Communication and Interview Techniques

Communication Strategies

• Rapport is important in establishing a foundation for a collaborative relationship.
• Rapport is to be used for a child's benefit.

Strategies to Facilitate Rapport and Data Collection

• Introduce yourself.
• State the purpose of the interview.
• Ensure Privacy
• Direct the focus of the interview with open-ended questions
• Ask questions one at a time
• Observe the parent-child interaction and behavior
• Involve the child
• Be honest with the child
• Use language understood by both parent and child.
• Use an interpreter, if needed.

Careful Listening

• Avoid asking questions
• Take note of their tone of voice.
  • Look for signs of anxiety, anger, apathy, or concern
• Pay attention to underlying themes
• Note nonverbal behavior such as
  • Posture
  • Gestures
  • Eye contact
  • Facial expressions

Components of Health History

• Gather general information about the patient like
  • Demographic data
  • Emergency contact information
  • Historical information
• Collect physiologic and psychosocial data.
• Determine developmental status

Sequence of Examination

• For young children use a foot-to-head sequence to allow completion of the least distressing parts of the exam first.
• For older children use a head-to-toe approach.
• The sequence of the exam may vary due to preferences, sleep, and cooperation of the patient.

Facilitating Examination of Infants Under 6 Months of Age

• Promote physical comfort and relaxation
• Distract the infant with colorful toys.
• Use gentle, warm hands and and a pre-warmed stethoscope.
• Auscultate when the infant is quiet or sleeping.
• Do procedures that provoke crying at the end of the examination

Facilitating Examination of Toddlers

• Keep the child close to the parent.
• Provide a security object.
• Demonstrate instruments on a parent or another before examining the child.
• Allow the child to have as much control and choice as possible.
• Examine ears, eyes, and mouth at the end of the exam.

Facilitating the Examination of Preschoolers

• Consider what sequence is best.
• Allow children to touch and play with equipment.
• Use games to reduce anxiety.
• Give positive feedback

Facilitating Examination of Older Children and Adolescents

• Ensure Modesty and privacy
• Offer choices
• Explain body parts and functions.
• Decide on parental presence or absence.
• Consider the need for non-parent chaperones.
• Reassure adolescents of normalcy

General Appraisal

• Note appearance
• Note their behavior
• Note their interaction with the parents
• Note their interaction with the examiner

Growth Measurements

• Measure weight
  • Use an infant scale
  • Use a standing scale
  • Consider diapers and clothing
• Measure length
  • Measuring board (up to 24 months) should be used
• Measure height after age 2
  • Use a stadiometer(standing)

Growth Measurements

• Measure head circumference
  • Measure twice
  • Up to age 2 years
  • Around supraorbital and occipital prominences
• Body mass index (BMI): measure of body fat based on height and weight
  • Calculation: weight in kg/m² of height.
  • Can use a BMI calculator

Skin and Hair

• Skin assessments include:
  • Color, temperature, and moisture
  • Skin turgor which indicates resilience
  • Capillary refill time
  • Rashes and lesions
• Hair assessments include:
  • Texture, amount, and fullness
  • Whether or not it is breaking off
  • Head lice

Head and Face

• Assess the shape of the head and face.
• Assess symmetry
• Assess the facial features

Head and Face

• Skull sutures are fibrous connections between the bones of the skull that have not yet ossified.
• Fontanels are formed at the intersection of these sutures where bone has not yet formed.
  • The posterior fontanelle closes between 2 and 3 months.
  • The anterior fontanelle usually closes between 12-18 months.

Eyes

• Inspect the external eye for
  • Hypertelorism (excessive space between eyes)
  • Palpebral slant (upward to downward slant of the eyes)
• Assess focus:
  • PERRLA
  • EOMs might not be symmetric in newborns
  • Irises are round, and the permanent color appears at 6-12 months of age

Eyes

• Assess vision using
  • Infant tracking
  • Age-appropriate tests of visual acuity
• When using a fundoscopy, look for
  • Red reflex
  • Corneal light reflex

Ears

• When inspecting ears, note:
  • Symmetry
  • Shape of tragus
  • Position and alignment
  • Ear canal
• Check the tympanic membrane

Ears

• Assess hearing with
  • Newborn screening
  • Audiometry
  • Noise and whisper tests
  • Bone and air conduction tests
• Indicators of hearing loss
  • Infant without startle reflex
  • No speech sounds by 6 months
  • No speech/words and not following directions by 2 years old.

