http://evolve.elsevier.com/Wong/clinical • The Child with Acute Diarrhea (Gastroenteritis) • The Child with Acute Renal Dysfunction • The Child with Acute Respiratory Infection • The Child with Attention Deficit Hyperactivity Disorder (ADHD) • The Child with Bacterial Meningitis • The Child with Congestive Heart Failure (CHF) • The Child with Diabetes Mellitus • The Child with Fluid and Electrolyte Disturbances • The Child with Impaired Cognitive Function • The Child with Nephrotic Syndrome • The Child with Seizure Disorder • The Child with Toxic Ingestion or Inhalation The summary is primarily intended for the recording of data, not the acquisition of information from the informant. Therefore it is not meant to be used as a questionnaire. The column titled “Comments” is intended to enhance and detail sections of the history, as well as to emphasize areas of possible intervention. For a more comprehensive discussion of approaches to taking a history, see Wong’s Nursing Care of Infants and Children or Wong’s Essentials of Pediatric Nursing.* Assess ability to speak and understand English. Conduct the interview in a private, quiet area. Begin the interview with appropriate introductions. Clarify the purpose of the interview. Inform the interviewees of the confidential limits of the interview. Demonstrate interest in the interview by sitting at eye level and close to interviewees (not across a desk), leaning slightly forward, and speaking in a calm, steady voice. Begin with general conversation to put the interviewees at ease. • Use comments such as, “How have things been since we talked last?” or (to the child) “What do you think is going to happen today?” to let the family express the main concern. Include all parties in the interview. • Direct age-appropriate questions to children (e.g., “What grade are you in at school?” or “What do you like to eat?”). • Be sensitive to instances in which family members, such as adolescents, may wish to be interviewed separately. • Recognize and respect cultural patterns of communication, e.g., avoiding direct eye contact (American Indian) or nodding for courtesy rather than to express actual agreement or understanding (many Asian cultures). • Use open-ended questions or statements that begin with “What,” “How,” “Tell me about,” or “You were saying,” and reflect back key words or phrases to encourage discussion. • Encourage continued discussion with nodding and eye contact, saying “Uh-huh,” “I see,” or “Yes.” • Use focused questions (questions that ask for a specific response, e.g., “What did you try next?”) and closed-ended questions (questions that ask for a single answer, e.g., “Did you call the doctor?”) to direct the focus of the interview. • Ensure mutual understanding by frequently clarifying and summarizing information. • Use active listening to attend to the verbal and nonverbal aspects of the communication. • Verbal cues to important issues include the following techniques: • Nonverbal cues to important issues include the following: • Use silence to allow persons to do the following: • Break silence constructively with statements such as, “Is there anything else you wish to say?”, “I see you find it difficult to continue; how may I help?”, or “I don’t know what this silence means. Perhaps there is something you would like to put into words but find difficult to say.” • Convey empathy by attending to the verbal and nonverbal language of the interviewee and reflecting back the feeling of the communication (e.g., “I can see how upsetting that must have been for you”). • Provide reassurance to acknowledge concerns and any positive efforts used to deal with problems. • Avoid the following blocks to communication: • Watch for the following signs of information overload: Close the interview with an opportunity for others to bring up overlooked or sensitive concerns with a statement such as, “Have we covered everything?” Summarize the interview, especially if problems were identified or interventions were planned. Discuss the need for follow-up, and schedule a time. Allow children time to feel comfortable. Avoid sudden or rapid advances, broad smiles, extended eye contact, or other gestures that may be seen as threatening. Talk to the parent if the child is initially shy. Communicate through transition objects such as dolls, puppets, or stuffed animals before questioning a young child directly. Give older children the opportunity to talk without the parents present. Assume a position that is at eye level with the child. Speak in a quiet, unhurried, and confident voice. Speak clearly, be specific, and use simple words and short sentences. State directions and suggestions positively. Offer a choice only when one exists. Allow children to express their concerns and fears. Involves expressing a feeling in terms of a third person (“he,” “she,” “they”) Is less threatening than directly asking children how they feel, because it gives them an opportunity to agree or disagree without being defensive Approach allows children three choices: (1) to agree and, hopefully, express how they feel; (2) to disagree; or (3) to remain silent, in which case they probably have such feelings but are unable to express them at this time. Reveals child’s thinking and attempts to change child’s perceptions or fears by retelling a somewhat different story (more therapeutic approach than storytelling) Begins by asking child to tell a story about something, followed by another story told by the nurse that is