LEARNING OUTCOMES

By the end of this section you should be able to:

RATIONALE

To obtain information via observation, history taking and physical examination, this will form a baseline for immediate action and ongoing assessment and evaluation, to assist in developing your plan of action. Assessments are undertaken at various times such as presentation to a primary healthcare setting, paramedic visits at home, on admission to hospital, and on an acute or ongoing needs basis and from shift to shift.

SUBJECTIVE INFORMATION (HISTORY)

Subjective information refers to that obtained from the child and their parents. The child and their parents have the most intimate knowledge of the problem and are therefore the best source of data. Here you are attempting to build a profile of the child and their problems using information regarding the presenting complaint, previous hospital admissions, their prenatal, birth and neonatal history, allergies, current medications (including any over-the-counter preparations), immunisations, personal habits, nutrition, hygiene, elimination, developmental history (Bee & Boyd 2007), family, cultural and social history (Gleadle 2007), significant life events, psychosocial history, education, physical activity and home circumstances (Engel 2006). This is a vital part of the process, however when assessing children it is sometimes difficult to get a comprehensive history due to their age or if the parent/carer is too stressed by the seriousness of the situation to articulate the relevant information; in these situations, the majority of the information may only be gathered through the objective assessment. Questioning needs to be sensitive so as not to cause undue alarm or embarrassment for the child or parents. It also needs to be delivered at the child’s and parents’ level of understanding, avoiding the use of medical jargon (Byrnes 1996).

It is important here to also consider assessment of the child or young person’s mental health, as 10% of children are known to have a mental health problem (Office of National Statistics 2005), with 40% having a mental illness during their childhood (Health Advisory Service 1995). However, these figures are based on those children that are known to have mental health problems and therefore many are unnoticed. Additionally, the importance of assessing CAMH has been emphasised within recent governmental policies such as the Children’s National Service Framework, standard 9 (DoH 2004), since a child’s mental health is equally as important as their physical health for their holistic well-being (National Mental Health Association 2003). Assessment of the child should therefore routinely include a review of physical health, mental health, intelligence, school performance, family situation and behaviour in all settings (Honeyman 2007, p 40). There are a variety of tools available to assess children’s mental health, such as the Paediatric Symptom Checklist (Jellinek et al 1988, which can be downloaded from www.brightfutures.org/mentalhealth/pdf/professionals/); while it will not be considered in depth in this chapter, further reading of this subject is advised (see Honeyman 2007).

OBJECTIVE INFORMATION (PHYSICAL EXAMINATION/OBSERVATION)

Objective information refers to that obtained by the practitioner through observation, physical examination and any investigative tests. The younger the child, the more important it is to observe their well-being and any physical signs from a distance; sleeping children should be observed before waking them up to examine them (Epstein et al 1997). You can evaluate a wealth of information before touching and without abruptly handling or examining with an instrument. Examination should be approached using your eyes and hands before your ears, using the standard format of inspection, palpation, percussion and auscultation (Archer & Burch 1998). Some aspects of respiratory function and the musculoskeletal and neurological systems can be assessed while the child plays, or mobilises, around the room. For example, children with respiratory distress may exhibit the tripod position to make breathing easier; this is exhibited as an extension of the arms forward and downwards while the back is arched (Thomas 1996). The child’s breathing can be observed – is it rapid, laboured, noisy or shallow? If the child is coughing, wheezing or stridulous, this may indicate respiratory distress (Thomas 1996). For the musculoskeletal system, one could observe the shape and contour of the body and assess the gait, looking for knock-knee, clubfoot, scoliosis and bowleg (Engel 2006). Asking the child to stick out their tongue and close their eyes would provide information about the cranial nerves (Engel 2006).

AGE-SPECIFIC APPROACHES

Infants are usually easier to examine and care must be taken to prevent hypothermia when exposed (ALSG 2005). The examination is best approached in a top-to-toe fashion, starting with the head and encompassing the entire body down to the feet in a systematic fashion while linking the systems together, auscultating the heart, lungs and abdomen while the infant is quiet. Palpation and percussion of areas should be conducted together. Reflexes can also be elicited as the body is being examined, but generalised primitive reflexes should be determined last. Traumatic procedures should be performed at the end of the examination, for example checking the mouth for intact palate. Many sick infants will exhibit distress and deterioration in their condition when handled to measure vital signs. In these infants, taking recordings using equipment such as blood pressure monitors can cause more harm than good; visually observing for changes will be a much more accurate indication of well-being. For example, the nurse should visually observe for changes in the respiratory rate such as increasing effort, efficacy and efficiency of breathing; grunting, wheeziness and stridor; changes in skin and mucosal colour; and changes in movement and responsiveness before measuring rate (Table 6.1).

