Chapter 10: Observing and Assessing Children, Pregnant Women and Older Adults

Introduction

In this module so far, you have studied the processes involved in accurately and comprehensively observing and assessing adults. In this chapter, you will study the observation and assessment of special patient groups - including children, pregnant women and older adults. This chapter provides an overview of the key anatomic and physiologic differences between adults and children, pregnant women and older adults, and how these impact on observation and assessment. It also describes how to collect a focused health history from a child (or their parent / caregiver, as appropriate), a pregnant woman and an older adult. Finally, this chapter explains how to correctly complete a physical examination of a child, a pregnant woman and an older adult, identifying normal and abnormal findings for each group.

Observing and assessing children

The observation and assessment of children is complex for a number of reasons. Firstly, a child's anatomy and physiology, developmental milestones and psychosocial issues, etc., vary significantly according to their age (see the information in the table below). Furthermore, it is important to remember that children are observed and assessed both as individuals and in the context of their family / caregivers. Children may also be resistant to cooperating in observation and assessment processes, and nurses must use a variety of strategies to respond positively to this problem; some of these strategies are explored in the example essay which accompanies this chapter.

This section of the chapter will describe the processes involved in observing and assessing children of a variety of ages:

Age Group Descriptor	Ages
Newborn (neonate)	Birth to 6 weeks of age
Infant	6 weeks to 12 months of age
Toddler	1 year to 3 years of age
Preschool	3 years to 5 years of age
School age	5 years to 12 years of age
Adolescent	12 to 18 years of age

Anatomic and physiologic differences in children

When observing and assessing children, it is important for nurses to remember that children differ anatomically and physiologically from adults in a number of important ways; in general, the younger the child is, the greater the difference. The most significant differences include:

• Younger children have thinner skin than older children and adults.
• Neonates and young infants have a smaller amount of subcutaneous fat and a larger body surface area, which can lead to problems with thermoregulation.
• Adolescents have greater activity of the apocrine and sebaceous glands in the skin.
• Neonates' cranial bones are soft and unfused; areas called fontanelles remain open until 3 months (anterior) and 19 months (posterior).
• Neonates' and infants' heads are larger in proportion to their body.
• The brain / central nervous system is very immature at birth, and vulnerable to injury.
• The Eustachian tubes in children are shorter / straighter, increasing the risk of ear infection.
• Neonates and young infants are obligate nose breathers.
• The airways are narrow and less-rigid, and the tongue larger, in young children.
• Deciduous teeth erupt between 6 and 24 months; permanent teeth erupt from 6 years.
• Neonates and young infants rely on the diaphragm / abdominal muscles for breathing.
• In a neonate, several anatomic shunts in the heart are present (closing soon after birth).
• The heart in children lies more horizontally in the chest.
• Heart murmurs are common in childhood, and usually resolve by adolescence.
• Children's bones are softer, making them vulnerable to fractures.
• Lymph tissue increases between the ages of 6-9 years (children often have large tonsils).
• Primitive reflexes are present at birth and disappear in a predictable pattern in early infancy.
• The genitalia do not undergo development until the onset of puberty.

Observation and assessment of children - focused health history

As you have seen in previous chapters of this module, health observation and assessment involves three concurrent steps:

When assessing a young person, the nurse must commence by collecting a health history. This involves collecting data about:

Component	Rationale
Biographic data	The same biographic data collected for adults (as described in a previous chapter of this module) is collected for children; however, the nurse should also record the adult accompanying they child and their relationship to the child (as relevant).
Reason for presentation	It is important for nurses to remember that a child may not present to a health care service with a specific health issue; rather, they may present for routine vaccinations and general check-ups, etc.
Present health status and past health history	The same data about present health status and past health history collected for adults (as described in a previous chapter of this module) is collected for children; however, a nurse should also focus on collecting data about a child's perinatal history (for neonates and infants in particular), their development (e.g. achievement of milestones) and their immunisation history.
Family history	Information about diseases present in the child's family members, especially among first-degree relatives, as this can provide important information about the types of disease for which a person may have a congenital risk.
Personal and psychosocial history	A nurse asks about the child's current level of function, their social and family relationships (e.g. their family composition, home environment, socioeconomic status, etc.), their behaviours and health habits (e.g. diet / nutrition, sleep, development, etc.), and their mental health (as appropriate); this provides important information about a young person's overall wellbeing.
A review of the young person's body systems	The nurse should review each of the young person's body systems: the integumentary system, the cardiovascular system, the immune / lymphatic system, the endocrine system, the nervous system, the reproductive system, the respiratory system, the musculoskeletal system, the digestive system and the urinary system. The nurse should also review any general or systematic symptoms the young person experiences (e.g. fatigue, pain, etc.).

It is important for nurses to remember that the majority of the information collected during the health history is collected from the adult accompanying the child (often, the child's parent/s). However, it is also important that the nurse involve the child in the process of collecting health history data, including by questioning the child directly if possible. Questions should be phrased using language and concepts appropriate to the child's age and understanding.

