There are many components of the health history. These elements are covered thoroughly at the initial health visit with the family. Then for subsequent wellchild care visits, obtain a brief update.

It is important for the nurse to “set the stage” for the encounter with the family. When entering the room for the encounter, observe the situation, noting the appearance of family and their interactions. Be cognizant of your verbal and nonverbal communication (body language) and convey a professional and courteous demeanor. Address the adults as Ms. Smith and Mr. Smith; the infant or child by their first name.

When interacting with an adolescent, discuss confidentiality with the family. During the history ask the family to leave the room so the adolescent has the opportunity to speak more freely. Assure the adolescent that the interview will be confidential unless there are safety issues such as the adolescent has thoughts of harming self or others.

Be cognizant of the influence of culture on the family’s beliefs and behaviors. Utilize an interpreter if there are language differences. When using language services, maintain eye contact with the historian, not the interpreter. Document the name of the interpreter and the language used during the encounter. During the interview process, use both open-ended and closedended questions to elicit the history. Document the reliability of the historian and involve the child when developmentally appropriate. Avoid the use of healthcare jargon and use layman’s terms when necessary, acknowledge concerns as appropriate. At the end of the interview summarize the key points and document the main concerns of the family.

Establish rapport with the child and family. Some key questions to ask include the following:

Create a genogram depicting the family medical history.

Document the prenatal and birth history of the child. Some key questions include the following:

Inquire about the child’s past medical history. Pertinent questions include:

Ask about any allergies to medications or foods and document the type of allergic response to the allergen.

Document medications used, both over the counter and prescription. Ask about current medications as well as used in the past. Document the name of the medication, indication, dosage, route, and frequency.

Review the child’s immunization record and document his/her immunization status. Obtain the following information:

At the end of the visit, if vaccines are required, update the immunization record.

Familiarity with the normal developmental milestones for infants and children enables the nurse to recognize deviations from normal (see Chapter 2). The developmental domains include: gross motor, fine motor/adaptive, personal/social, language, and cognition. Be cognizant that the sequence of development is the same but that the rate of achievement varies. Also, the rate of achievement in one domain may not parallel the achievement in another area. Understand that the infant must lose the primitive reflex before the infant can achieve voluntary movements.

Identify when an infant or child is meeting their milestones, not meeting their milestones, or has regressed or lost previously achieved milestones. Also, knowing what an infant or child can do at a particular age can alert the nurse to potential abuse situations where the story does not correspond to what the child is developmentally able to do. Provide anticipatory guidance and injury prevention education to the family knowing the next major milestones the child will soon achieve. For instance, a young infant starts to roll over from back to front around 3 months of age. Instruct the family to never leave the infant unattended on the changing table, sofa, or bed, where he or she may roll off and sustain a fall-related injury.

Key questions to assess diet and elimination vary based on the child’s age. These include:

Query the family about the sleep habits of the child. Pertinent questions include:

Several areas are included in assessing the social history. Ask questions directly to the child as appropriate: