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Health of Infants, Children and Young People

Assignment 1: Child Health Assessment Report

SECTION 1: Child Health Assessment Pro Forma (500 words)

Conducted by

Christina Hankins


Child’s first name

Parent Consent Gained




Physiological Findings

Growth chart, Vital functions; BP 96/58,


Emotional Development

She is confident and delight showing off her talents. She also displays increasing awareness of her own emotions and developing better techniques for self control. Other notable developments were;

  • Rigid, demanding, and unable to adapt

  • Eager for fresh experiences

  • Protective tendencies towards their pets and friends

  • Starting to show growing interest in taking care of herself without help

General Assessment (Physical and General assessment 500 words)

Smooth, elastic and firm with slight dullness

Hair and nails

Silky, strong and elastic

Even molding

Clear and bright

Tympanic membrane is pliable

Audrey had a minor operation 18 months ago where tympanostomy (gromments) where inserted to allow her Eustachian tubes grow to the required size to work naturally. This was also done to correct two other conditions;

She was experiencing middle ear fluid for more than few months

Having more than 5 acute ear infections in one year. This also happened to both ears.

Intact nasal angle

Mouth and throat

Lips are smooth and moist, gums are firm and coral pink in colour, mucous membranes is smooth, moist and pink, tongue has a rough texture with no lesions, teeth are white and intact

Pulse and blood pressure within normal limits

Chest and Respiratory

Chest; lateral diameter is increased in proportion to anteroposterior diameter. Respiratory within range for age. However, there is presence of stridor from a distance.


Auscultation: beginning with right upper quadrant reveals, no liver bruits or rubs. There are no sounds from bowels in the left upper quadrant. The periumbilical regions reveal no signs of bruits or rubs.

Palpation of the abdomen: The consistency of the liver palpated when asked to inspire deeply shows nodular shape of the liver. But with slight irritable bowel.

Percussion: liver and spleen sizes were normal. There was no abnormal gas collection.

  • No strong persistent urge to urinate

  • No feeling of burning sensation when urinating

  • The amount of urine passed is normal; no frequent and small amounts of urine

  • The urine colour is normal (clear with straw yellow colour)

  • The smell is normal (no strong smelling urine passed)

  • She does not experience pelvic pain


Inspection—on visual examination, range of motion of joints is normal and active

Percussion—using ulnar surface of fist for examining, spine shows normal function

Palpation—using finger tips and thumbs to palpate joint muscle shows normal function

Motor examination—neuromuscular testing for reflexes, strength and sensation shows normal function

Auscultation—using stethoscope for temporomandibular joint (TMJ) and slight tendinous rubs might show abnormal function


Appears alert, emotional stable and responsive.

Record any other comments made by the child about their general health status ie Allergies

Nil allergies but extremely dislikes Brussels sprouts.


Age appropriate sleep

At her age she has been going to bed between 7 and 9 p.m. and wakes up between 6 and 8 a.m. This has translated to a total of 10 – 12 hours of sleep every day. She was still napping at early stages of her 6th year. However, this has been reducing with time. Also noticed is that with school, social and family activities; average age appropriate sleep is about 9 hours.

Age appropriate Nutrition

Her nutrition has been a blend of energy giving foods, fats, vitamin, iron and fruits and vegetables. Energy foods has been pasta and packed bread to school. Fatty foods have been given occasionally with butter as the only option. She likes vitamin related foods with her favourite being milkshakes. This is supplemented with oily fish as iron supplement. The nutrition includes fruits and vegetables such as lettuce and cherry tomatoes.

Age appropriate physical activity

She has been having one hour or more of moderate to vigorous physical activity either in school or at home on most or all days. There have been periods where she is allowed time for free plays. This is incorporated in either daily routine or household chores.