Observation and assessment of children - physical examination

Once a health history of the young person has been obtained, as described in the previous section of this chapter, a nurse may commence a physical examination. A stepwise process of physically examining a young person, with normal (expected) and common abnormal findings, is presented in the following table:

Component	Normal (Expected) Findings	Abnormal Findings
Measure the vital signs, including height and weight	Normal parameters for each vital sign differ according to the age of a child; nurses should refer to the parameters used by their organisation, as these can differ between organisations.	Measurements outside the normal parameters for a child's age.
For neonates and infants, measurement of head circumference.	For term newborns, head circumference should be 33 to 36 centimetres; this steadily increases as the child grows. Nurses should refer to the parameters used by their organisation.	Measurements outside the normal parameters for a child's age.
Examination of the skin, hair and nails.	As for adults (described in earlier chapters of this module).	As for adults (described in earlier chapters of this module). For neonates and infants: birthmarks (either pigmentation or vascular variations); primary skin lesions (e.g. milia, erythema toxicum); seborrheic dermatitis, etc. For toddlers and children: communicable diseases / bacterial infections (e.g. herpes varicella, tinea corporis, impetigo, etc.); alopecia; headlice. For adolescents: acne; persistent nail-biting, etc.
Examination of the head, eyes, ears, nose and throat.	For neonates: the head may be asymmetric due to molding during birth; the fontanelles may be soft and slightly depressed; fontanelles close by 3 months (anterior) and 19 months (posterior); the child should be alert to objects within their view; the child should respond to noises, including by turning their head (by 4-6 months) and responding to their name (by 6-10 months); there should be a strong suck reflex; the tongue should fit well into the floor of the mouth. For toddlers and children:  as for adults (described in earlier chapters of this module); tonsils are normally larger than in adults (but should not obstruct swallowing / breathing). For adolescents: as for adults (described in earlier chapters of this module).	Also refer to abnormalities for adults (described in earlier chapters of this module). For neonates: deeply depressed or bulging fontanelles; fontanelles open longer than expected; lack of pupil reactivity (may indicate blindness); lack of response to loud noises (may indicate deafness); low-set or asymmetrical ears; obstruction of the nares (remembering that neonates are obligatory nose breathers). For toddlers and children: as for adults (described in earlier chapters of this module); frequent earache; lesions on the corners of the mouth / beneath the nose; swollen / tender lymph nodes. For adolescents: as for adults (described in earlier chapters of this module).
Examination of the respiratory system	For neonates and infants: sneezing is often normal as it helps to clear the nasal passages (remembering that neonates are obligatory nose breathers); respiratory pattern may be irregular (with periods of apnoea). For toddlers and children: as for adults (described in earlier chapters of this module); the thorax of the child may be comparatively larger / more rounded than for adults. For adolescents: as for adults (described in earlier chapters of this module).	Also refer to abnormalities for adults (described in earlier chapters of this module). For neonates and infants: stridor, grunting, sternal / supraclavicular retractions, nasal flaring, etc. For toddlers and children: as for adults (described in earlier chapters of this module). For adolescents: as for adults (described in earlier chapters of this module).
Examination of the cardiovascular system.	For neonates and infants: sinus dysrhythmia may be normal; capillary refill is very rapid; acrocyanosis and murmurs may be normal within the first days of life. For toddlers and children: as for adults (described in earlier chapters of this module); pulse may normally increase on inspiration / decrease on expiration; sinus dysrhythmia and a hum in the jugular vein may be normal. For adolescents: as for adults (described in earlier chapters of this module).	Also refer to abnormalities for adults (described in earlier chapters of this module). For neonates and infants: central cyanosis; persistent murmurs; shifting of heart sounds weak / thin peripheral pulses; bounding pulses; absent femoral pulses / different amplitude between upper and lower pulses. For toddlers and children: as for adults (described in earlier chapters of this module); cyanosis and / or pallour; laboured respiration. For adolescents: as for adults (described in earlier chapters of this module).
Examine the abdomen and the gastrointestinal system.	As for adults (described in earlier chapters of this module). For neonates and infants: umbilical cord remnant should be dry by 5 days of age and should fall off spontaneously by 14 days of age. For toddlers and children: as for adults (described in earlier chapters of this module); rounded ('potbelly') abdomen may be normal; abdominal breathing (e.g. limited thoracic movement). For adolescents: as for adults (described in earlier chapters of this module).	Also refer to abnormalities for adults (described in earlier chapters of this module). For neonates and infants: redness, discharge, odour of the umbilical cord remnant; absence of bowel sounds. For toddlers and children: as for adults (described in earlier chapters of this module); umbilical hernia; abdominal pain (though young children are often very ticklish). For adolescents: as for adults (described in earlier chapters of this module).
Examine the musculoskeletal system.	For neonates and infants: joint movements are stable, smooth and without crepitus; full range of motion; normal reflexes (refer to the information later in this chapter). For toddlers and children: as for adults (described in earlier chapters of this module); steady gait; gait may be wide and 'waddle'-like; there should be a direct line between the hips-knees-ankles. For adolescents: as for adults (described in earlier chapters of this module).	Also refer to abnormalities for adults (described in earlier chapters of this module). For neonates and infants: 'clicking' noises during joint rotation; asymmetric back curve, masses; hair tufts; dimples; hypoactive or hyperactive reflexes. For toddlers and children: as for adults (described in earlier chapters of this module); unsteady gait; hip dysplasia (abnormal pelvic tilt when standing). For adolescents: as for adults (described in earlier chapters of this module).
Examine the neurologic system.	For neonates and infants: normal reflexes for age (refer to the information later in this chapter). For toddlers and children: as for adults (described in earlier chapters of this module); child should be bright and alert; child should be interactive and cooperative. For adolescents: as for adults (described in earlier chapters of this module).	Also refer to abnormalities for adults (described in earlier chapters of this module). For neonates and infants: hypoactive or hyperactive reflexes; larger than normal head circumference; lethargy / weakness; irritability; shrill or weak cry; hypotonia or hypertonia; jitteriness; tightly-flexed hands; flexion / extension of the extremities; asymmetric posture, etc. For toddlers and children: as for adults (described in earlier chapters of this module); excessive clumsiness / difficulties with basic motor skills; language disturbances; spasticity; paralysis; seizures, etc. For adolescents: as for adults (described in earlier chapters of this module).

