Get a better history from a sick or hurt child
What you learn can be lifesaving
The history given to Melea Anderson, DNP, MS, RN, CNP, critical care practice lead/trauma program manager at Children's Hospitals and Clinics of Minnesota in Minneapolis, seemed straightforward. The parent stated that the child had had ear pain for the last week, with no fever or other symptoms.
"I performed the physical exam. Upon approaching the child's ear with the otoscope, the child whispered to me, 'Can you see the rock in my ear?' The parent was unaware that the child put a small pebble in his ear while playing at the park a week ago," she recalls.
When obtaining a history on a pediatric patient, include the child, recommends Elaine Beardsley, MN, RN, CPEN, ED clinical nurse specialist at Seattle Children's Hospital.
At triage for a 5-year-old boy with vomiting and headache for about 10 days, Beardsley asked the mother when the headache was there. "The mom said throughout the day. The boy added some more information that it is 'most bad' when he wakes up," says Beardsley. Based on that information, I did a more detailed neurological assessment and conveyed my concerns to the physician. The boy was diagnosed with a brain tumor." Here are tips to obtain a better history from a child:
• Ask children to point to the pain.
A child might indicate that their entire abdomen hurts. "But if you ask them to point with one finger to where it hurts, they will point to the right lower quadrant, for example," says Lisa Newton, RN, an ED nurse at Phoenix (AZ) Children's Hospital.
•Ask open-ended questions.
"When asking children for information, try to avoid questions that the child could answer with a 'yes' or 'no,'" says Newton.
The best practice is to allow the children to participate to the extent they wish to, says Anderson. "You have some pediatric patients that will give you endless amounts of information, and others that will not say a word and will allow their parents to answer all questions," she adds.
• Ask children to describe their bowel movement.
"Asking a child when they last had a bowel movement cannot always rule out constipation if the answer is today," says Newton. "Often children with constipation will have multiple bowel movements that are like small rocks, or they may have an impaction and stool is squirting around it. When concerned about constipation, I always ask when was the last bowel movement and was it normal, like rocks, or toothpaste."
• Avoid terms that can make children anxious.
"Saying the word 'stitches,' 'needles,' or 'shots,' can be very anxiety-provoking, even in children who have never had a previous experience with sutures," says Anderson. She recommends saying the following instead: "We are going to use some cold numbing jelly to help make your cut not hurt. When we fix your cut, we are going to use some soapy stuff to clean and then squirt it with a special squirt gun to also clean it. When we are all done, you can take the special squirt gun home. When we fix your cut, you will see some string that we use to fix your cut. You will see a scissor that we use to cut the string and another thing that kind of looks like a scissor to hold the string."
• Give a child choices when possible.
Anderson gives these examples: Ask,"Which ear should I look in first: This one, or that one?" or "Do you want to drink your medicine from a little cup, or squirt it in your mouth with a syringe?"
"Either way, they need to take their medicine, but they can choose which way they prefer to take it," Anderson says. "This gives them a sense of control."
For more information on obtaining a history on a pediatric patient, contact:
- Melea Anderson, DNP, MS, RN, CNP, Critical Care Practice Lead/Trauma Program Manager, Children's Hospitals and Clinics of Minnesota, Minneapolis. Phone: (612) 813-8890. E-mail: firstname.lastname@example.org.
- Elaine Beardsley, MN, RN, CPEN, Clinical Nurse Specialist, Emergency Department, Seattle Children's Hospital. Phone: (206) 987-4590. E-mail: email@example.com.
- Lisa Newton, RN, Emergency Department, Phoenix (AZ) Children's Hospital. Phone: (480) 206-2194. E-mail: lnewton@phoenixchildrens hospital.com.
To assess a child, listen to mom first
Try this "trick" at triage to assess the breath sounds of toddlers with stranger anxiety:
"Pretend to listen to the mom with the stethoscope first, then the child," says Lisa Newton, RN, an ED nurse at Phoenix (AZ) Children's Hospital. "If the child only allows me to listen for a short time, I will go back to 'mommy's turn.'"