SECTION 2: How communication would build rapport and efficient therapeutic process with the child

Therapeutic nurse-client relationship is the basis, the very core, of all psychiatric nursing treatment that ought to engage Audrey. The process needs to be communicative with both parties engaging one another in the process. To ensure this, there are elements that need to be established.

The very first process that ensures communicative and well rapport process with the client is to develop an understanding in Audrey that makes her feel the process is safe, confidential and reliable. This can be summed up by being genuine. Genuineness or self-awareness of her feelings as they can be seen within the process of interacting and the ability to communicate them when necessary can be a key ingredient in trying to build trust with clients. Basically, being genuine with her is acting in a manner that meets person to person in a therapeutic relationship. This can be conveyed through actions such as listening to and communicating with her without distorting her messages, not hiding the role of a nurse, and being clear in communication with her. Being genuine also means refraining from rigid or parrot like communication.

Good therapeutic process that creates rapport needs empathy. Empathy within this context means one understands the ideas expressed, as wells as Audrey’s feelings. Empathy also entails three major aspects; communicating her understanding and checking with her for accuracy, acting on such accuracy in a helpful way toward finding a solution and accurately getting her perspective, situation and feelings. For example, asking Audrey question such as, «Audrey, you mentioned that you were concerned that your bone pain won’t be addressed in a timely manner?» makes her feel one is part of her problem.

Communication is another way that not only builds rapport but also good therapeutic relationship. Communicating with Audrey include both verbal and non-verbal and encompass ability to connect with and understand her state of mind. The first step in this case would be clear introduction using the preferred name and title as a nurse. This is also connected with being professional while communicating. Professional and respectful language goes along way despite the age of Audrey. In many cases, this process will avoid being informal as so shows lack of professionalism and can be perceived by her as disrespectful. It is best to err on the side of formality; for instance, “How do you feel Audrey?” even if she feels to correct by saying, “please call me sweetheart.” Other two aspects of verbal communication included in this case are; first, positive tone of voice that will put Audrey at ease. Second, using plain language with no medical terms or abbreviations.

Being aware of non-verbal commutations from parties creates good environment for therapeutic process. One way of non-verbally expressing keenness is to node appreciatively when the she expresses concern(s). Creating good rapport through communication is to avoid negative interactions that may portray contrasting values, cultural orientations or preferences. This is achieved by developing awareness and pretending as if her cultures and preferences are one of own.

SECTION 2: Analysis and Interpretation of the Assessment Data

Audrey’s general appearance was the single most important parameter where the assessment about her health was conducted. The appearance could reflect among other things, brain perfusion, adequacy of oxygenation, ventilation, CNS function and body homeostasis.

Beginning with the eye, Heldrich, Barone and Spiegler (2009) explain that a child within the age of 4-8 showing a benign appearance would be one with good eye colour, good eye contact; spontaneously reaching for a tongue blade. Comparing this with Audrey, she has clear and bright eyes. This indicates normal eyes which is safe from inadequate oxygenation, brain perfusion, metabolic abnormalities like hypoglycemia or hemorrhage. Though pediatricians and ophthalmologists feel that children with clear and bright eyes might not develop eye related problems, vision screening should be part of Audrey’s pediatric check-ups (Shaikh et al. 2010; Winberg et al. 2009). Amblyopia is a good example of a secondary condition that Audrey might develop even though earlier signs do not indicate. This condition has been suggested since from close look, Audrey has ‘mild’ misaligned eye. It will therefore necessary to treat the underlying problem.

