Child Health Assessment - Assignment Example

Health of Infants, Children and Young People Assignment 1: Child Health Assessment Report In Section 1 (500 words) enter the raw data (your recorded observations and measurements) from your assessment of the child. Short phrases or dot points are suitable in section one. No referenced material can be included as data. SECTION 1: Child Health Assessment Pro Forma (500 words) Conducted by Jane Smith Date 5th September, 2013. Child’s first name Miriam Age 15 Parent Consent Gained Yes Gender Female PHYSICAL ASSESSMENT Height 5’3 Weight 53 Kgs H/C 47.4 cm Temperature 36.5 degree Celsius Pulse 80 beats per minute Respirations 18 breaths per minute Physiological Findings Past medical history The child has a past medical history of asthma which developed when she was 10 years old. Her medical history indicates that she was admitted twice due to asthma attack. Miriam states that she gets recurrent episodes or severe episodes of coughing, shortness of breath, and wheezing. Additionally, she reports that she gets colds which do not go away faster. She reports that the episodes of wheezing, dyspnoea and coughing worsen when she is exposed to smoke, or cold air. She also gets wheezing and coughing in the morning, after a physical activity, after excitement or laughter. However, she states that she is not awakened by the cough or wheezing at night. She was vaccinated with influenza vaccine. She manages her asthma with Inhaled corticosteroid, but uses Short-acting bronchodilators to relieve symptoms of asthma. Family health history None of the parents has asthma. However, Miriam states that her father was a heavy smoker but he now does this on occasional basis. She also states that in many occasions, his dad’s friends come to visit and they smoke either in the house or within their house compound. However, she notes that most of the time they smoke outside the house. Current health status In order to maintain her health status, Miriam avoids exposure to or contact with environmental irritants and allergens like air pollution, second-hand smoke, and dust. Some of Miriam’s family friends smoke. This becomes a big challenge to the family hence her parents need to advice their visitors about asthma and smoke. All these are thought to be the major triggers of her asthma. She follows her written action plans of asthma for self-management which helps improves her outcome. Miriam reports that she was given influenza vaccination, as it is indicated in her medical records. She manages her asthma with Inhaled corticosteroids but for relieve of her symptoms, she uses Short-acting bronchodilators. Because of education on self-management, Miriam recognizes her own capacity of control as well as signs of increasingly worsening symptoms of asthma. She also understands the use of medication and adherence in terms of correct techniques of using inhaler. Psychosocial/ Emotional Development Miriam gets emotional support from her family particularly her mother who reassures her always. She also has good friends both at school and at home who give her support hence enhances her general health outcome. General Assessment Skin Fairly hydrated, no any skin disease or bruises, brown in complexion. She states that she had acne which was managed. Hair and nails Both are in good condition. Long hair, neatly held back and clean short nails. Head The scalp is clean and fairly moisturized. Eyes She wears spectacles. Ears Clean ear. No infection, one pierce on both ears. Nose Clean nose. Mouth and throat Clean tongue, hydrated lips but has a tooth cavity. Clears throats frequently. Cardiac No cardiac condition. 80 beats per minute Chest and Respiratory No chest retractions. Gastrointestinal No ulcers. Occasionally experiences bloating Urinary Pale yellow urine, no foul smell, right quantity for age. Urine output of 350mL Muscolo-skeletal No malformation or fractures. Good reflexes in terms of coordination. Neurologic Good communication Record any other comments made by the child about their general health status ie Allergies SOCIAL HISTORY Age appropriate sleep On average, Miriam gets an 8 hour sleep. Age appropriate Nutrition Miriam states that she has major allergies to some dietary products; hence avoiding specific foods helps her a lot. Age appropriate physical activity Miriam takes up on physical exercise remedy that helps boost her breathing. This is important to her it enhances her overall fitness even though it does not have definite benefit for asthma. However, she avoids heavy exercises and activities since she gets asthmatic attacks when she gets involved in heavy exercises or activities. In Section 2 (500 words) write a description about how you would communicate and establish a therapeutic relationship with a child of your chosen age group. Please include appropriate touch, body language, eye contact, verbal and non verbal communication, legal and ethical issues and cultural competence. SECTION 2: Discuss how you would communicate and build rapport with a child of your chosen age group. (500 words) Include in your discussion the use of body language, eye contact, appropriate touch between nurse and child, cultural considerations you have made, listening techniques and legal and ethical issues associated with a child health assessment. This part of the assignment should not be in the first