Obtaining a Health

History
 Equipment: paper and pencil/pen
 General Guidelines
1. Gather equipment
2. Wash hands
3. Explain purpose of health assessment to parent
/child (promotes cooperation)
 All children, regardless of their age should be
recognized by their first name.
 Chief complaint: Why is the child being seen today?
e.g. “He has runny nose.”
Present Illness
 Describe the child’s signs and symptoms (signs and
symptoms should be listed in order mentioned)
 Specific questions:
- Is the child coughing? What kind?How much?
- How long ? How is the child acting?
- Has the child been exposed to an illness?
- What kind of treatment has been used?
Past History
 Birth
a. Prenatal
- How’s the mother’s health during pregnancy?
- Where did she receives prenatal care and for
how long?
- If she had any illnesses or infections, when
during the pregnancy did she have them?
Past History
 Birth
a. Prenatal
- if she took medications during her pregnancy,
what did she take and when did she start taking
them?
- what is her blood type and the child’s blood
type?
- did she receive any x-rays during pregnancy?
Past History
 Birth
a. Prenatal
- was she on special diet during pregnancy?
-if she was hospitalized during pregnancy, what
was the reason?
- when was she in the hospital and for how long?
- how many living children does she have?
(GTPAL)
Past History
 Birth
a. Prenatal
- was she or her doctor worried about her
pregnancy?
-if so why and how long was this pregnancy?
Past History
 Birth
b. Natal
- how long was the labor?
- were there any problems?
- what type of delivery
- if anesthesia was used, what kind was it and were
there any problems with it?
- Where was the baby born?
- What was the weight?
Past History
 Birth
b. Natal
- what was the baby’s condition at birth?
- did the baby cry spontaneously?
- was the baby blue?
- did the baby need oxygen?
-who was with the mother during the delivery
Past History
 Birth
b. Postnatal
- how long the baby stay in the nursery?
- did the baby have any problems in the nursery?
if so what were they?
- Did the mother and baby come home from the
hospital at the same time?
- Was the baby ever jaundiced or cyanotic?
Past History
 Birth
b. Postnatal
- did the baby develop any rashes?
- how much weight did the baby lose?
• Allergies
- is the child allergic any foods?medications?
insects?animals?
- Does the child seem to have any allergies during
any particular time of the year?
- describe what happens when the child has an a
allergic reaction?
- does the child ever break out into a rash? if so why?
 Accidents:
- has the child ever had an accident?
- if so, where was it (home,school, car, on bicycle
or other sporting equipment)
- describe what happened,how was it treated?
- where was the child treated?how did the child
react?
- have there been any residual problems?
 Illnesses:
- has the child had any infections? When?
- when?where?how was it treated? how was it
followed up?
- has the child had any childhood diseases? If so,
what diseases, did the child have ( measles,
mumps, roseola, chickenpox, whooping cough)?
- is the child ever had any x-ray?
 Surgeries:
- has the child ever any surgery?If so when? For
what condition? What was the outcome?
• Hospitalization
- if the child has ever spent any time in the hospital,
what was the reason
 Immunizations
- is the child had any immunizations? What are
those?
- did the child have any reactions to immunizations?
- if so, what was the reaction?
- is the child received any booster?
- if so, which ones?
- has the child ever been tested for TB?if so
- how? When?what was the result?
Family History
 Family Members
- what is the mother’s age and health status?
- what is the father’ age and health status?
- what are the ages and genders of this child’s
siblings?
- what is the status of each?
 Family Diseases:
- within the immediate family (grandparent, first
aunts/uncles, parents, siblings) are any of the
following conditions , present:
- EENT : nosebleeds, sinus problems, glaucoma,
cataracts , myopia , or strabismus? Any other
problems not listed?
 Family Diseases:
- Cardiorespiratory: is there any asthma? Hay
ever? TB? Hypertension? Heart murmurs?heart
attack strokes?anemia?Rheumaticfever?leukemia?
Pneumonia?emphysema?any other problem not
listed?
