This assignment is to give you experience in conducting a comprehensive health history and writing your findings in a document that is organized and easy to read. It will also evaluate your learning in class.
A comprehensive health history is conducted by the school nurse for a child who is being evaluated for an initial IEP, 504 or for a child in the school district with a health condition that will need an IHP. It is important to have this information for yourself and for the school staff to guide your care of this child.
For this assignment:
1. Identify a child, who has either a physical or developmental disability and is between the ages 3-18.
2. Make an appointment with the parent and child to sit down in a quiet place where you will not be interrupted.
3. If you already know the child has specific health problems, you may want to spend a little time looking in the text under that system for questions you should ask in the history (i.e. if the child has vision or eye problems, see Assessment of the Eyes, p.306)
4. Conduct the interview.
5. Remember to tailor your history/write up to be specific to the age of the child. 6. Write up your health history labeling each required section (see below). Part of your
grade will be on the organization and presentation (i.e. easy for school staff to read and understand).
Health History Write-Up Guidelines (see Chiocca, chapter 6 and p. 105 for additional
explanation).
Biographical Data: Use initials and faux address etc. Do not include any real names or other identifying information.
Source of Information: Who is giving the information? Is the source of information reliable?
Reason for IEP/IHP/Seeking Care (also referred to as chief complaint, state in child/parent's own words): This may be:
• the reason/diagnosis for which you are writing an IHP,
• the reason/diagnosis for which the student is being evaluated for an IEP, or • the reason the child has come to the clinic.
History of Present Illness: Give a complete history of Reason for IEP/IHP/Seeking Care (-i.e. diabetes, seizure disorder, ADHD etc.)
Past Medical History: (include all components listed in Past Medical History in table on p. 105 in Chiocca)
o Tailor this section to the age of the child. For example with a four month old you will need much more detail regarding the pregnancy history than with a 17 year old.
o Include the date of the last PE.
o Immunizations: List all IZs and dates, note source of information (don't just state "up-to- date").
o Include Family medical history. Focus on any positive family history. Write the details of any positive history. INCLUDE a family health history genogram, see page 86 in text. (You may scan and fax this part to me if necessary).
Review of Systems (ROS)
The review of systems is done to establish past and present health state of each body system. Include all systems listed in table in Chiocca on p. 105. You MUST demonstrate what you asked as part of the ROS by writing negative responses to your questions as well as positive responses. Make this pertinent to the age of the child. This is subjective information only. (Note: This is not where physical exam belongs.)
Example: For a 5 year-old: History of croup x1 at 18 months of age resolved with palliative care.
Denies history of epiglottitis, pharyngitis, tonsillitis, peritonsilar abscess, foreign body aspiration, asthma, shortness of breath, chronic cough, laryngomalacia, cystic fibrosis, pneumonia, bronchiolitis, TB etc. In the “real” world you would only note positive responses
and significant negative findings that pertain to your assessment, but for this assignment, you will need to write down all the negative responses.
In applicable sections of the ROS describe the Health Promotion activities (if any) and /or self- care that the family/child is currently utilizing. This is not the place to list things they should be doing. In the case of a child with a developmental disability note any special adaptation for
health promotion.)
For example: In the ROS for skin, your write up might look like this.
Skin: Denies history of rash, lesions or injury to skin, etc. (include all negatives and positive findings that you asked about)
Health Promotion- currently uses skin screen when his mom makes him, would prefer to get a dark tan to be cool. Is worried about getting acne, using a Stridex pad on his face, but hasn't told his mom about his worry (only put HP comments as applicable-will not include in every system, remember these are what the child is currently doing, not what you would educate them to do).
Note that Health Promotion for each section of the ROS should be indented as in this model.
Physical Activity: Notes amount of physical and sedentary activities.
Elimination Patterns: Assessment of stool and urination patterns according to age.
Safety: Assesses the safety of the child's environment and identifies teaching needs. Include any global health promotion activities related to the age of the child such as car seat use, smoke detectors, home safety.
Sleep Patterns: Hours of sleep per night, naps, or sleep problems.
Social History: Varies according to child's age; includes assessment of family situation, child's behavior and temperament. How does the parent/caretaker feel about their role? How are things going in the family? Include school history: Note school functioning, i.e. attendance, academic performance, peer/adult relationships at school, extra curriculum activities, note any grade retention. Add questions from Dr. Byrd's article as indicated. Note if there is a special education
setting and IEP. If so, note the date of the latest IEP and the qualifying diagnosis for special education.
Sexual History: Body image, dating patterns, sexual activity, use of contraception, knowledge of sage sex, and screening for sexually transmitted infections.
Growth and Development: Assessment of physical and psychosocial developmental milestones.
• Includes significant developmental landmarks and note any variations. May include results of a developmental screening tools/assessments.
• Again, tailor this section to the client. For example, it is not important to note when a typically developing 17 year old starting sitting.
• This part of the history will require significant detail for the child who has a
developmental disability. In addition to the Bright Futures information, here is a useful link to the National Center on Birth Defects and Developmental Delays that may assist you with your assessment.
• NC Developmental Delays
I encourage you to use the HEADSS format if you are taking a history on an adolescent (you can find HEADSS in the Dixon text for NURS 526 (p. 551).
Spiritual History: Assessemtn of family's religious or spiritual beliefs and how they affect health and illness.
Anticipatory Guidance
• Include at least three key areas of anticipatory guidance that should be included for
THIS child or adolescent based on your health history and explain WHY (what did you
learn while taking the history that indicates a need for this anticipatory guidance.) • Briefly describe what information/resources you would give for each of the 3 areas.
• The Bright Futures text will be invaluable to you regarding anticipatory guidance. Remember to think about unintentional injury (UI). UI is the leading cause of death for children and youth in the US.