person Central to therapeutic relationship establishment with the client who is a teenager, ability to employ a broad range of strategies of communication as well as useful interpersonal skills is imperative. Communication that is effective is a significant element in building and sustaining a successful relationship. In spite of the interaction’s length and setting, it is important to act in therapeutic approaches to manage the relationship’s boundaries. This entails: Introduction of self to client while the client is addressed by preferred title or name Listening to clients without instantaneously offering advice or diminishing the feelings of the client (this will include listening to, understanding and respecting the ethno-cultural beliefs, opinions, needs, and values of the client. It is also important to listen to the family’s concerns regarding the client and acting on the concerns correctly). In order to display cultural competence, it is important to respect the client and his or her beliefs and culture while being informed of own preconceptions and biases. Being sensitive to the client’s culture will also be demonstrated when the care provider is aware of cultural disparities in speech habits and patterns, styles of expression and speech, eye contact, and touch. Care providers ought to evaluate whether the client considers touch as threatening and unwanted or positive; it is not right to make assumptions that touching a client is acceptable Identifying the client’s wishes and goals thereafter incorporating them into care plan Providing the client opportunity and time to ask questions and explain self Exploring unusual attitudes, behaviors or comments of the client in order to discover the fundamental meaning Showing interest and empathy for the client. Being genuine, caring, empathetic and unconditionally accommodating the client Offering information to encourage client preference and to allow the client to settle on informed decisions Assisting the client get the optimal solution for him or herself, with regards to their personal beliefs, values, and various decision making approaches Discussion confidentiality boundaries with the client not forgetting the legal responsibilities of the care provider. The care provider should stress that he or she will be working with the client to address the health concerns The care provider should avoid using “why” in his or her questions. Instead guide the client in problem-solving by making him or her realize that he or she is able to solve problems In general, so as to develop a therapeutic relationship that is successful, effective communication is paramount, and responding appropriately to what clients say both nonverbally and verbally is also important. It is also recommended that a health care provider gets prepared to handle effectively situations of disagreement, and appreciate culture’s role in communication. A good rapport involves seeing the client’s perspective, consciously trying to suspend opinion, and avoiding assumptions’ making. In Section 3 (1,000 words) provide a referenced analysis and interpretation of the health assessment data using support from at least 3 additional peer reviewed journal articles that you have researched and located (2006 or later). (These are NOT from set course readings). SECTION 3: Analysis and Interpretation of the Assessment Data (1000 words) - within your referenced discussion identify expected parameters and normal and abnormal findings of the child’s data from section one. Discuss future health implications for the child in relation to health assessment data. Nutrition plays a significant role in young people especially teenagers like Miriam. However, in situations when one has allergy to some food, it is important to put that in mind because some foods or preservatives in some foods trigger asthma (Issues in difficult asthma management, 2012). This is why Miriam is cautious about her nutrition. Miriam, just like any another adolescent gets an 8hour sleep. This is not very bad as the recommended sleep for adolescents is 9 to 10 hours (Tilbury et al, 2009). Being active is considered great for both wellbeing and health. Occasionally, however, playing sport or physical exertion can trigger asthmatic episode, commonly referred to as exercise-induced asthma (EIA) (Burns et al, 2006). Adolescents with asthma like Miriam should have the ability to take part in nearly any exercise or sport apart from scuba diving. Regular physical exercise is essential to the well-being and health of every student. However, students who are asthmatic as well as their families frequently perceive asthma as a hindrance to being active physically. Asthma that is poorly controlled can result in school absences, debilitating symptoms, and events that are life-threatening that call for emergency care (Harver & Kotses, 2010). Miriam is 5’3 tall and weighs 53 kg. Body Mass Index (BMI) is obtained from the calculation of height and weight (Tilbury et al, 2009). BMI is considered a reliable body fatness indicator for most teens and children. With this reference, Miriam’s BMI is 20.7, putting the girl’s BMI for age at the 55th percentile (Tilbury et al, 2009). This indicates that Miriam weight is healthy. Skin is an important organ of the body. Research indicates that acne affects around 80 percent of adolescents. However, it is not brought