might deny need for help to avoid appearing
helpless or dependent.
|
Sickle cell disease
Hemoglobin C disease
Diabetes
Pneumonia
Asthma
Cardiovascular disease
Lactose intolerance (preschoolers and older)
Obesity
Drug/alcohol use
|
| Cambodians/Laotians |
Family key social and economic unit.
Extended family source of support and assistance.
Husband is head of household, decision maker.
Family problems are considered private.
|
Physical discipline rare; discipline occurs through verbal reprimand.
Respect for older siblings, adults predominant. Children learn through observation and imitation. Infants carried a great deal; not allowed to cry, walk later than Western children.
|
Coin rubbing, using a coin or metal spoon, is used to treat a variety of common ailments.
Pinching involves pinching area between eyebrows until it turns red.
Pinching and coin rubbing might leave bruising.
Ginseng, Tiger Balm are common selftreatments.
|
Tend to seek professionals only if very ill.
Passive role in therapeutic relationship.
Expect treatments and medications.
Might see blood tests as life threatening.
|
Tuberculosis
Intestinal parasites
Anemia
Hepatitis B
Dental caries
Lactose intolerance
|
| Chinese |
Large extended families in a single household; unmarried children live at home until marriage.
Husband is breadwinner, takes care of finances, and disciplines children.
Wife takes care of household and usually makes health decisions.
Divorce considered a disgrace.
Serious decisions can involve all family members.
Young obliged to take care of elderly.
|
Discipline might seem harsh to Westerners.
Open affection rarely displayed.
Toilet training initiated early.
High value placed on success in school and at work.
|
Practices based on combination of folk, traditional, and modern medicine.
Word of mouth, family practices, magic, and religion important.
Illness results from disequilibrium of opposing forces.
Cures are sought from substances associated with perceived deficiencies (e.g., eating brains to get wiser).
Food is essential to harmony with nature and is used to explain causes of illness and to treat disease.
|
Health professionals highly respected;
Chinese patient might not question out of respect.
Might find team approach confusing as
Chinese are more familiar with having a close relationship with one or two professionals.
Prefer older professionals and Chinese physicians, if available. Strong respect for intactness of body so might refuse surgery.
Might become intensely distressed by drawing of blood as blood is considered source of all life and is not believed to regenerate.
High expectations of treatment; might not understand limitations.
Prevention difficult because many Chinese seek help only if ill.
|
Hepatitis
Tuberculosis
Intestinal parasites
Lactose intolerance
Dental caries
|
| Filipino |
Family highly structured.
Extended family is central and contains maternal and paternal relatives.
Kinship extended to neighbors and friends and is initiated through sharing of Roman Catholic rituals.
Community obligations shared through extensions of kinship and include shared labor, food, and financial resources.
Conflict is avoided in relationships through use of euphemisms.
Go-between selected in sensitive situations.
|
Children adored.
Children indulged until age of 6 years when they begin to be socialized through negative feedback.
Children expected to be obedient, respectful, to contain emotions, and to be polite.
Children might appear shy and quiet.
|
God’s will and supernatural forces govern universe.
Misfortunes such as ill health are result of violating God’s will.
Head considered sacred. Feet lowest part of body so considered rude to show bottom of shoes.
Some illnesses considered imbalance of hot and cold.
Need to treat hot illnesses with cold foods and cold illnesses with hot foods. Diarrhea and fevers considered hot illnesses; chills and colds considered cold illnesses.
Some health practices based on imitative qualities (e.g., nursing mothers avoid dark foods so that babies will have light skin).
Fish heads and onions considered brain foods.
Honey and certain herbs used to treat diabetes.
|
Communication polite and formal.
Loud talking considered rude.
Elders never addressed by first name.
Sensitive topics such as income and personal health avoided.
Direct eye contact avoided as can be considered sexually aggressive, but if eye contact made, it is appropriate to return it.
|
Dental caries
Lactose intolerance
|
| Hispanics |
Couple expected to set up independent household but has close ties with extended family.
Extended family includes blood relatives and godparents.
Husband responsible for work outside the home and the wife for household duties.
Physical force is acceptable in arguments.
Men give orders to women and older give orders to younger.
Grandparents often involved in major decisions.
Family honor is important.
|
More physical aggression present in urban than in rural families.
Children tend to play in groups and to roam neighborhood.
Children highly desired and valued.
Children might react strongly to separation from mother.
|
Might associate hospitalization with death.
Might resist bathing a fevered child.
Health is achieved through equilibrium of temperature.
Some medications, such as antibiotics, are seen as “hot” and therefore undesirable for a fever.
Disabled might be restricted to privacy of home.
|
Physicians are held in high esteem; nurses might not hold much status.
Health professional needs to avoid going directly into health concerns; talk first about unrelated matters.
Prescriptions are expected.
Careful explanations about alternative measures, diagnostic assessments, and preventive measures are beneficial.
Might be late for appointments because of present time orientation.
Females will bring female relative when visiting male professionals.
Discussion of sexuality is taboo for a female in the presence of a male.
|
Malnutrition
Dental caries
Scabies
Fevers
Bronchitis
Asthma
Eczema
Worms
Parasites
Diabetes
Lead poisoning
|
| Iranians |
Extended family considered important for advice, support, and for employment, security, and influence.
Paternal influence strong.
Sex roles very strong.
Children are least respected in family.
|
Verbal abuse can be common; spanking is less common.
Children have many limits.
Children have little say in family matters.
|
Highly fatalistic; what occurs is will of God.
Hot and cold used to treat minor illnesses.
