Topics

• History Components
• Pediatric Variations
• Geriatric Variations
• Clinical Reasoning Frameworks

NDNP 819 - Advanced Health Assessment Across Lifespan

Module: History Data, Clinical Reasoning

Pediatric Variations

When collecting past medical histories on children, it is important to include prenatal, birth and neonatal history, acute and chronic illnesses, surgeries (type and date), injuries/trauma (lacerations, fractures, ingestions), and hospitalizations (include ICU admissions, ER visits, w/dates and diagnosis). A developmental history includes ages of milestone achievements for gross motor, fine motor, social and language skills--“How old was your son when he was able to walk? When he was able to say 3 sentences? Is he able to follow directions in school? Does he have friends?”

Include these areas for all pediatric histories and direct the questions based on the age of the child:

• Nutrition: Breast or bottle (formula type, amount, how often)-Solids- when introduced, meal frequency-Fluid intake/hydration- milk, juice, water, sport drinks-Nutritional supplements (fluoride use)-Reactions to any foods
• Elimination: Urinary and Bowel Patterns: number of wet/soiled diapers (infant) bed-wetting, soiling (preschool through adolescence) toilet-trained (toddler-preschool). constipation, diarrhea.
• Sleep/Activity: number of hours, timing of naps, where child sleeps, position, sleep disturbances, night terrors/mares
• Safety: car seat- rear or front-facing, water safety, home environment, violence/weapons in home, smoke detectors/ carbon monoxide detectors, child safety locks in outlets, cabinets, meds kept out of reach and not visible

For Health Maintenance, ask the parents or caregivers about past screenings relevant to the child’s age and risk factors: Lead/TB/Cholesterol, anemia, Vision/hearing/dental, Blood pressure, Newborn, Mental Health. For adolescents, depression, HIV and obesity.

The CDC Immunization Schedule Website has information about current child immunizations

Easy-to-Read Schedule for Children, Birth through 6 Years

Detail immunizations with dates. Do not document “immunizations up to date”.

In Personal/Social History, also include daycare, safety concerns, potential exposure to toxins, occupation of parents & marital status, composition of household include siblings household pets, economic situation and water source.

For teens, use open-ended questions and don’t force the adolescent to talk. Allowing them an opportunity to “write” their concerns may be more helpful. Two mnemonics that are helpful for gathering an adolescent history are HEADS (H-Home, E-Education, A-Activities, D-Drugs, S-Sex) and PACES  (P-Parents, Peers, A-Accidents, Alcohol, Drugs, C-Cigarettes, E-Emotional Issues, S-School, sexuality).

Bright Futures for Health Care Providers has excellent overview materials for infant, preschool, school age and adolescent well child visits and there are some examples of documentation used in practice with cues for asking history questions (nutrition, ROS, development) based on age.