similar to child’s tale but with differences that help child in problem areas • Example: Child’s story is about going to the hospital and never seeing his or her parents again. Nurse’s story is also about a child (using different names but similar circumstances) in a hospital whose parents visit every day, but in the evening after work, until the child is better and goes home with them. Uses books in a therapeutic and supportive process Provides children with an opportunity to explore an event that is similar to their own but sufficiently different to allow them to distance themselves from it and remain in control General guidelines for using bibliotherapy are as follows: • Assess child’s emotional and cognitive development in terms of readiness to understand the book’s message. • Be familiar with the book’s content (intended message or purpose) and the age for which it is written. • Read the book to the child if child is unable to read. • Explore the meaning of the book with the child by having child do the following: Involves presenting a partial statement and having child complete it Some sample statements are as follows: • The thing I like best (least) about school is _________________________________________________. • The best (worst) age to be is ____________________________________________________________. • The most (least) fun thing I ever did was __________________________________________________. • The thing I like most (least) about my parents is ____________________________________________. • The one thing I would change about my family is ___________________________________________. • If I could be anything I wanted, I would be ________________________________________________. • The thing I like most (least) about myself is ________________________________________________. One of the most valuable forms of communication, it provides both nonverbal (from looking at the drawing) and verbal (from child’s story of the picture) information. Children’s drawings tell a great deal about them because they are projections of their inner selves. Spontaneous drawing involves giving child a variety of art supplies and providing the opportunity to draw. Directed drawing involves a more specific direction, such as “draw a person” or the “three themes” approach (state three things about child and ask child to choose one and draw a picture). Use spontaneous drawings, and evaluate more than one drawing whenever possible. Interpret drawings in light of other available information about child and family. Interpret drawings as a whole rather than concentrating on specific details of the drawing. Consider the following individual elements of the drawing that may be significant: • Gender of figure drawn first—Usually relates to child’s perception of own gender role • Size of individual figures—Expresses importance, power, or authority • Order in which figures are drawn—Expresses priority in terms of importance • Child’s position in relation to other family members—Expresses feelings of status or alliance • Exclusion of a member—May denote feeling of not belonging or desire to eliminate • Accentuated parts—Usually express concern for areas of special importance (e.g., large hands may be a sign of aggression) • Absence of or rudimentary arms and hands—Suggests timidity, passivity, or intellectual immaturity; tiny, unstable feet may be an expression of insecurity, and hidden hands may mean guilt feelings • Placement of drawing on the page and type of stroke—Free use of paper and firm, continuous strokes express security, whereas drawings restricted to a small area and lightly drawn in broken or wavering lines may be a sign of insecurity • Erasures, shading, or cross-hatching—Expresses ambivalence, concern, or anxiety with a particular area Is universal language and “work” of children Tells a great deal about children because they project their inner selves through the activity Spontaneous play involves giving child a variety of play materials and providing the opportunity to play. Directed play involves a more specific direction, such as providing medical equipment, a doll, or a dollhouse for focused reasons, such as exploring child’s fear of injections or exploring family relationships. Explain to interpreter the reason for the interview and the type of questions that will be asked. Clarify whether a detailed or brief answer is required and whether the translated response can be general or literal. Introduce interpreter to family, and allow some time before the actual interview so that they can become acquainted. Give reassurance that interpreter will maintain confidentiality. Communicate directly with family members when asking questions to reinforce interest in them and to observe nonverbal expressions, but do not ignore interpreter. Pose questions to elicit only one answer at a time, such as “Do you have pain?” rather than “Do you have any pain, tiredness, or loss of appetite?” Refrain from interrupting family members and interpreter while they are conversing. Avoid commenting to interpreter about family members, since they may understand some English. Be aware that some medical words, such as “allergy,” may have no similar word in another language; avoid medical jargon whenever possible. Respect cultural differences; it is often best to pose questions about sex, marriage, or pregnancy indirectly—ask about “child’s father” rather than “mother’s husband.” Allow time after the interview for interpreter to share something that