A nurse should only examine a young person's reproductive system if indicated. The nurse should bear in mind the changes to a young person's reproductive system that occur at different stages of puberty. In most situations, examination of the external genitalia is most appropriate. The nurse must ensure that, when examining a young person's reproductive system, they are familiar with the signs of sexual abuse, and that they understand how to respond appropriately to these signs or a child's admission of abuse.

Activity

You are encouraged to read the Royal College of Nursing's (2014) Safeguarding Children and Young People - Every Nurse's Responsibility: RCN Guidance for Nursing Staff document. This document can be obtained online, by searching for its title.

When examining a neonate or infant, the nurse should completely undress the child (but keep the nappy in place until they are ready to examine the buttocks and genitalia). Care should be taken to ensure the child remains warm throughout the examination; not only will a cold child be distressed, but this may also result in the collection of inaccurate data. Invasive procedures (e.g. examining inside the mouth or the ears) should be left until the very end of the examination, as this is likely to result in the child becoming distressed; as described in an earlier chapter of this module, it can be very difficult to accurately assess a child who is distressed.

As noted in the above table, it is important for a nurse to assess the reflexes of a neonate / infant. As described in an earlier chapter of this module, neonates and infants have different reflexes to adults. Read the information in the following table:

Reflex	Technique for Evaluation	Normal Response	Age Reflex Normally Disappears
Moro's	The neonate / infant is startled by a loud noise, or by jarring the surface they are resting on.	Child extends their arms and legs, then pulls their arms and legs in towards their body.	1 to 4 months
Palmar / plantar grasp	An object (e.g. the nurse's finger) is touched against the neonate's / infant's palm or sole.	The child will tightly grasp the object (palmar), or flex their toes downward (plantar).	3 to 4 months (palmar); 8 to 10 months (plantar)
Babinski's reflex	The nurse strokes the lateral surface of the neonate's / infant's sole.	The child fans their toes.	18 months
Step in place	The nurse holds the neonate / infant in an upright position, with their feet flat on a surface.	The child will 'step' forward.	3 months

When examining a toddler or a young child, it is important to encourage the child's cooperation with the examination process. The nurse should explain the procedure to the child, show them the assessment equipment and allow them to touch / use this equipment (e.g. listen to their own heart with a stethoscope, etc.). Involving an adult who the child trusts can also be important in encouraging the child's cooperation with physical examination.

When examining an adolescent, the nurse should follow the same basic process as with an adult (as described in earlier chapters of this module). It is important that a nurse considers the appropriateness of having an adolescent's parent or caregiver present during the physical examination. Wherever possible, young adults should be encouraged to assume responsibility for their own health care, within their capacity to do so.

Observing and assessing pregnant women

There are a number of signs which indicate the presence of pregnancy - including amenorrhoea, breast fullness, nausea / vomiting, urinary frequency, quickening (fetal movement). There are also a number of laboratory tests which are used to determine the presence of pregnancy; the most common of these in the presence of human chorionic gonadotropin (β-hCG), in combination with a positive ultrasound scan. In the United Kingdom, pregnant women are regularly assessed to ensure abnormalities and problems are identified, and can be addressed early; women are assessed for specific health needs and issues at the following gestational time-points:

8 to 12 weeks (booking appointment). 8 to 14 weeks (dating scan). 16 weeks. 18 to 20 weeks (anomaly scan). 25 weeks. 28 weeks.

31 weeks. 34 weeks. 36 weeks. 38 weeks. 40 weeks. 41 weeks (if required).

There are a number of important anatomic and physiologic changes associated with pregnancy, with which a nurse must be familiar in order to perform an accurate assessment:

• Increased oestrogen increases vascularity to the skin, often causing minor itchiness.
• Increased secretion of melanotropin causes pigmentation in the skin (e.g. chloasma, linea nigra, and increased pigmentation to the nipples and areola).
• As the breasts / abdomen increase in size, striae gravidarum (stretch marks) may occur.
• Uterine enlargement creates pressure on the diaphragm, resulting in shortness of breath.
• Respiratory rate and tidal volume may increase; breathing becomes more thoracic.
• Blood volume increases by up to 1.5 Litres, resulting in an increased cardiac workload.
• Increased pelvic pressure may result in varicosities / oedema in the lower extremities.
• Rise in β-hCG may cause nausea and / or vomiting (particularly in the mornings).
• Uterine enlargement displaces the intestines, causing heartburn and constipation.
• Increased pelvic pressure may result in haemorrhoids.
• Increased oestrogen and vascularity may result in swollen, bleeding gums.
• Increased pressure on the bladder results in urinary frequency and nocturia.
• Increased size of the uterus results in lordosis, back discomfort, 'waddling' gait, etc.
• The breasts become full and tender from early pregnancy; nipples / areola enlarge.

