WILLIAM PATERSON UNIVERSITY
COLLEGE OF SCIENCE AND HEALTH
DEPARTMENT OF NURSING
EXPANDING FAMILY AND ADAPTATION NURSING
NURSING 312/314 - Pediatric Component
THE PEDIATRIC HEALTH HISTORY
Initial History
The initial history is obtained at the child’s initial health care visit. Since taking the history is
time consuming, allow an additional 30 minutes for that visit. When the appointment is
scheduled, the secretary should advise the parent and/or child of the extended visit and request
that they have immunization, birth, developmental, and illness records available.
I.
Informant’s relationship to patient.
II.
Family history
A.
Parents
1.
Age
2.
Health Status
B.
Chronological listing of mother’s pregnancies, including miscarriages. List
name, age, sex, and health, and consanguinity of children.
C.
Familial review of systems (include parents, siblings, grandparents, aunts, uncles).
1.
Skin. Atopic dermatitis, cancer, birthmarks.
2.
Head. Headaches (migraine, cluster).
3.
Eyes. Visual problems, strabismus.
4.
Ears. Hearing deficiencies, ear infections, malformation.
5.
Nose. Allergies, sinus problems.
6.
Mouth. Cleft palate, dental status.
7.
Throat. Frequent infections.
8.
Respiratory. Asthma, chronic bronchitis, tuberculosis.
9.
Cardiovascular. Cardiac disease, hypertension.
10.
Hematologic. Anemias, hemophilia.
11.
Immunologic deficiencies.
12.
Gastrointestinal. Ulcers, pyloric stenosis, chronic constipation, or
diarrhea.
13.
Genitourinary. Renal disease, enuresis.
14.
Endocrine. Diabetes, thyroid problems, abnormal pattern of sexual
maturation.
15.
Musculoskeletal. Dislocated hips, scoliosis, arthritis, deformities.
16.
Neurologic. Convulsive disorders, learning disabilities, craniosynostosis,
mental retardation, mental illness.
17.
General. Obesity, unusual familial pattern of growth, cystic fibrosis.
NUR 312-314-Pediatric Health History
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III.
Social History
A.
B.
C.
D.
E.
F.
G.
Occupation
1.
Mother.
2.
Father.
Housing
1.
Ownership of home.
2.
Age and condition of home.
Parents marital status
1.
Duration of marriage.
2.
Marital relationship.
3.
Single parent, support system.
Parents’ source of medical care.
Medical insurance
Financial status and source of support.
Social outlets of parents and family.
IV.
Pregnancy
A.
Prenatal care
1.
Location and duration.
2.
Prenatal classes.
B.
Mother’s health
1.
complications: vaginal bleeding, excessive weight gain, edema,
headaches, hypertension, glycosuria.
2.
Infection: rubella, urinary tract infection.
3.
Exposure to radiation, drugs (alcohol, medications, smoking).
C.
Planning of pregnancy
1.
Methods of contraception.
2.
When contraception discontinues.
V.
Birth
A.
Location
B.
Gestational age in weeks
C.
Labor
1.
Induction.
2.
Duration.
3.
Medication, natural birth.
4.
Father present.
D.
Delivery
1.
Presentation: vertex, breech, transverse.
2.
Method: spontaneous, forceps, cesarean section (repeat, emergency).
E.
Parents’ reaction to labor and delivery, including mother’s physical and mental
recuperation.
F.
Complications
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G.
Neonatal health
1.
Birth weight.
2.
Condition at birth.
a.
APGAR score.
b.
Resuscitation, oxygen.
c.
Special nursery.
d.
Congenital anomalies.
3.
Hospital course.
a.
Respiratory distress.
b.
Cyanosis.
c.
Jaundice; physiologic, ABO, Rh, other.
d.
Difficulty sucking.
e.
Vomiting.
f.
Other complications.
(1)
Infection.
(2)
Seizures
g.
Length of stay.
h.
Low weight and discharge weight.
VI.
Nutrition
A.
Feeding
1.
Breast: duration.
2.
Formula: amount, type.
B.
Problems
1.
Scheduling.
2.
Vomiting.
3.
Diarrhea.
4.
Colic.
C.
Vitamins and fluoride
D.
Solids
1.
When introduced - cereal, vegetables, fruits, meats, eggs, juices.
2.
How prepared.
3.
Infant’s tolerance.
E.
Present diet
1.
Appetite.
a.
Balanced -0 relate to growth pattern.
2.
Food intolerances and dislikes.