 Family Diseases:
- GIT/GUT: does any one have ulcers?colitis?
kidney infections?bladder infections?any other
problem with GIT / GUT not listed
- Musculoskeletal: does any one in the family have
the following: dislocated hips, club foot, muscular
dystrophy, arthritis? Any other problems with
bones, joints or muscles not listed
 Family Diseases:
- Neurological: does any one have seizures? Mental
retardation?mental problems?epilepsy? Any other
problems not listed.
-special senses: is any one blind or deaf?
 Family Diseases:
- chronic: does anyone have diabetes?cancers /
tumors? Thyroid problems? Congenital
anomalies?
- general: are there any medical problems in the f
family that are important to know about?
Social History
 Where does the family live?(in a house,
apartment?room?
 How large is the place?
 Is there a yard?fenced?
 Does any one live with the family (grandparents,
aunts)
 Does the father or mother work?full time or part time
Social History
 What are their occupation?
 If no one works, how are they supported?Is there nay
outside help?
 Does the child go to child care?Pre school?school?
 What are the relationship of the family like (happy,
said,chaotic, depressed, violent)
ROS (Review of Systems)
 Skin: Does the child have any rashes?birth marks?
dislocations
• EENT: Does this child have any persistent nosebleeds?
- Frequent sore throats or colds (more than
four a year)? Pneumonia?Trouble breathing?
Epistaxis?Nasal discharge?Frequent
earaches? Difficulty hearing?Pain? Ear
discharge?
ROS (Review of Systems)
 EENT: Myringotomy?Do the child’s eyes ever
cross?Do they tear excessive? Have there been
any eye injuries?discharge?puffiness?redness?
has the child ever worn glassess?
any difficulty swallowing?Dental
defects?swollen glands?stiffness in neck?
Neck assymmetry
 Cardiorespiratory:
- Does the child have any trouble breathing?
Running?finishing a three-to-four once bottle
without tiring (if an infnat)?cough?hoarseness?
wheezing?Does the child turn blue? Have there
been any heart defects? Heart murmurs?
“ Heart trouble”?Pain over the heart or in the
chest?
 Gastrointestinal
- Does the have any problems with diarrhea?
Constipation?Bleeding around the rectum? Bloody
stools? Pain? Vomiting?What has the appetite
been like?abdominal pain or distention?Jaundice?
 Genitourinary
- Does the child have a straight, strong urinary
stream or does the urine dribble out? How often
does the child urinate?Is there any pain?is there
any discharge? How much does the child void
during the day?Does she (an old girl) menstruate?
If so, what was the age of onset?How often does
she menstruate? Are there any problems
 Neurological:
- has the child ever had a seizure?fainting spell?
Tremors?Twitches?Blackouts? Dizzy spells?
Fequent headaches?Any incoordination?
Numbness?
 Musculoskeletal
- Has the child ever broken any bones? Had any
sprains?Complained of pain in the joints or
swelling or redness around the joints?Difficulty
moving extremities or in walking?
 Special Senses:
- Does the child see well? hear well? Does the child
seem clumsy?
- Can the child see the blackboard from where he or
she sits in the classroom?
- Does the child fall or walk into doors?
 Chronic condition:
- Does the child have any long term disease?
If so describe the child’s disease
• General:
- Does the child have any other problems you would
like to talk about? If yes please describe.
Habits
 Nutrition
- How would you describe the child’s appetite?
(good, fair, varied)
- Is the child breast fed or bottle fed? If the child is
receiving formula, what kind is it?
- How much and how often does the child eat in 24
- hours period?
- How is the formula prepared?
 Nutrition
- What kind of food (meat, fruits, vegetables,
cereals, milk, eggs, juices, sweets, snacks) and
how often does the child eat? What are the
portion sizes? Does the child take vitamins?
If so what kind? How often? How much?
- Does the child feed himself/herself?
- Does the child use a cup? Utensils?
 Nutrition
- Would you describe the child as messy?
- Does the child eat with the family?
- What is the emotional climate (relaxed, rushed,
tense? of the family meals?
- What are the child’s favorite foods?
- What food does the child dislike?
 Elimination:
- Describe the child’s bowel or bladder patterns
(frequency, consistency,color, discomfort).
- Is the child toilet trained? If not , is it planned in
the future? When? If the child is toilet trained,
describe any problems. Does the child have any
accidents? When do they occur? How frequent do
they occur?