about by uncleanliness and probably food only plays an insignificant role. Increased levels of hormone stimulate the skin’s oil glands. These glands generate a substance which in turn may block the pores hence causing pimples and blackheads. Pimples and blackheads are not to be squeezed or picked since this can lead to permanent scarring. Nearly all acne cases can be managed successfully. This is evident in Miriam’s case whose acne was successfully managed. The appropriate body temperature is 36.5 to 37.5 degrees Celsius (Tilbury et al, 2009). Miriam’s temperature is 36.7 degrees Celsius which lies within the normal parameter. With regards to texture, a hydrated skin indicates a healthy skin while a dehydrated skin which is characterized by scales indicates a poorly maintained skin or it may be caused by health conditions. Bruises, lesions, rashes and Mongolian blues spots are all indicators of skin conditions or diseases. Healthy hair and nails are indicators of good health. With regards to Miriam, she has a thick, long and fairly distributed hair. She does not have scalp sores, indicating that she takes good care of her head in general. Eyes may have a number of infections or conditions. Proper care is hence mandatory. For instance, Miriam has eye aid as she is myopic. She takes good care of her eyes though and visits the family physician for check up. She does not have hearing issues. Her ears are in good condition. No discharge from the nose. The nose is in proper condition since there is no malformation. Oral hygiene is very important at every age. in teenage, besides prevention of cavity there are some challenges like maintaining as attractive smile as well as fresh breath (Tilbury et al, 2009). A mouth that is clean calls for day to day removal of food particles and plaque beneath the gum line and between the teeth. Food particles can bring about decay as seen in Miriam’s tooth. The lips and the tongue maintenance is good. Presence of infections like ulcers or broken lips is not healthy. Hence oral hygiene is paramount. In cardiac assessment, Miriam’s pulse rate is 80 beats per minute. This is considered good since the normal parameter of pulse rate for anyone above twelve years is 60-100 beats per minute (Rhee et al, 2010). Chest and respiratory assessment is important, particularly for asthma. At the time of assessment, Miriam’s inspiration and expirations were good as evidenced by proper movement of the diaphragm. Difficulty in breathing is seen in asthmatic individuals. Auscultation is the best way of assessing breath sounds. With regards to asthma, there is establishment of abnormal breath sounds like reduced breath sounds. Wheezing and stridor which are also abnormal sounds are indicative of asthma. Gastrointestinal assessment involves bowel habits, pain after eating, constipation, bloating and gas. Miriam notes that she experiences bloating during her monthly periods. With respect to bowel habits, she empties her bowel on a regular basis and never experiences pain after eating. It is important to drink a lot of water every day. This facilitates frequent urination, which washes out bacteria from the urinary tract. Urination should be when there is the urge although holding urine for long periods is not advisable. The normal urine output ranges from 200 to 500 mL (Rhee et al, 2010). Miriam’s output is 350mL which is within the normal parameter. The normal urine’s color ranges from pale yellow to deep amber. Good coordination, gait and posture indicate proper musculo-skeletal formation. In terms of neurologic assessment, Miriam depicts good communication as seen by her use of proper gesture and appropriate articulation of words. Supportive family and friends for asthmatics is very important (Harver & Kotses, 2010). This boosts emotional, psychosocial and physiological development because the teen does not feel neglected. Family structure also plays a significant role in asthma management because it enhances collaborative care (Rhee et al, 2010). With regards to Miriam’s family, doing away with smoke and pets around the house will be very beneficial to her health. Participating in various household activities is important in order to keep the teen active. Getting support from the school is encouraging. This helps in facilitating of proper asthma care plan because the staff will know how to handle the student prior, during and after an asthma attack. Height (in Feet) Age (in years) 3.3 3 4.0 6 4.5 9 5.0 12 5.3 15 Weight (in kilograms) Age (in years) 17 3 26 6 38 9 46 12 53 15 Head circumference (in cm) Age (in years) 43.0 3 44.0 6 46.0 9 48.0 12 49.0 15 REFERENCE LIST Burns, JJ, Sadof, M, & Kamat D, 2006, The adolescent with a chronic illness or condition, Ann Pediatr, 35, 207–213. Harver, A, & Kotses H, 2010, Asthma, health, and society: A public health perspective, New York: Springer. Issues in difficult asthma management: Difficult asthma, assessment and management, 2012, Allergy and Asthma Proceedings, 33(4). Rhee, H, Belyea, MJ, & Brasch J, 2010, Family support and asthma outcomes in adolescents: barriers to adherence as a mediator, Adolesc Health, 47, 472–478. Tilbury, C, Talay-Ongan, A, Bigner, JJ, Berk, LE, Murray, RB, Dickson, C, & University of Western Sydney (2001), 2009, Family health care: Child & adolescent nursing 400760, Frenchs Forest, N.S.W: Pearson Australia. Read More