Pregnant women - focused health history

When assessing a pregnant woman, the nurse must commence by collecting a health history. This involves collecting data about:

Component	Rationale
Reason for presentation	It is important for nurses to remember that a pregnant woman may not present to a health care service with a specific health issue; rather, they may present for routine check-ups as described earlier in this chapter.
Present health status and past health history	The same data about present health status and past health history collected for adults (as described in a previous chapter of this module) is collected for pregnant. A nurse should focus on collecting information about the medications and supplements a woman is taking, as many of these can interfere with foetal development.
Family history	Information about diseases present in the woman's family members, especially among first-degree relatives, as this can provide important information about the types of disease for which a woman and / or her child may have a congenital risk. The nurse should consider the childbearing history of the woman's mother and sister/s, as well as the presence of chromosome abnormalities, genetic disorders and congenital disorders in the child's family.
Personal and psychosocial history	A nurse asks about the woman's current level of function, their social and family relationships (e.g. their family composition, home environment, socioeconomic status, etc.), their behaviours and health habits (e.g. diet / nutrition, sleep, etc.), and their mental health (as appropriate); this provides important information about a woman's and family's overall wellbeing.
Gynaecologic and obstetric history	The nurse should collect information about the woman's gravidity (number of pregnancies), parity (number of births) and abortions, etc., including key issues and abnormalities associated with each previous pregnancy, labour and delivery.
A review of the woman's body systems	The nurse should review each of the woman's body systems: the integumentary system, the cardiovascular system, the immune / lymphatic system, the endocrine system, the nervous system, the reproductive system, the respiratory system, the musculoskeletal system, the digestive system and the urinary system. The nurse should also review any general or systematic symptoms the woman experiences (e.g. fatigue, pain, etc.).

When collecting a health history from a pregnant woman, a nurse must remember that there are a variety of normal and expected signs and symptoms associated with pregnancy:

• Skin marks, including pigmented lines and varicosities.
• Minor pruritus.
• Enlargement, engorgement and tenderness of the breasts.
• Nipple discharge.
• Bleeding and / or stuffiness of the nose.
• Bleeding and / or swelling of the gums.
• Nausea, vomiting, loss of appetite, food aversions / cravings.
• Heartburn, epigastric pain.
• Constipation, haemorrhoids.
• Changes in hearing, sense of 'fullness' in the ears.
• Dryness of the eyes, minor visual changes.
• Urinary pain, frequency, urgency (must distinguish from a urinary tract infection).
• Vaginal discharge, minor bleeding ('spotting').
• Shortness of breath.
• Palpitations.
• Oedema in the extremities.
• Orthostatic hypotension (dizziness on standing).
• Backache, aching legs / feet.
• Minor headaches.

When collecting a health history from a pregnant woman, a nurse must ensure they identify the factors associated with a high-risk pregnancy, including:

Maternal characteristics:	Maternal habits:
<16 years of >35 years of age. Lacking a supportive relationship. Short stature (under 150cm tall). Weight of <45 kg or >90kg. Low socioeconomic status, poverty. Low level of education.	Alcohol consumption. Use of drugs (illicit or prescription). Smoking. Failure to obtain early prenatal care. High-risk sexual behaviour. Poor diet / poor nutritional status.
Obstetric history:
Previous birth of an infant weighing >2500g or <4500g. Previous pregnancy of a premature infant. Previous pregnancy ending in perinatal death. Previous pregnancy associated with congenital or perinatal disease. Previous pregnancy of a child with isoimmunisation / ABO compatibility. More than 2 previous spontaneous abortions.
Current medical problems:
Chronic illnesses (e.g. diabetes mellitus, thyroid disorder, heart disease, hypertension, pulmonary disease, renal failure, anaemia, etc.). Sexually-transmitted infection/s (STIs). Infectious disease (e.g. rubells, cytomegalovirus, etc.).
Problems with current pregnancy:
Bleeding. Pregnancy-induced hypertension (PIH), pre-eclampsia, eclampsia. Foetal position breech or transverse at term. Polyhydramnios or oligohydramnios. Multiple pregnancy (twins, triplets, etc.). Postmaturity (gestation of >40 weeks). Premature rupture of membranes. Inadequate or excessive weight gain.