Rest and Sleep
- Where does the child sleep?
- What time does the child go to bed at night?
- What time does the child wake up in the morning?
- Does the child wake up during the night?
- If so, how often?
- Describe what the child does.
- Describe how the parents responds
Rest and Sleep
- Does the child have any night mares? Night terrors?
- Does the child nap during the day?
- If so, when?
- How long does the child nap?
- How many hours does the child sleep ion a 24
hour period?
- Does the child seem to need more sleep than he or
she is getting?
 Play and Activity
- What types of play or games is the child involved
in during the day? How often?
- Does the child participate in sports, team
activities and or regular exercise?
- Ask child and parent to describe the child’s
friendhips.
 Safety and Accident Prevention:
(see Box III-I)
• Development
- How does the child development compare with
siblings and peers?
- When did the child first roll over?sit?stand?walk?
talk?
- What grade is the child in at school?
 Development
- Does the child like school?
- What does the child like to do in school?
- Tell me about the child’s playmates
 Personality
- How would you describe the child’s personality
(quiet, outgoing, independent,dependent)
- How does the child cope with stress (withdraw,
aggressive, etc?)
- Describe the child’s temper.
- Describe how the child handles anger, fear,
jealousy
 Personality
- How does the child relax?
- How does the child separate from parents?
- How does the child react to discipline?
- How does the child relate to baby sitter or others
Documentation:
 Write the time and date data was obtained.
 Client / family responses to the health history
questions
CONDUCTING A PE
II. Conducting a Physical
Examination
 Equipment:
- paper and pencil / pen
- a general physical exam outline or standard
format used at the health care agency
- stethoscope
- tape measure
- pen light
- tongue blade
- otoscope / opthalmoscope
General Guidelines
1. Gather equipment. Promotes organization and
efficiency.
2. Wash hands. Reduces spread of microorganism.
3. Explain purpose of physical examination to parent /
child. (Promotes cooperation and reduces anxiety and
fear)
4. Provide time for play and becoming acquianted (talk
to child/parent, make eye contact, play with
equipment, etc. (Helps reduce child’s anxiety and
increase cooperation.)
Procedure
1. The child’s first name, regardless of age, should be
used throughout the examination. Promote trust
2. The child’s weight and height/length should be
obtained before the actual examinations begins. The
specific methods for weighing and measuring the
child’s height/length follow the PE guidelines.
Non-invasive procedure should be carried out first to
assure cooperation.
Procedure
3. VS ( TPRBP) need to be obtained either right as the
examination begins or during to be obtained either
right as the examination
General appearance
 Note the overall appearance of the child
 Is the child small, obese, well nourished, awake, alert,
cooperative, developmentally appropriate for
age,lethargic or distressed?
 What is the client’s state of consciousness
 Skin
-inspect and palpate the skin color.
(take note: room color, gown color and lighting
affect observation)
- evaluate for jaundice in natural lighting of a
window; cyanosis, blanches momentarily, bruises
do not.
- Also not pigmentation, temperature, texture,
moisture and turgor
 Note and describe all lesions for the following;
location – exactly where on body
pattern – clustered, confluent, evanescent, linear
size – measured in centimeters
color – red, pink,brown,white,hyperpigmented/hypo
elevation – raised (papular), flat (macular),fluid
filled (vesicular)
blanching – do they pale when pressure is applied
 Hair
- Note color, texture, distribution,quality and loss.
Look in hair behind the ears for nits.
• Nails
- Note color, cyanosis, shape and condition of nails.
Clubbing is determined by checking nail angle.
- Normal angle is 160 degrees. An angle 0f 180
degrees or larger is seen in clubbing caused by
hypoxia.
 Head
- inspect and palpate, feeling for bogginess, sutures,
and fontanels.
- in children under 2 years of age ,measure anterior
two dimensions
(4-5cm x 3-4cm)
- Fontanels should be flat
 Neck
- Inspect for swelling, webbing, nuchal fold and
vein distention.
- Palpate for swelling, carotid pulse, trachea and
thyroid
 Ears
- Inspect for shape, color, symmetry, helix formation
and position.
- The top of the ear should go through an imaginary
line from the inner canthus to the outer canthus
of the eye to the occiput.
