This is a systematic approach by a nurse to gather relevant data of a child in the health facility in order to use the necessary information needed to manage the present health problems. The nurse uses communication skills, observation with all the senses to obtain information. A developmentally approach system is used to obtain the age appropriate history.
Aims
· Guide in diagnosing a patient’s condition
· Establish the context of the child’s illness
· Serve as a base line data
· Develop nursing care plan
· Establish and maintain a good relationship with the child/caregiver which will aid in the therapeutic process
Types
· Comprehensive History
· Focused History
· Emergency History
· Interval History
· Follow-Up History
Requirements
· Pen and paper
· Patient folder (manual or electronic)
· Conducive environment
· Table and chair
Steps
1. Perform hand hygiene
2. Ensure privacy
3. Establish rapport (refer steps)
4. Explain procedure to child, caregiver/family (refer steps)
5. Take biographical data: name, sex, date of birth and the corrected age if child was born pre-mature
6. Note the source of information and relationship with the child
7. Obtain presenting complaints
8. Use OPQRST to understand the reason for care or history of presenting illness
9. Obtain past medical history
a. Childhood illnesses
b. Serious accident or injury
c. Chronic health illness
d. Surgeries or hospitalizations
e. Allergies: medications, food, environment and type of reaction
f. Medications and use of complimentary alternative therapies
g. Age of child at the time of illness
10. Pregnancy History
a. Parity of mother
b. Duration of pregnancy
c. Any illness during pregnancy
d. Drugs or other treatment taken during pregnancy
11. Birth History
a. Place of delivery (home, maternity clinic, hospital)
b. Mode of delivery
c. Presentation of fetus
d. Respiration (spontaneous or assisted)
e. Birth weight
f. Neonatal period (neonatal jaundice, pallor etc.)
g. Duration of hospitalization before discharge
12. Developmental history
a. Fine and gross motor skills
b. Speech and language skills
c. Social interaction, behavior and temperament
d. Educational level
e. Academic performance
13. Obtain information on the patient’s nutritional status
a. duration breast feeding
b. Artificial feed (type, age at introduction, duration, amount and frequency)
c. Age at introduction of solids
d. Present diet pattern (24 hour dietary recall)
14. Obtain family history
a. Find out the health status of immediate family members to document any chronic or inherited diseases
b. Record the relationships, ages and health status or cause of death and age of death
c. Find out about any close family marriages (Consanguinity)
d. Note communicable diseases, illnesses related to unhealthy life style
e. Use a family tree
15. Obtain the social history of the child
a. Family history, structure and function
b. Family composition, relationships among members
c. Home environment
d. Age of mother and father
e. Occupation and education of family members
f. Economic status of parents
g. Cultural and religious traditions and spiritual beliefs (ask questions about beliefs, values and culture that will affect the care of the child and help in the care)
16. Obtain a functional history
a. Sleep and safety
b. Physical activity
c. Coping and stress management
d. Economic status of child (if working)
e. Supportive services
f. Special equipment and supply use for daily care
17. Immunization History
a. Ask whether or not child receive any immunization
b. Enquire about immunization records (Maternal and Child Health Record Book)
c. In the absence of maternal and child health record book enquire about the following:
ü Ask about route and sites of administration of vaccines
ü Enquire about age at which each vaccination was received
ü Check for the BCG scar
d. Ask about any adverse reaction after vaccinations
e. Ask reasons incase child was not immunize at all or schedule wat not completed (ignorance or beliefs)
18. Express appreciation to child /caregiver for their cooperation
19. Document data in the nurse’s notes (manual/electronic)
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