Pregnant women - physical examination

Once a health history has been obtained from a pregnant woman, as described in the previous section of this chapter, a nurse may commence a physical examination of the woman. A stepwise process of physically examining a pregnant woman, with normal (expected) and common abnormal findings, is presented in the following table:

Component	Normal (Expected) Findings	Abnormal Findings
Measurement of the vital signs.	As for other adults (described in earlier chapters of this module); HR, RR and BP may all be slightly increased from normal.	As for other adults (described in earlier chapters of this module); excessive shortness of breath / dyspnoea; hypertension, etc.
Measurement of height and weight.	Weight gain of 1.6-2.3kg (first trimester), 5.5-6.8kg (second trimester), 5.5-6.8kg (third trimester).	Inadequate or excessive weight gain; pre-pregnancy body mass index of over 29.
Inspect the hands and nails for colour, surface characteristics, movement and sensation.	As for other adults (described in earlier chapters of this module).	As for other adults (described in earlier chapters of this module); numbness of fingers; carpal tunnel syndrome, etc.
Inspect and palpate the lower extremities for oedema, surface characteristics, redness, tenderness.	As for other adults (described in earlier chapters of this module); some oedema and varicosities of the lower peripheries may be normal.	As for other adults (described in earlier chapters of this module); excessive oedema; redness / tenderness of the lower legs.
Inspect the head and face for skin characteristics, pigmentation and oedema.	As for other adults (described in earlier chapters of this module); chloasma (blotchy, brownish pigmentation of the face) is normal; growth of fine hair on the face is normal.	As for other adults (described in earlier chapters of this module); facial oedema, etc.
Examination of the breasts (if indicated).	Breasts become fuller; may be tender; striae and subcutaneous veins may develop; nipples become darker / flattened; there may be a small amount of discharge from the nipple, etc.	Asymmetry of the breasts (e.g. areas of bulging, retraction); masses; isolated areas of tenderness / pain; thickening of the nipple tissue; loss of skin elasticity; nipple discharge which is foul-smelling, bloody, purulent, etc.
Examine the musculoskeletal system.	As for other adults (described in earlier chapters of this module); some degree of lordosis, kyphosis and slumped shoulders may be normal; 'waddling' gait may be normal.	As for other adults (described in earlier chapters of this module); muscle strain (e.g. chronic back pain), muscle cramps; numbness, etc.
Examination of the neurologic system, and particularly the reflexes (hyperactivity can indicate pre-eclampsia).	As for other adults (described in earlier chapters of this module).	As for other adults (described in earlier chapters of this module); seizures; hyperactive or hypoactive reflexes; numbness, etc.
Examination of the abdomen.	As for other adults (described in earlier chapters of this module); linea nigra, striae gravidarum and obvious veins are all normal findings; from the 20th week the woman should feel foetal movements; from the 28th week of gestation foetal movements may be palpated; fundal height should roughly correlate with gestational age (i.e. 29 weeks gestation = fundal height of 29cm);	As for other adults (described in earlier chapters of this module); absence of foetal movement after the 28th week; fundal height is larger or smaller than expected.
Auscultation of the foetal heart sounds, using a Doppler or ultrasound (if appropriately trained), from 12 weeks gestation.	Foetal heart rate of between 120 and 160 beats per minute.	Foetal heart rate outside the expected range.

Nurses may also be able to determine the foetal lie (i.e. the relationship of the long axis of the foetus to the long axis of the uterus), foetal presentation (i.e. the part of the foetus that enters the pelvis first) and foetal position (the relationship of the presenting part to the maternal pelvis) by palpating the abdomen; however, this is a specialised skill which usually involves additional training.

Observing and assessing older adults

Observing and assessing older adults is fundamentally similar to observing and assessing other adults, as described in detail throughout other chapters of this module. However, there are a number of important anatomic and physiologic changes associated with older adulthood, with which a nurse must be familiar in order to perform an accurate assessment:

• There is a decrease in the activity of sebaceous and sweat glands, resulting in drier skin.
• The skin loses elasticity, collagen and mass, resulting in folding and wrinkling.
• Subcutaneous fat distribution shifts, creating an angular appearance of the bony prominences.
• Decreased melanin production results in grey hair; there may be thinning of the hair.
• Nails become thicker, brittle, hard and yellowish in colour.
• The production of tears is diminished, resulting in dry eyes.
• Colour perception changes as the lens becomes more rigid.
• Conductive and sensorineural hearing losses occur with ageing.
• There may be a decrease in smell and taste.
• There may be an increase in curvature of the cervical spine; height may decrease.
• Decrease in bone mass increases the risk of stress fractures.
• Tendons and muscles decrease in elasticity, tone and strength.
• The compliance of the chest wall / strength of the respiratory muscles may diminish.
• Mucous membranes become drier.
• Gastrointestinal motility may decrease, increasing the risk of constipation.
• Bladder decreases in size and muscle tone, resulting in more frequent urination.
• Heart size tends to decrease, and response to increased oxygen demand is slower.
• Memory, cognition and proprioception may slow.

Older adults - focused health history

When assessing an older adult, the nurse must commence by collecting a health history. This involves collecting data about:

Component	Rationale
Present health status and past health history	The same data about present health status and past health history collected for adults (as described in a previous chapter of this module) is collected for older adults.
Family history	Information about diseases which have caused the death of a person's family members, especially first-degree relatives, can provide a nurse with important information about the diseases for which an older adult is particularly at risk.
Personal and psychosocial history	A nurse asks about the person's current level of function, their social and family relationships (e.g. their family composition, home environment, socioeconomic status, etc.), their behaviours and health habits (e.g. diet / nutrition, sleep, etc.), their functional ability and their mental health (as appropriate); this provides important information about an older adult's overall wellbeing.
A review of the person's body systems	The nurse should review each of the person's body systems: the integumentary system, the cardiovascular system, the immune / lymphatic system, the endocrine system, the nervous system, the reproductive system, the respiratory system, the musculoskeletal system, the digestive system and the urinary system. The nurse should also review any general or systematic symptoms the person experiences (e.g. fatigue, pain, etc.).