- Palpate for firmness and pain and observe for and
describe any discharge from the ear canal.
 Ears
- Assess for gross hearing.
- Infants less than 4 months of age startle to sound.
- Older infants turn to localize the sound of jingling
keys and other objects.
- Use the whisper test with verbal and cooperative
children
 Eyes
- Inspect for position , assignment, lid closure, inner
canthal distance (average = 2.5cm), epicanthal folds
and slant of fissure. Note dark circles under the
eyes (usually present in children with allergies)
 Eyes
Brows - note separateness, nits
Lashes – note if they curve into eye
Lids – note color, swelling, lesions, discharge

Conjunctiva
Palpebral (should be pink) – note redness,pallor
Sclera and bulbar – note injection, redness, color
(should be white, yellow in
jaundice)
blue in osteogenesis imperfecta
Pupils –note shape, size and briskness of reaction
to light by constricting directly and
consensually and accommodations for near
and far vision.
Iris – note color, roundness, any clefts or defects
 Extraocular Movements (EOMs)
- 6 cardinal fields of gaze
Hold chin and have the child’s eye follow your
finger moving in the shape of an H. Note
asymetric eye movement or nystagmus
- a few beats of nystagmus in the far lateral gaze are
normal
 Extraocular Movements (EOMs)
- Corneal light reflex
hold light 15 inches from bridge of nose and
shine on bridge. It should reflect in the same
place and shine on bridge. It should reflect
in the same place in each eye in normally
aligned eyes
 Extraocular movements (EOMs)
Cover-uncover test
- check for movements when one eyes is covered
and the other is gazing at a distant object.
- Remove cover and note movement of covered
eye. Repeat using a near object
 Extraocular movements (EOMs)
Gross vision
- newborn blink and hyperextend their necks to
light
- infants who can fix on and follow objects.
- Grossly assess older children’s vision by having
them describe what they see on the wall or
outside the window.
 Face
- note color, symmetrical movement, expression,
skin folds, and swelling
 Nose
- inspect for color of skin, any nasal crease, nasal
mucosa, any discharge and its color and patency
- check for flaring of nares (RDS)
- assess turbinates by shining a light into the nares
while pushing up gently on the tip of the nose
(red and swollen – possible allergic rhinitis)
 Nose
- Palpate sinuses for tenderness
- Frontal sinuses are not developed completely
until approximately 8 years
 Mouth
- inspect all area
- note number and condition of teeth
- observe tonsils for swelling
a. grade 1+ - indicates mild swelling
b. Grade 4+ - indicates touching or kissing
tonsils
- color (should be same color as buccal mucosa)
and discharge
 Mouth
- Examine the hard and soft palate for color, patency
and lesions
- The uvula should rise symmetrically
- A bifid uvula could indicate a submucosal cleft
- Note tongue shape, size, color and movement, and
inspect for any lesions (most common lesions are
white and are thrush)
- Note breath odor
 Thorax and lungs
- inspect for symmetry, movement, color,
retractions, breast development and type and
effort of breathing.
- count respiration (breathing is abdominal until
age 7 years old)
 Thorax and lungs
- Note nasal flaring and use of accessory muscles
- retractions usually start subcostal and substernal,
then progress to suprasternal and supraclavicular
and lastly intercostal indicating severe distress.
- Palpate for tactile fremitus (increased in
congestion and consolidation)
- Percuss for resonance (sound becomes dull with
fluid or masses
 Thorax and lungs
- Auscultate side to side for symmetry of sound.
- Infants breathe deeper when they cry;
- toddlers and preschooler can breathe deeper
when they blow bubbles or try to “ blow out the
light” of your pen light.
- Assess all fields
- Listen to the back to assess to the lower lobes
in children younger than 8 years old
 Thorax and lungs
- Auscultate in the axillae to best hear crackles
(for Pneumonia)
- Normal sounds are vesicular or bronchovesicular
- Infants breath sounds are louder and more
bronchial because they have thin chest walls.