he or she felt could not be said earlier; ask about interpreter’s impression of nonverbal clues to communication and family members’ reliability or ease in revealing information. Arrange for family to speak with same interpreter on subsequent visits whenever possible. I Family personal and social history* BOX 1-1 Review of Systems General—Overall state of health, fatigue, recent and/or unexplained weight gain or loss (period of time for either), contributing factors (change of diet, illness, altered appetite), exercise tolerance, fevers (time of day), chills, night sweats (unrelated to climatic conditions), frequent infections, general ability to carry out activities of daily living Integument—Pruritus, pigment or other color changes, acne, moles, discoloration, eruptions, rashes (location), tendency toward bruising, petechiae, excessive dryness, general texture, disorders or deformities of nails, hair growth or loss, hair color change (for adolescent, use of hair dyes or other potentially toxic substances such as hair straighteners) Head—Headaches, dizziness, injury (specific details) Eyes—Visual problems (ask about behaviors indicative of blurred vision, such as bumping into objects, clumsiness, sitting very close to the television, holding a book close to the face, writing with head near desk, squinting, rubbing the eyes, bending the head in an awkward position), cross-eye (strabismus), eye infections, edema of lids, excessive tearing, use of glasses or contact lenses, date of last optic examination Nose—Nosebleeds (epistaxis), constant or frequent running or stuffy nose, nasal obstruction (difficulty breathing), alteration or loss of sense of smell Ears—Earaches, discharge, evidence of hearing loss (ask about behaviors such as need to repeat requests, loud speech, inattentive behavior), results of any previous auditory testing, pulling or rubbing ear Mouth—Mouth breathing, gum bleeding, toothaches, toothbrushing, use of fluoride, difficulty with teething (symptoms), last visit to dentist (especially if temporary dentition is complete), response to dentist Throat—Sore throats, difficulty in swallowing, choking (especially when chewing food—may be from poor chewing habits), hoarseness or other voice irregularities Neck—Pain, limitation of movement, stiffness, difficulty in holding head straight (torticollis), thyroid enlargement, enlarged nodes or other masses Chest—Breast enlargement, discharge, masses, enlarged axillary nodes (for adolescent female, ask about breast self-examination) Respiratory—Chronic cough, frequent colds (number per year), wheezing, shortness of breath at rest or on exertion, difficulty in breathing, sputum production, infections (pneumonia, tuberculosis), date of last chest x-ray examination, and skin reaction from tuberculin testing Cardiovascular—Cyanosis or fatigue on exertion, history of heart murmur or rheumatic fever, anemia, date of last blood count, blood type, recent transfusion Gastrointestinal—Nausea, vomiting (not associated with eating, may be indicative of brain tumor or increased intracranial pressure), jaundice or yellowing skin or sclera, belching, flatulence, recent change in bowel habits (blood in stools, change in color, diarrhea, and constipation) Genitourinary—Pain on urination, frequency, hesitancy, urgency, hematuria, nocturia, polyuria, unpleasant odor to urine, force of stream, discharge, change in size of scrotum, date of last urinalysis (for adolescent, sexually transmitted disease, type of treatment; for male adolescent, ask about testicular self-examination) Gynecologic—Menarche, date of last menstrual period, regularity or problems with menstruation, vaginal discharge, pruritus, date and result of last Pap smear (include obstetric history as discussed under birth history when applicable); if sexually active, type of contraception Musculoskeletal—Weakness, clumsiness, lack of coordination, unusual movements, back or joint stiffness, muscle pains or cramps, abnormal gait, deformity, fractures, serious sprains, activity level, redness, swelling, tenderness Neurologic—Seizures, tremors, dizziness, loss of memory, general affect, fears, nightmares, speech problems, any unusual habit Endocrine—Intolerance to weather changes, excessive thirst and urination, excessive sweating, salty taste to skin, signs of early puberty Lymphatic—History of frequent infections, enlarged lymph nodes in any region, swelling, tenderness, red streaks
Assessment
Health History
General Guidelines for Communication and Interviewing
Giving unrestricted and sometimes unasked-for advice
Offering premature or inappropriate reassurance
Giving overready encouragement
Defending a situation or opinion
Using stereotyped comments or clichés
Limiting expression of emotion by asking directed, close-ended questions
Interrupting and finishing the person’s sentence
Talking more than the interviewee
Specific Guidelines for Communicating with Children
Creative Communication Techniques with Children
Verbal Techniques
Third-Person Technique
Example: “Sometimes when a person is sick a lot, he feels angry and sad because he cannot do what others can.” Either wait silently for a response, or encourage a reply with a statement such as, “Did you ever feel that way?”
Mutual Storytelling
Bibliotherapy
Sentence Completion
Nonverbal Techniques
Drawing
Guidelines for Evaluating Drawings
Play
Guidelines for Using an Interpreter
Outline of a Health History
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Assessment