Older adults - physical examination

Once a health history has been obtained from an older adult, as described in the previous section of this chapter, a nurse may commence a physical examination of the person. A stepwise process of physically examining an older adult, with normal (expected) and common abnormal findings, is presented in the following table:

Component	Normal (Expected) Findings	Abnormal Findings
Measurement of the vital signs, including height and weight.	As for other adults (described in earlier chapters of this module); T may be slightly lower than in other adults.	As for other adults (described in earlier chapters of this module).
Examination of the skin, hair and nails.	As for other adults (described in earlier chapters of this module); the skin may take on a 'parchment'-like appearance; skin may lose elasticity and hang loosely on the frame; solar lentigo (benign, deeply-pigmented spots) are often normal; hair is often grey, thin and coarse; coarse eyebrow and nasal hair may develop; nails may be thick and brittle.	As for other adults (described in earlier chapters of this module); skin tears; excessively dry skin; 'tenting' of the skin; cool skin; alopecia; nails which split and crack, etc.
Examination of the head, eyes, ears, nose and throat.	As for other adults (described in earlier chapters of this module); eyes often appear sunken; there is a decline in vision; cornea should be transparent and clear; there may be a minor loss of hearing (e.g. difficulty discerning high-pitched sounds); surface of the lips may be wrinkled; the gums may be drier; the teeth may be yellowish / stained, etc.	As for other adults (described in earlier chapters of this module); a stiff neck; ectropion; marked loss of central vision; significant dullness, lack of lustre or spots present in the eyes; significant loss of hearing; bleeding gums; malocclusion of the teeth, etc.
Examination of the respiratory system.	As for other adults (described in earlier chapters of this module); decreased elasticity of the respiratory muscles; shallow breathing.	As for other adults (described in earlier chapters of this module).
Examination of the cardiovascular system.	As for other adults (described in earlier chapters of this module); occasional ectopic beats are often normal.	As for other adults (described in earlier chapters of this module); cool extremities; weak pedal pulses, etc.
Examination of the abdomen and gastrointestinal system.	As for other adults (described in earlier chapters of this module); abdomen is often softer than for other adults; bowel sounds may be hypoactive, etc.	As for other adults (described in earlier chapters of this module).
Examination of the musculoskeletal system.	As for other adults (described in earlier chapters of this module); decreased muscle mass compared with other adults; reduced range of motion of the joints, etc.	As for other adults (described in earlier chapters of this module); atrophied muscles; asymmetric muscles; pain; crepitus; dizziness; limited movement, etc.
Examination of the neurologic system.	As for other adults (described in earlier chapters of this module); slower responses (including for reflexes) and movements are normal.	As for other adults (described in earlier chapters of this module); significantly slowed or absent responses and movements, etc.

Conclusion

In this module so far, you have studied the processes involved in accurately and comprehensively observing and assessing adults. In this chapter, you studied the observation and assessment of special patient groups - including children, pregnant women and older adults. This chapter as provided an overview of the key anatomic and physiologic differences between adults and children, pregnant women and older adults, and how these impact on observation and assessment. It has also described how to collect a focused health history from a child (or their parent / caregiver, as appropriate), a pregnant woman and an older adult. Finally, this chapter explained how to correctly complete a physical examination of a child, a pregnant woman and an older adult, identifying normal and abnormal findings for each group.

This chapter concludes this module. In this module, you have been introduced to the knowledge and skills necessary to observe and assess a variety of patients in a range of different clinical settings. You have seen that health observation and assessment is a systematic process undertaken to collect data about a patient, which provides information about the patient's condition and is used to inform the care which is appropriate for that patient and to evaluate the effectiveness of that care. You have studied in detail the processes involved in obtaining a health history from a patient, and measuring and recording the patient's vital signs. You have also studied the focused assessment of each of the major body systems - including the cardiovascular, respiratory, neurological, genitourinary, gastrointestinal, musculoskeletal and integumentary systems. You also learned how to undertake targeted observation and assessment of problems affecting more than one body system - including pain, mental health and nutrition. Finally, you studied the observation and assessment of special population groups - children, pregnant women and older adults. In completing this module, you have equipped yourself with the knowledge and skills necessary to observe and assess a variety of patients in a range of different clinical settings - a fundamental nursing role.

Reference list

Cox, C. (2009). Physical Assessment for Nurses (2nd edn.). West Sussex, UK: Blackwell Publishing, Ltd.

Jensen, S. (2014). Nursing Health Assessment: A Best Practice Approach. London, UK: Wolters Kluwer Publishing.

Wilson, S.F. & Giddens, J.F. (2005). Health Assessment for Nursing Practice (4th edn.). St Louis, MI: Mosby Elsevier.