Table 6.1 Normal respiratory rates

Reproduced by kind permission from Hull and Johnston 1993.

The older infant/toddler will prefer to be sitting on the parent’s lap during examination. The advantage of this position is that the parent can also gently hold the child still if necessary (RCN 2003), since this age group strongly objects to being held in one position even when non-invasive examination is taking place, for example placing a temperature probe under the arm. It may be worthwhile gaining the assistance of a play specialist or another person to provide distraction with toys while the child is being examined. Infants from 6 months upwards may demonstrate stranger and separation anxieties (Bee & Boyd 2007), which could impede assessment. These anxieties peak at 9 and 13 months, respectively and by the age of 2 years, have usually significantly reduced. This may be overcome by having someone with the child that is familiar to them, such as one or both parents or another familiar caregiver. These children prefer minimal physical contact initially and so equipment should be introduced slowly. Areas of the body could be inspected through play, such as tickling toes, or asking toddlers to point to different parts of their body; this will also assist in gaining cooperation. Parts of the physical examination where cooperation is required can then be conducted, such as auscultating the apex beat, although it may be best to perform these when the child is quiet. Again, traumatic procedures should be left until the end of the examination (Vessey 1995). Unless the examination is being undertaken rapidly because of the severity of the child’s condition, time should be taken to ensure that the child and parents feel sufficiently relaxed in order to gather a thorough history before proceeding onto the examination.

Pre-schoolers are more obliging and like to follow simple instructions. By this age, they will know most external body parts and possibly three to five internal body parts. They will prefer to be standing or sitting close to their parents, but are likely to want to undress themselves. The examination can be approached in a top-to-toe direction if they are cooperative, or as above, if not. These children like stories about the task and to examine the equipment before it is used. You should offer the child choices to assist in gaining their cooperation.

The school-age child is more knowledgeable about internal body parts and understands simple scientific explanations. They are likely to be cooperative in most positions, although prefer sitting. The older child may prefer their parents not to be present. The examination should follow the top-to-toe pattern, leaving examination of genitalia (if necessary) until last. The school-age child likes to be given an explanation of the rationale for examination and the equipment used (Vessey 1995, Hockenberry 2005).

The adolescent will generally prefer privacy; however, you should offer the option of having their parents present. They will have a basic knowledge of anatomy and physiology and hence will like to be told findings of the examination throughout. Although the top-to-toe pattern can be used, it is best to expose only the area being examined, thus allowing privacy to be maintained (Vessey 1995, Hockenberry 2005).

RESPIRATORY EXAMINATION

Respiratory disorders in infancy can be acute, life-threatening or chronic. In the acute, life-threatening situation, e.g. epiglottitis, early assessment of airway and breathing is vital if the child is to be treated effectively (ALSG 2005).

The most common reason for infants and toddlers to attend the GP surgery is an acute respiratory tract infection, normally upper, i.e. ear, nose, mouth and throat (Gill & O’Brien 2007). You may wish to refer to the NICE Asthma Guidelines (NICE 2000, 2002, 2007a). It is much better to stand back and observe rather than to immediately place your hands and stethoscope onto the child. The good observer will often be able to distinguish between an upper and lower respiratory tract infection by carefully looking and listening. Observation is also the most useful, since auscultation is frequently drowned by environmental noise.

INSPECTION

You should observe the pattern, work and rate of breathing. The respiratory rate should be counted over a full minute to ensure accuracy. In infants and children under the age of 6–7 years, the abdominal movements should be counted, as they are primarily abdominal and diaphragmatic breathers (Wong 1997) (see Tables 6.1–6.5 for normal age-related vital signs). The nurse should observe for respiratory distress, for example nasal flaring, grunting, wheezing, dyspnoea, recession, use of accessory and intercostal muscles, chest shape and movement. What is the child’s colour? Is there finger clubbing? Are there traumatic petechiae around the eyelids, face and neck following a severe bout of coughing? Remember that infants are nose breathers; therefore any form of nasal obstruction will also cause problems with feeding.

Table 6.2 Grading of pulses

After Wong (1997).

Table 6.3 Normal heart rates

From Wong (1995), with permission.

Table 6.4 Normal blood pressure values

After Hull and Johnston 1993.

Table 6.5 Normal temperature

After Wong (1995).