HESI Health Assessment Study Guide History Taking Child

HESI Health Assessment Study Guide History Taking Child • Biographic Data: Include the child's name, nickname, address and phone number, parents' names and work numbers, child's age and birth date, birthplace, sex, race, ethnic origin, and information about other children and family members at home. • Source of History: 1. Person providing information and relation to child 2. Your impression of reliability of information 3. Any special circumstances (e.g., the use of an interpreter) • Reason for Seeking Care: Record the parent's spontaneous statement. Because of the frequency of well-child visits for routine health care, there will be more reasons such as “time for the child's checkup” or “she needs the next baby shot.” Reasons for health problems may be initiated by the child, the parent, or a third party such as a classroom teacher or social worker. Sometimes the reason stated may not be the real reason for the visit. A parent may have a “hidden agenda,” such as the mother who brought her 4-yearold child in because “she looked pale.” Further questioning revealed that the mother had heard recently from a former college friend whose 4-year-old child had just been diagnosed with leukemia. • Present Health or History of Present Illness: If the parent or child seeks routine health care, include a statement about the usual health of the child and any common health problems or major health concerns. Describe any presenting symptom or sign, using the same format as for the adult. Some additional considerations include: Severity of pain: “How does your child behave when he or she is in pain?” (e.g., pulling at ears alerts parent to ear pain). Note the effect of pain on usual behavior (e.g., does it stop child from Downloaded by denis munene () lOMoARcPSD| playing?). Associated factors such as relation to activity, eating, and body position. The parent's intuitive sense of a problem. As the constant caregiver, this intuitive sense is very accurate. Even if proved otherwise, this factor gives you an idea of the parent's area of concern. Parent's coping ability and reaction of other family members to child's symptoms or illness. • Past Health: Prenatal Status-Start with an open-ended question: “Tell me about this pregnancy.” Then ask: “How was this pregnancy spaced? Was it planned? What was the mother's attitude toward the pregnancy? What was the father's attitude? Was there medical supervision for the mother? At what month was the supervision started? What was the mother's health during pregnancy? Were there any complications (bleeding, excessive nausea and vomiting, unusual weight gain, high blood pressure, swelling of hands and feet, falls, infections—rubella or sexually transmitted infections)? During which month were diet and medications prescribed and/or taken during pregnancy (dose and duration)?” Record the mother's use of alcohol, street drugs, or cigarettes and any xray studies taken during pregnancy. • Labor and Delivery-Parity of the mother, duration of the pregnancy, name of the hospital, course and duration of labor, use of anesthesia, type of delivery (vertex, breech, cesarean section), birth weight, Apgar scores, onset of breathing, any cyanosis, need for resuscitation, and use of special equipment or procedures. Postnatal StatusAny problems in the nursery, length of hospital stay, neonatal jaundice, whether the baby was discharged with the mother, whether the baby was breastfed or bottle-fed, weight gain, any feeding problems, “blue spells,” colic, diarrhea, patterns of crying and sleeping Downloaded by denis munene () lOMoARcPSD| (Fig. 4-7), the mother's health postpartum, the mother's reaction to the baby, placement on back when sleeping. • Childhood Illnesses: Age and any complications of measles, mumps, rubella, chickenpox, whooping cough, strep throat, and frequent ear infections; any recent exposure to illness. • Serious Accidents or Injuries: Age of occurrence, extent of injury, how the child was treated, and complications of auto accidents, falls, head injuries, fractures, burns, and poisonings. • Serious or Chronic Illnesses: Age of onset, how the child was treated, and complications of meningitis or encephalitis; seizure disorders; asthma, pneumonia, and other chronic lung conditions; rheumatic fever; scarlet fever; diabetes;