Example essay

A parents presents their six-year-old child to an after-hours clinic with an acute onset of asthma. The child is very distressed, and is clearly frightened by the clinical environment. Describe the techniques a nurse may use to observe and assess, and provide general emergency care to, this child.

In the United Kingdom (UK), there is a focus on the provision of child-centred care - that is, care in which the child is an active partner, and where care "is integrated and co-ordinated around [the child's] particular needs and the needs of their family" (Department of Health, 2003: p. 13). Nurses play a fundamental role in the provision of child-centred care, including by utilising appropriate observation and assessment techniques to collect accurate and comprehensive data and inform effective care (Wilson & Giddens, 2005). This essay describes a variety of techniques a nurse may use to effectively observe and assess a six-year-old child who presents, distressed and frightened, to an acute care setting with an exacerbation of asthma.

At the age of six years, the child in this case study is entering middle childhood and is probably at a transitional phase in their development. The child is likely to be in a period of development defined broadly by exploration for purpose, mastery of competency and the need for praise (Seifert et al., 2000). The child is developing autonomy, and is focused on exploring their environment (Seifert et al., 2000). The child will also be striving for mastery of competency, and will seek praise and recognition for their achievements (Seifert et al., 2000).

Prior to commencing observation and assessment, the attending nurse must permit the child appropriate freedom to investigate their surroundings, allowing the child to become more familiar and comfortable with their situation; this is fundamental in facilitating the child's comfort and facilitate their cooperation in with observation and assessment (Wilson & Giddens, 2005). To promote a child's cooperation, Wilson and Giddens (2005) suggest a nurse should show the child the assessment equipment to be used and allow the child to practice using this equipment themselves (e.g. on a doll or teddy bear). Incorporating play into the assessment of a child of the age of the child in this case study is also important; for example, during spirometry - a technique to assess lung function in a person with asthma - the child may be asked to imagine themselves "blowing out a BIG candle!" (Wilson & Giddens, 2005; Lodrup Carlsen et al., 2011) The involvement in the observation and assessment process of an adult the child trusts can also be useful in encouraging their cooperation and participation in games related to the assessment process (Wilson & Giddens, 2005).

To promote a child's comfort and facilitate their cooperation in with observation and assessment, it is also important that a nurse provides the child with information about the procedures to be used. Research suggests that providing a child with information about assessment procedures can significantly reduce their distress associated with these procedures (Tak & van Bon, 2006; Hughes, 2016). This is particularly true for children below the age of six years (Hughes, 2016), such as the child in this case study, who research suggests - contrary to widespread belief among health care providers - are able to understand relatively complex medical concepts (Myant & Williams, 2005; Alderson et al., 2006). The information a nurse provides to a child should be individualised, and account for their unique cognitive abilities and previous experience (Kilk et al., 2000; Tak & van Bon, 2006). Children who are anxious should receive only basic information, whilst children who are curious can receive more detailed information (Karlsson et al., 2014).

In developing and maintaining the therapeutic relationship, it is particularly important that the nurse provides the child with information about potentially-distressing assessment procedures. For example, it is likely that the child in this scenario will require venepuncture, initially for blood testing during the physical examination and subsequently for the administration of intravenous fluid and / or medication. Because of the pain involved in this procedure, venepuncture can be one of the most distressing procedures performed on a child in an acute care setting (Gilboy & Hollywood, 2009). Research suggests that providing a child with information about (1) the anaesthetic cream used to reduce pain at the venepuncture site, and (2) the venepuncture procedure itself, including the occurrence of a 'sting' and visible blood, can significantly reduce the distress of a child (Tak & van Bon, 2006; Hughes, 2016).

Research suggests that speaking with a child in an acute care setting - including making 'small talk' - can be both reassuring and distracting (Karlsson et al., 2014). It can be particularly important technique in calming a young child who is screaming and crying during assessment; screaming and crying can result in a reduction of pressure in the trachea and the subsequent collapse of the airway (Johnson, 2007) - problematic for the child in this case study considering their serious underlying respiratory condition. In addition to providing the child in this case with explanation and reassurance, therefore, the nurse should also consider engaging them in 'small talk' (e.g. about their family, their school, their favourite things, etc.).

If the child in this case study is very dyspnoeic, the nurse should focus on collecting only the observation and assessment data which is required for their immediate care; the treatment of their dyspnoea should then commence, before the assessment and observation process continues. The British Guideline on the Management of Asthma (British Thoracic Society, 2016) recommends that children presenting with acute asthma receive immediate supplemental oxygen, a high-dose inhaled β₂ agonist and inhaled corticosteroids. As stated by Lawlor (2015: p. 327), "the choice of inhaler device [for children with asthma] should not be underestimated, as poor inhaler technique is a primary cause of poor asthma control" in this age group. Devices called spacers can be used to increase the entry of corticosteroid medication into a young child's lungs, and therefore helping to keep the dose of corticosteroids needed at a minimum (Lawlor, 2015). Research suggests that equipment used in the management of a child with asthma should be "safe and friendly" (Wallinger & Hucker, 2012: p. 26); for example, spacers may be made of coloured plastic or decorated with stickers, etc.