Examining Nose and Sinuses

• Inspection
• Palpation
• Percussion
• Patency
• Smell

Mouth and Throat

• Assess:
  • Lips
  • Teeth
  • Gums
  • Mucosa
  • Tongue
  • Throat and tonsils

Neck and Lymph Nodes

• Assess the neck for
  • Full ROM
  • Midline trachea
  • No palpable masses
  • Short in infants
• Palpate lymph nodes for
  • Small, palpable, non-tender, and mobile nodes

Chest

• Inspect the
  • Shape
  • Chest deformities
  • Breasts

Chest

• Inspect for
  • Movement, excursion (measurement of the movement of the diaphragm)
  • Respiratory effort, retractions, respiratory rate

Heart

• Assess pulses
• Check capillary refill time
• Note peripheral cyanosis and edema
• Check blood pressure
• Auscultate rate and rhythm

Auscultation of the Heart

• Sounds will usually sound distinct and crisp because of the thin chest wall

Abdomen

• Inspect the abdomen for
  • Shape
  • Umbilicus
  • Abdominal movements
  • Inguinal area
• Auscultate for
  • Bowel sounds

Genitalia and Perineal Areas

• Positioning is important
• Consider timing in examination
• Females:
  • Labia should be symmetric, with no lesions and hair in an inverted triangle shape
• Tanner Staging(aka Sexual Maturity Rating) is a sexual maturity scale used to track development of secondary sex characteristics

The Stages of Female Sexual Maturation

• Tanner Staging/Sexual Maturity Rating is used to track the development of secondary sex characteristics
• Primary sex characteristics are ovaries, vagina
• Secondary sex characteristics develop during puberty. Including breast development and pubic hair
• Tanner I = Pre-pubertal
• Breast budding is the first secondary sex characteristic in females (ages 9-12). It occurs at Tanner II

Genitalia and Perineal Areas

• Males
  • Penis
    • Urethral meatus at the top of the penis
    • Foreskin might not be retractable in infants and young children
  • Scrotum
    • Skin is loose
    • The left testicle hangs lower than the right
    • Enlarges with darker skin during puberty

The Stages of Male Pubic Hair and External Genital Development With Sexual Maturation

• Use Tanner Staging
• Testicular enlargement is the first secondary sex characteristic in males (9-10 years old). It appears at Tanner II

Musculoskeletal System

• Holds head erect when held upright; thoracic kyphosis when sitting describes the normal Spinal curve for 2-3 month olds
• Sits without support; spine is straight describes the normal Spinal curve for 6-8 month olds
• Walks independently; straight spine describes the normal Spinal curve for 10-15 month olds
• Protruding abdomen; lumbar lordosis. describes the normal Spinal curve for toddlers
• Height of shoulders and hips is level; balanced thoracic convex and lumbar concave curves describes the normal Spinal curve for school-age children

Evaluating Spinal Alignment

• Scoliosis is an abnormal lateral curvature of the spine.
• To evalutate for scoliosis
  • Stand behind the child and observe height of shoulders and hips. Look to see if the shoulders and hips are level. Also look if the creases at the waist are a similar hight
  • Have the child bend forward at the waist with arms hanging. Then run fingers along spine to assess for alignment

Nervous System

• Assess cognitive functioning
  • Behavior
  • Communication Skills
  • Memory
  • Level of consciousness -Assess cerebellar function
  • Balance
  • Coordination
  • Locomotion, gait

Cranial Nerve Assessment

• I Olfactory Not usually Tested. Child:Give familiar smells one naris at a time.
• II Optic Shine a bright light in eyes. Child test vision and visual fields
• III Oculomotor IV Trochlear VI Abducens Shine light. Watch for drooping eyelids.
• V Trigeminal Stimulate the rooting sucking reflex. Child: Chewing, touch with cotton ball when eyes closed.
• VII Facial Observe the facial expression- does the face stay symmetric?
• VIII Acoustic Produce a loud sound near the head. Child: Whisper and have them repeat
• IX Glossopharyngeal X Vagus Look for good swallowing during Feeding & gag present
• XI spinal accessory Child: Ask child to move shoulders and neck.
• XII Hypoglossal Observe. Does tongue extend?

Common Newborn Reflexes

• Tonic neck reflex (Fencer Position) Elicited when supine turn head to one side. Extremities will flex. Persists until the third or fourth month.
• Palmar grasp reflex- touch the newborns palm object will be grasped. Persists until the fourth month
• Moro reflex occurs when newborn is startled by loud noise. Extremities will extend and then rapidy abducts while fingers form a c-shape
• Sucking and Rooting elicited by touching face. Newborn turn towards touch and opens the lips to suck. Persists until four months old
• Stepping reflex newborn will put one foot in the front of the other (stepping Reflex). Is lost in 4 Weeks. .
• Babinski Reflex stroke outer edge of foot to the toes. Infant toes will spread upward disappears by 1-2 years.

Deep Tendon Reflexes

• Biceps: partial flexion of elbow
• Triceps: partial extension of elbow
• Patellar: partial extension of knee
• Achilles: partial flexion of foot