 Adventitious breath sounds:
- Rhonchi
- Crackles (fine and coarse)
- Wheezes
- Stridor
 Rhonchi – a continuous, low pitched sound with a
snoring quality
 Crackles – intermittent, brief, repetitive sounds
caused by small collapsed airways popping open.
a. Fine crackles - soft, high pitched and brief
b. Coarse crackles – louder, lower pitched and
slightly longer than fine crackles
 Wheezes – more continuous sounds produced by
rapid movement of air through narrowed passages.
Usual progression of wheezing starts with expiratory
wheezes, then inspiratory wheezes only(airways are
collapsing on expiration) and finally no sounds
because there is little air movement
 Stridor – inspiratory wheeze heard louder in neck
than in chest, usually right over trachea
 Take note: infants with upper airway congestion can
have sounds transmitted to lungs because they are
obligate nose breathers. Listen to their lungs when
they are crying and breathing through their mouths to
decrease the amount of transmitted noise and better
assess their breath sounds.
Cardiovascular
 Inspect for point of maximum impulse (PMI),
cyanosis, mottling,edema, respiratory distress,
clubbing, activity intolerance and tiring with feeds.
Palpate PMI and brachial, radial, femoral and pedal
pulses.
 Auscultate the following areas with bell and
diaphragm of the stethoscope
abdomen
 Inspect for pulsation , contour, symmetry, peristaltic
waves, masses and normal skin color.
 Auscultate before palpating so normal bowel sounds
are not disturbed.
 Listen in all four quadrants for a full minute. Normal
sounds should be heard every 10 to 30 seconds(4-5
sounds per minute. Less than 4 minutes indicates
decreased bowel sounds .
 Listen for a full 5 minutes before concluding that they
are absent
 Percuss for dullness over the client’s liver and full
bladder. The rest of the abdomen should percuss for
tympani.
 Palpate using a light pressure first.
 Have the child bend the knees up while lying on his or
her back to relax the abdomen.
 Use the child’s hands under if the child is very ticklish
or tense.
 With deep palpation, support the child from the back
then palpate.
 Start in lower quadrant and move upward to detect an
enlarged liver or spleen. Note areas of tenderness, pain
or any masses.
Anus
 Inspect the skin and perineum for excoriation,
bruising,discoloration or tears.
 rashes
Genitourinary system
 Female genitalia – note for redness,excoriation,
discharge and odor.
 Male genitalia – note if circumcised or
uncircumcised (if uncircumcised, see if foreskin is
retractable). Note position of meatus.
 Close off the canals and feel for the testes or any
masses in the scrotal sac. If you feel a mass other than
the testes, transilluminate for fluid.
Lymphatic System
 Nodes should be firm, a small (1 cm or less), freely
movable and non tender. Palpate preauricular, anterior
and posterior cervical chains, supraclavicular, axillary
and inguinal lymph nodes with pads of fingers.
Musculoskeletal System
 incorporate assessment into the examination
 Observe walking, sitting, turning, and range of motion
in all joints.
 Observe for spinal curvature and mobility.
 Exaggerated lumbar curve is normal in toddlers.
 Sacral dimples or tuft of hair at the base of the spinal
column.
 Note symmetry and movement of the extremities
 Test muscle strength. Strength is graded 0-5 scale
0 – no contraction noted
1 - barely a trace of contraction
2 - active movement without gravity
3 - active movement against gravity
4 – active movement against gravity and resistance
5 – active movement again full resistance without
tiring
 Note size, color ,temperature and mobility of
joints.Examine palmar creases. Note extra digits and
deformities.
 Note stance and gait. Bowed legs (genu varum) are
normal in toddlers until approximately 2 years old.
 Knock knees (genu valgum) are normal from 2 to 10
years old.
 Note for foot deformities.
 Stroke the side of the of the foot to see if it returns to a
neutral position.
 Check for the dislocatable hips using Barlow’s test and
Ortolani’s maneuver in infants. Also look for uneven
skin folds.
Neurological System
 Observe grossly for speech and ability to follow
directions in an older child.
 In an infant, observe activity and tone
 In ambulatory patients, observe gait and balance.
 Check for deep tendon reflexes.These are graded 0-4+
Neurovascular System
Documentation
 Time and date of examination was performed
 Heal to toe findings of examination
 Estimated time to complete the procedure: 20 – 30
minutes or longer, depending on child’s age and
cooperation.