Obtaining an accurate and complete history is essential in the overall assessment and diagnosis of pediatric respiratory disorders. Before begin- ning the history portion of the visit, it is important that the nurse properly introduce himself/herself to the child and family. Building rapport with the child and family will allow the nurse to glean quality, pertinent infor- mation regarding the reason for the visit. Health history questions should be organized so that all components are addressed. Additionally, questions should be age specific and open-ended, thereby allowing the child and the family the ability to share their concerns and to explain completely the reason for the visit.
In addition to a list of current allergies and medications, the respiratory health history includes the chief complaint, history of the present illness, past medical history (including birth history), review of systems, family history, social history, and environmental history. The chief complaint should be in the child’s/parents’ own words. The history of the present illness is an investigation of the current symptoms. It should include when the symptoms first appeared, the frequency of the symptoms, duration of symptoms, the quality of the symptoms (i.e., sharp or stabbing), onset of symptoms (sudden or gradual), when symptoms occur (i.e., at rest or with activity), where symptoms occur (i.e., at home or in school), aggravating and alleviating factors, therapies attempted (including alternative thera- pies), and response to therapies (Lippincott, 2007). Common respiratory symptoms include coughing, wheezing, shortness of breath, chest pain, chest tightness, sputum production, and hemoptysis (coughing up blood).
A thorough evaluation of the symptoms is necessary. The following pres- ents a list of questions that can be utilized to characterize common respira- tory symptoms.
40 Nursing Care in Pediatric Respiratory Disease
Cough
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When does the cough occur? Does the cough occur both day and night?•
Does the cough occur with activity? What type of activity does it occur with? Does the cough stop with rest?•
Does the cough limit his/her activity? If yes, in what way?•
Does the cough keep the child up at night/wake the child? How often does this occur?•
Does the cough sound wet or dry?•
Describe the cough. What does it sound like? Is it hacking, barking, or whooping?•
Is there a recent history of choking?•
Is the cough productive of mucus? If yes, does it occur daily? How much mucus is produced? What color is it?•
Do any other symptoms occur with the cough? If yes, what symptoms occur?Wheeze
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When does the wheeze occur? Does the wheeze occur both day and night?•
Describe the wheeze. What does it sound like?•
Does the wheeze occur when the child breathes in or breathes out?•
Does the child wheeze after meals? If yes, does he/she gag or choke during meals?•
Does the child wheeze with activity? What type of activity does it occur with? Does the wheeze stop with rest?•
Does the wheeze limit his/her activity? If yes, in what way?•
Does the child wake up wheezing? How often?•
(If the child is old enough) Point to where you hear/feel the wheezing.•
Do any other symptoms occur with the wheeze? If yes, what symptoms occur?Shortness of breath
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When does the shortness of breath occur? Does the shortness of breath occur both day and night?•
Does the shortness of breath occur at rest?•
Does the shortness of breath occur with activity? What type of activity does it occur with? Does the shortness of breath stop with rest? Is the shortness of breath out of proportion with the other children he/she is playing with?•
Does the shortness of breath limit his/her activity? If yes, in what way?•
(If the child is old enough) Is it difficult to get the air in, out, or both?Pediatric respiratory health history and physical assessment 41
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Do any other symptoms occur with the shortness of breath? If yes, what symptoms occur?Chest pain
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When does the chest pain occur?•
Does it occur when the child takes a breath in, at rest, or with activity?What type of activity does it occur with? Does the chest pain stop with rest?
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Describe the pain.•
Did the child sustain any injuries to the chest?•
Has the child had a fever?•
Do any other symptoms occur with the chest pain? If yes, what symp- toms occur?Chest tightness
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When does the chest tightness occur?•
Does it occur at rest or with activity? What type of activity does it occur with? Does the chest tightness stop with rest?•
Point to where you (the child) feel the tightness.•
Do any other symptoms occur with the tightness? If yes, what symp- toms occur?Sputum production
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How often is mucus produced?•
How much mucus is produced (use measurements child/parents can understand, such as teaspoon, tablespoon, or cup)?•
What color is the mucus?Hemoptysis
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What color was it (i.e., pink, red, or brown)?•
How much bleeding occurred (use measurements child/parents can understand, such as teaspoon, tablespoon, or cup)?•
Is this the first time it happened? If no, how often has it occurred?•
Has the child traveled outside of the country or been exposed to foreign travelers?The child’s birth history can be useful in determining the reason for the current symptoms. It is important to ascertain whether the child was born full term or preterm and if there were any respiratory complications after birth. If born preterm, ask what the child’s gestational age was at birth.
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Airway hyperresponsiveness has been demonstrated in both children who were born premature and those who had been diagnosed with broncho- pulmonary dysplasia (Bhandari & Panitch, 2006).
The nurse must establish if the child required supplemental oxygen or mechanical ventilation during the newborn period. If supplemental oxygen and mechanical ventilation were utilized, the nurse must determine the duration of therapy and whether the child was discharged home on these therapies or medications. A history of airway problems, stridor, or diffi- culty tolerating extubation is also helpful.
When obtaining a past medical history, the nurse must ask about any previous respiratory-related illnesses, such as bronchopulmonary dyspla- sia, foreign body aspiration, respiratory syncytial virus, chronic sinusitis, or asthma. Non-respiratory-related illnesses should also be uncovered as they may have an impact on the respiratory system (e.g., gastroesphageal reflux may present with coughing, and frequent episodes of otitis media may be due to immotile cilia). Any previous emergency department visits or hospitalizations should be documented. Finally, it is important to note the child’s immunization history to determine if immunizations are up-to-date.
A head-to-toe review of systems should also be conducted. The nurse should ask about headaches, nasal congestion, rhinorrhea, postnasal drip, snoring, reflux, and eczema. Positive pertinent findings can have an impact on the current diagnosis.
It is often difficult to obtain an accurate environmental, social, or family history because of the sensitive nature of certain questions. However, these areas are vital components of the respiratory health history and should be investigated.
Important environmental factors include age of dwelling, location of dwelling, type of heating and cooling used, as well as the presence of carpets, pets, smokers, cockroaches, mice, or mold. Social history should include the number of occupants in the home, whether the child attends day care or school, the number of missed daycare/school days due to respiratory symptoms, whether the child smokes, and the type of activities the child participates in. When obtaining a family history, the nurse should go back two generations and determine if there is a family history of any respiratory-related illnesses such as asthma, bronchiectasis, cystic fibrosis, or chronic obstructive lung disease. The nurse should also ask about aller- gies, eczema, heart disease, and obstructive sleep apnea.
In addition to obtaining information from the child and parents, the health history component of the assessment is a prime opportunity to offer age-appropriate anticipatory guidance. During the infant and toddler years, it is important to remind parents to keep children away from sick contacts, large crowds, and small objects. The nurse should also discuss the dangers associated with smoking with school-age and adolescent chil- dren. Furthermore, parents should be reminded of the importance of annual influenza vaccinations.
Pediatric respiratory health history and physical assessment 43