All children should have a yearly health maintenance visit. By six years of age, most children can provide reasonably accurate medical information, and it is a good idea to talk to the child as well as to the parent. If this is patient is new to you, obtain the complete family medical and social history. Use the School-Age Child Health Maintenance guide to complete the age-related history and physical examination. Click on the highlights below for more detail or to branch to a hyperlink within the popup. You can get to a print version of the form on the side bar.
Quickchecks: Developmental Milestones
Whether the setting is a hospital or other healthcare facility, it is important to gather information regarding the child’s history and current status. Collecting Subjective DataInformation spoken by the child or family is called subjective data. Conducting the Client InterviewMost subjective data are collected through interviewing the family caregiver and the child.
Interviewing Family CaregiversThe family caregiver provides most of the information needed in caring for the child, especially the infant or toddler.
Interviewing the ChildIt is important that the preschool child and the older child be included in the interview.
Interviewing the AdolescentAdolescents can provide information about themselves.
Obtaining a Client HistoryWhen a child is brought to any health care setting, it is important to gather information regarding the child’s current condition, as well as medical history.
Collecting Objective DataObjective data in nursing is part of the health assessment that involves the collection of information through observations. The collection of objective data includes the nurse doing a baseline measurement of the child’s height, weight, blood pressure, temperature, pulse, and respiration. General StatusThe nurse uses knowledge of normal growth and development to note if the child appears to fit the characteristics of the stated age.
Measuring Height and WeightThe child’s height and weight are helpful indicators of growth and development.
Measuring Head CircumferenceThe head circumference us measured routinely in children to the age 2 or 3 years or in any child with a neurologic concern. Measuring head circumference using a tape measure. Image via: YouTube.com
Vital SignsVital signs, including temperature, pulse, respirations, and blood pressure, are taken at each visit and compared with the normal values for children at the same age. Temperature
Pulse
Respirations
Blood pressure
Physical ExaminationData are also collected by examining the body systems of the child. Head and NeckSymmetry or a balance is noted in the features of the face and in the head.
Chest and LungsChest measurements are done on infants and children to determine normal growth rate.
HeartIn some infants and children, a pulsation can be seen in the chest that indicates the heart beat, which is called the point of maximum impulse.
AbdomenThe abdomen may protrude slightly in infants and small children.
Genitalia and RectumWhen inspecting the genitalia and rectum, it is important to respect the child’s privacy and take into account the child’s age and stage of growth and development.
Back and ExtremitiesThe back and extremities should also be assessed for abnormalities.
NeurologicAssessing the neurologic status of the infant and child is the most complex aspect of the physical exam.
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