Thin children believed to be unhealthy; children tend to be overfed.
|
Older, male health professionals (especially physicians) generally preferred.
Health visits need to allow time for undivided attention and to listen to long accounts of health and personal matters.
Personal relationship sought with caregiver.
Diagnostic tests and medications expected.
Several family members might contact health professional about patient.
|
|
| Japanese |
Extended families more common in traditional family units.
Husband is breadwinner; role of wife is to respect and honor the husband and care for the children.
Wife might consult with older family members regarding decisions related to the children.
Mother-in-law might assume responsibility for ensuring daughter-in-law meets all her obligations.
Woman responsible to care for all members, young and Old, in family.
Woman is not encouraged to work outside home.
Etiquette and conduct of family members very important.
Problems are not shared outside family.
|
Babies encouraged to be passive and not to cry.
Toilet training initiated before a year.
Infant sleeps with adults.
Discipline is permissive until child reaches school age.
Discipline involves consideration for child and use of example.
Light spanking is acceptable.
Tidiness and good manners are encouraged.
Children taught to respect elders and to distinguish between family and non-family.
|
Humans inherently good; illnesses caused by polluting agents.
Evil removed through purification.
Believe in removing diseased part.
Use acupuncture, herbs, moxibustion, and Western and Chinese medicine.
Fear of stomach ailments is stronger than any other fear.
|
Physicians held in high esteem; other health care professionals less so.
Tend to prefer physicians from own culture.
Expect thorough examination at health visit, medication, and explanation of illness.
Only exception is when diagnosis is cancer, when family and not patient is told.
Family and friends expect to visit in hospital and to take active part in care.
|
Cleft lip/cleft palate Cardiovascular diseases
Oguchi’s disease
Acatalasemia
|
| Koreans |
Loyalty to family more important than individual needs.
Generational ties more important than marriage ties, although this is changing.
Male is always head of family; if father unable to fulfill role, then eldest son assumes head, even if still a child.
Women assume full responsibility for child care and housekeeping
Elders held in high esteem and are expected to relax and enjoy life once they reach 60 years.
Rising expected when elders enter room.
|
Parents very close to child.
Birth order determines privileges; oldest males receive more privileges than younger children.
Opinions of elders must be respected.
|
Might adhere to shamanism.
Good appetite means good health.
Foods such as ginseng and ginger tea given to promote good health.
Food taboos during pregnancy related to imitative beliefs (e.g., eating bruised fruit can cause baby to have poor skin).
|
Communication quiet.
Excessive laughter might indicate embarrassment.
Direct disagreement is uncommon.
Disagreement indicated by tipping head back and hissing through teeth.
Direct eye contact expected.
Touching uncommon.
|
Dental caries
Lactose intolerance
|
|
Native
Americans
|
Many variations in family structure and values.
Tribe and extended family tend to come before self.
Elders are source of wisdom.
Extended family structures.
|
Children learn through observation, imitation, legends.
Male child held in higher esteem than female child.
|
Health is a state of harmony with nature.
Spirituality interwoven with medicine.
All disorders believed to have element of supernatural.
Native healers used in some tribes.
Do not believe in germ theory.
Illness prevented through religious rituals and charms.
|
Going to hospital associated with illness.
Native American healers ask few questions.
Present, not future oriented, therefore preventive practices difficult to understand.
Time is on a continuum, therefore set intervals (e.g., with medication dosing) may need careful explanation.
Take time to form opinions of health professionals.
Silence, avoiding direct eye contact show respect.
|
Tuberculosis
Suicide
Lactose intolerance
Drug/alcohol abuse
Accidents
Ear infections
Obesity
|
|
Puerto
Ricans
|
Families usually large; home important.
Father is head of household; wife and children subordinate.
Father makes decisions for family.
|
Children valued, seen as gift from God.
Children expected to obey.
Corporal punishment considered acceptable.
|
Believe in hot-cold theory of causation of illnesses.
Use hot and cold treatments to treat illnesses.
Evil spirits can cause illness.
Use folk healers, herbs, rituals.
|
Suspicious of hospitals and use health care systems infrequently.
Relaxed sense of time and might not be on time for appointments.
|
Asthma |
| Vietnamese |
Family main source of identity.
While traditional households often include grandparents, unmarried children, an adult couple, and children, traumatic circumstances might have separated many from family in Vietnam.
Might limit ability to become established in new surroundings. Women have fewer rights than men.
Males are main decision makers.
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Children are highly valued.
Most training is through example.
Discipline might include quiet verbal admonitions, shouting, or slapping.
Beatings, although rare, are considered to be private family matters.
Quiet compliance is expected of children; open anger rare although children might express anger through stubbornness or passive non-cooperation.
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Herbal remedies, isolation of sick, and visits to shrines practiced.
Ideas of health center around hereditary causes of illness, supernatural causes of illness, hot and cold equilibrium, and good and bad wind and water.
Being “hot” might refer to having a symptom believed caused by heat imbalance in body— not necessarily fever.
Might use rituals to prevent illness.
Coin rubbing or placing a hot cup on the body might leave bruises.
|
Regard physicians very highly; public health nurses more highly regarded than any other nurses because they are government employees.
Visits are expected to be formal, unhurried, without detailed questions about health or social background.
Touching or removal of clothing produces discomfort.
Stoical with illness and pain; some illnesses are to be ignored. More accepting of prescriptions than changes in behavior.
|
Hepatitis B
Pulmonary tuberculosis
Intestinal parasites
Incomplete immunization
Constipation
Malnutrition
Anemia
Dental caries
Lactose
intolerance
|
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.
Establishing a Setting for the Health History
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.