Analyzing data from her muscolo-skeletal examination, research argue that age differences are associated with important developmental differences in social skills and psychomotor (Ahern et al. 2011). Audrey manifests range of normality with her joint muscle, temporomandibular joint, spine, reflexes, strength and sensation. However, Ahern et al. (2011) add that the slight rubs noticed on temporomandibular joint might be a sign of Marfan syndrome. Other researches indicate that children who manifest joint problems might suffer from connective tissue disorder such as skin striae or scoliosis (Hergenroeder et al. 2008). Relating her muscolo-skeletal examination with neurologic assessment, Audrey appears alert, emotional stable and responsive. She seems to be having normal nervous system. Her future life might not develop scaring seizure related disorders such as epilepsy. This is also related with her cardiac results. Newman (2011) links nervous system, cardiac, and muscolo-skeletal with neurologic functioning. He explains that children within the age of 6-8 and with normal neurological function are unlikely to suffer from nervous system, cardiac, and muscolo-skeletal disorders. As a matter of fact, this justifies Audrey’s psychosocial development and physiological findings where she is confident and delight showing off her talents. She also displays increasing awareness of her own emotions and developing better techniques for self control.

Recent evidence-based researches argue that work of breathing is accurate immediate way of indicating ventilation and oxygenation compared to convectional adult measures like chest auscultation or counting RR (Kay et al. 2010; Majd et al. 2008). This is basically what chest and respiratory reveals. Audrey has lateral diameter which is increased in proportion to anteroposterior diameter. This is actually a respiratory within range for age. Work of breathing can reflect her physiologic compensatory response to cardiopulmonary stress or any other related problems. However, with the result above, there is a clear indication that she has not developed any chest and respiratory problems. However, assessment of breathing on children entails careful listening for abnormal airway sounds as well as observation of specific visual information regarding breathing effort. While Audrey has no signs of abnormality, presence of abnormal sounds could have been linked with breathing difficulties—sign of breathing problem and level of hypoxia. In as much as there are no signs of wheezing, altered speech or grunting, the detected stridor is a perfect example of abnormal sound. This can easily suggest upper airway obstruction. While she might not be having lower airway disease, presence of stridor might suggest that Audrey may suffer from asthma if the problem persists.

The child has smooth, elastic and firm with slight dullness skin. While the smoothness, elasticity and firmness can be a good indicator of a skin with good supply of oxygen, slight dullness noticed indicates that there is slight problem with blood flow. The possible cause in this case is presence of blue blood and there could be slight problem with the lungs or heart. On the other hand, it is normal for slight dullness to be found in feet, hands, and areas around the mouth. This can be confirmed with the tests from mouth and throat where she has smooth and moist gums with smooth mucous membrane. However, it is recommended that further tests be conducted to ascertain any possible complication (Hudson et al. 2010). Cross examination on her ears indicates that she might develop some complications in the future. Besides, the 18 months old gromments indicates that she has some problems with her Eustachian tubes. Though tympanostomy (gromments) tube insertion in her is a common procedure, acute otitis media is a frequent sequel in future. Audrey also complained about experiencing middle ear fluid that has been on and off. While treatment options for this can be topical or systematic antibiotics, current evidence argue that a topical fluoroquinolone without or with orticosteroid should be the recommended treatment should Audrey develop acute otitis media (Majd et al. 2008; Shaikh et al. 2010).

On gastrointestinal tests; periumbilical regions, liver and spleen reveal no signs of bruits or rubs. While this was physical examination, it does not rule out possibilities of other complications. For instance, Ross (2011) explains that with auscultation, palpation and percussion on G1 tract might reveal no abnormalities, there could be functional disorders where bowel looks normal but its function is not normal. In as much, slight irritable bowel might suggest IBS (irritable bowel syndrome or spastic colon) due to either antacid medicines with calcium or resisting the urge to have a bowel movement. However, complications such as anal fissures, haemorrhoids or diverticular diseases are very unlikely in future since periumbilical regions show no suspicious signs.

Urinary system has no any sign(s) that show possibility of urinary tract infection (UTI). Normal passage of urine, clear, straw and yellow coloured urine, and lack of strong smelling urine passed are possible indicators that there are no parts of urinary tract that have been infected. However, there could be several factors that are likely to increase the risk of a UTI developing. These include; constipation that could put pressure on her bladder and dysfunctional voiding (Zorc et al. 2012).


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