Chong et al. (2009) state that allowing an early school-aged child personal accountability in asthma symptom management will result in that child assuming greater responsibility for appropriate self-intervention. Teaching a child to use the equipment involved in the administration of asthma medication is important in promoting their accountability (Lawlor, 2015). The nurse might allow the child to try the face mask on themselves, for instance, or show the child the basic functions and features of the mask. Chong et al. (2009) also note that many children dislike the potent smell and taste of asthma medicine, and that they will often refuse treatment for this reason. The nurse may offer sips of juice to help the child take the medication, or distract the child from the smell by playing a television program or speaking with them, etc. The nurse may create a make-believe game to encourage the child to wear the mask (for instance, pretending to be astronauts or deep-sea divers), or demonstrate the use of the face mask to the child. The nurse must be aware of the importance of recognizing and approving the child's positive behaviour (e.g. in relation to the correct use of the mask), however minor, in order to avoid the child to becoming frustrated and disinterested in the process; this is a theory of learning referred to as operant conditioning, or reinforcement (Seifert et al., 2000).

Johnson (2007) states that children of the age of the child in this case study, who are experiencing a health crisis, need to be provided with a degree of control, rather than having control taken from them by nurses. During observation and assessment, the nurse must take care to listen to the child's own self-expression of their symptoms, as this may provide useful information to inform effective care. Research suggests that listening honestly to a child's views and preferences, and providing care in a manner consistent to these to the greatest extent possible, is crucial to the provision of child-centred care in acute care settings (Runeson et al., 2002). Providing a child with alternatives (e.g. "Would you like me to use a red stethoscope or a blue stethoscope to listen to your lungs?") can also help to facilitate a sense of control (Runeson et al., 2002).

As demonstrated throughout this essay, nurses play a crucial role in the provision of child-centred care, including by utilising appropriate observation and assessment techniques (Wilson & Giddens, 2005). This essay has described the techniques a nurse may use to observe and assess a six-year-old child who presents, distressed and frightened, to an acute care setting with an exacerbation of asthma. This essay demonstrates that the use of key techniques - including the development of a therapeutic relationship between the child and the nurse, the provision of explanation and reassurance, the promotion of control, and the involvement of the child in the assessment process through exploration and play - can facilitate the collection of accurate and comprehensive assessment data and inform effective care. These are important findings this author can use in their own future practice in paediatric acute care settings.

References

Alderson, P., Sutcliffe, K. & Curtis, K. (2006). Children as partners with adults in their medical care. Archives of Disease in Childhood, 91(4), 300-303.

British Thoracic Society. (2016). British Guideline on the Management of Asthma. Retrieved from: https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2016/

Department of Health. (2003). Getting the Right Start: National Service Framework for Children. Retrieved from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/199953/Getting_the_right_start_-_National_Service_Framework_for_Children_Standard_for_Hospital_Services.pdf

Gilboy, S. & Hollywood, E. (2009). Helping to alleviate pain for children having venepuncture. Paediatric Nursing, 21(8), 14-19.

Hughes, T. (2012). Providing information to children before and during venepuncture. Nursing Children and Young People, 24(5), 23-28.

Johnson, T.D. (2007). Respiratory assessment in child and adolescent residential treatment settings: Reducing restraint-associated risks. Journal of Child and Adolescent Psychiatric Nursing, 20(3), 176-183.

Karlsson, K., Rydstrom, I., Enskar, K. & Dalheim Englund, A.C. (2014). Nurses' perspectives on supporting children during needle-related medical procedures. International Journal of Qualitative Studies in Health and Wellbeing, 9(1), doi: 10.3402/qhw.v9.23063

Kolk, A.M., van Hoof, R. & Fiedeldij Dop, M.J. (2000). Preparing children for venepuncture: The effect of an integrated intervention on distress before and during venepuncture. Child Care Health and Development, 26(3), 251-260.

Lawlor, R. (2015). Management of asthma in children. Practice Nursing, 26(7), 326-330.

Ledrup Carlsen, K.C., Hedin, G, Bush, A, Wennergren, G. de Benedictis, F.M., de Jongste, J.C., Baraldi, E., Pedroletti, C., Barbato, A., Malstrom, K, Pohunek, P., Pedersen, S., Placentini, G.L., Middleveld, R.J.M. & Carlsen, K.H. (2011). Assessment of problematic severe asthma in children. European Respiratory Journal, 37(1), 432-440.

Myrant, K.A. & Williams, J.M. (2004). Children's concepts of health and illness: Understanding of contagious illnesses, non-contagious illnesses and injuries. Journal of Health Psychology, 10(6), 805-819.

Runeson, I., Hallstrom, I., Elander, G. & Hermeren, G. (2002). Children's participation in decision-making processes during hospitalisation: An observational study. Nursing Ethics, 9(6), 583-598.

Seifert, K. L., Hoffnung, R. J. & Hoffnung M. (2000). Lifespan Development (2nd edn.). Boston: Houghton Mifflin Company.

Tak, J.H. & van Bon, W.H. (2006). Pain- and distress-reducing interventions for venepuncture in children. Child Care, Health and Development, 32(3), 257-268.

Wallinger, C. & Hucker, J. (2012). Caring for a child with asthma: Pre-registration education. Nursing Children and Young People, 24(3), 26-28.