VII.
Growth and development
A.
Physical
1.
Height and weight at birth, 6 months, 1 year, etc.
2.
Consistent growth rate.
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B.
C.
D.
E.
F.
G.
Motor
1.
Gross motor
a.
Sits by 6 months
b.
Crawls by 8 months
c.
Stands alone by 12 months
d.
Walks by 16 months
e.
Undresses, dresses by 2 years.
f.
Pedals tricycle by 3 years.
g.
Ties shoes by 6 years.
2.
Fine Motor
a.
Reaches for objects by 4 months.
b.
Pincer grasp by 1 year.
c.
Holds and drinks from cup by 1 - 2 years.
d.
Feeds self by 2 years.
e.
Catches ball by 3 years.
f.
Uses pencils by 4 years.
Language
1.
Single words other than “mama” and “dada” by 1 year.
2.
Phrases (two to three words) by 1 - 2 years.
3.
Sentences by 3 years.
Toilet training
1.
When started.
2.
Technique used.
3.
When achieved.
School
1.
Grade appropriate for age.
2.
Academic performance.
3.
Social adjustment to school.
a.
To teachers.
b.
To peers.
Personality traits as viewed by parents
1.
Relationships with parents; happy, self-actualizing, exhibits self control,
takes responsibility for own actions according to developmental stage.
2.
Relationships with siblings; cooperative rather than aggressive interaction.
3.
Relationships with peers; by school age, able to be a part of a peer group.
Behavioral traits
1.
Pica, tantrums, thumb sucking, rocking, etc.
2.
Sleep patterns.
3.
Hobbies, activities.
4.
Smoking, drugs, sexual practices.
5.
Ability to control behavior.
6.
Ability to anticipate and take responsibility for consequence of behavior.
7.
Ability to accept and return affection.
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VIII.
Parental reaction to child’s development
A.
Proud, understanding
IX.
Immunizations and screening tests
A.
Types and dates of immunizations, including boosters
1.
DTaP
2.
IPV
3.
MMR
4.
Varicella
5.
HIB
B.
C.
X.
Reactions to immunizations
Screening and dates of last tests
1.
Tuberculin.
2.
Sickle cell.
3.
Lead.
4.
Hearing.
5.
Vision.
6.
Urine.
7.
Hemoglobin, hematocrit.
Previous illnesses
A.
Contagious diseases
1.
Dates.
2.
Severity.
3.
Sequelae.
B.
Infections
1.
Dates.
2.
Severity.
3.
Sequelae.
C.
Other illnesses and complications
D.
Hospitalizations
1.
Illnesses, operations, injuries.
2.
Dates.
3.
Places.
4.
Complications.
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XI.
Review of systems
A.
Skin. Birthmarks, rashes, skin type.
B.
HEENT (Head, Eyes, Ears, Nose, Throat)
1.
Hair and scalp. Seborrhea, hair loss, pediculosis.
2.
Head. Injuries, headache.
3.
Eyes. Vision test, glasses, strabismus, infections.
4.
Ears. Hearing test, infections, discharge.
5.
Nose. Epistaxis, allergies, frequent colds, snoring, sense of smell.
6.
Mouth. Dental hygiene, visits to dentist, mouth breathing.
7.
Throat. Sore throats, swollen glands, difficulty swallowing, hoarseness.
Respiratory. Bronchitis, pneumonia, asthma, croup, persistent cough.
C.
XII.
D.
Cardiovascular. Heart murmur, cyanosis, dyspnea, shortness of breath, edema,
syncope, energy level.
E.
Gastrointestinal. Appetite, diet, abdominal pain, vomiting, diarrhea, constipation,
type and frequency of stools, jaundice.
F.
Genitourinary. Enuresis, urinary tract infection, dysuria, urinary frequency,
hematuria, vaginal discharge.
G.
Skeletal. Deformities, joint pains, swelling. limp, orthopedic appliances, injuries.
H.
Neurologic. Fainting spells, dizziness, tremors, loss of consciousness, seizures,
ataxia.
I.
Endocrine
1.
Sexual maturation.
a.
Male: hair, beard, voice, acne.
b.
Female: breast development: menarche, duration, regularity,
amount of menstrual flow, dysmenorrhea; acne.
2.
Growth disturbances.
a.
Consistent growth rate.
b.
Excessive weight gain.
3.
Excessive thirst.
Assessment
A.
Problems identified from subjective and objective data.
B.
Problem list developed with parent and/or child.
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