Building a Comprehensive Health History, Physical Assessment help

Advanced Health Assessment and Diagnostic Reasoning: NURS-6512

May 31, 2017

Building a Comprehensive Health History

Scenario: Pre-school aged white female living in a rural community

Techniques in Interviewing

When interviewing and communicating with a child, it is critical to make the setting for the exam in a comfortable and friendly environment. Putting oneself at the level of the children and using terms that the child would understand is critical to discover and identify risks. The use of play is helpful with this age group. A practitioner would typically incorporate an adult (the parent or legal guardian) with the interview as children are not considered reliable or dependable reporters until the age of seven. Creating a safe and positive experience for a pre-school age child is critical. This may mean interviewing the child while sitting on a parent’s lap or using play to identify developmental milestones. By using play, the practitioner can evaluate musculoskeletal, neurological, developmental, bonding between the parent and child, and decreases a child’s apprehension with the practitioner wants to complete the hands-on portion of the exam (Ball, Dains, Flynn, Solomon & Stewart, 2015).

Risk Assessment Instrument

I would use the ages and stages assessment tool provided by the American Academy of Pediatrics to evaluate for possible risk factors. The ASQ-3 and the ASQ- SE takes into consideration age, gender, and formulates strengths and areas of growth for children. This type of assessment tool is best used if taken at the beginning or before a well-child visit so the practitioner can review and identify key points. See website below for more information: http://agesandstages.com (Marks, 2013).

Five Target Questions

Given the patient’s age and history, I would focus on asking these five questions with follow-up education on recommendations or possible troubleshooting for potential issues.

1. Safety – Does the patient ride in a car seat and if so what kind? Does the patient wear a helmet when riding a bike or tricycle? Do you have a swimming pool and if so what safety measure are you taking?

2. Nutrition – What type of diet and appetite does the child have and how are you promoting quality food?

3. Hygiene – Is the patient brushing their teeth? Is the patient toilet trained?

4. Screen Time – Are you controlling screen time and setting limits?

5. School readiness – What is the child’s attention span and pre-school readiness?

By addressing these five target areas, a practitioner can gauge the health and wellness, safety, nutrition, development and even independence of the child (Sullivan, 2012).

Reference

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

Marks, K. (2013). Early Intervention Assembly: Implementing the ASQ-3 ™ & ASQ-SE in a Medical Home Setting. Retrieved from: http://agesandstages.com/wp-content/uploads/2015/02/Brookes-Early-Interventioners-Assemble_FINAL.pdf.