Observing and Assessing Children, Pregnant Women and Older Adults

Learning objectives for this chapter

By the end of this chapter, we would like you:

-To describe the key anatomic and physiologic differences between adults and children, pregnant women and older adults, and how these impact on observation and assessment.

-To explain how to collect a focused health history from a child, a pregnant woman and an older adult.

-To explain 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. 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.

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

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

• Biographic data
• Reason for presentation
• Present health status and past health history
• Family history
• Personal and psychosocial history
• A review of the young person’s body systems

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.

Observation and assessment of children – physical examination

A nurse may commence a physical examination:

• Measure the vital signs, including height and weight.
• For neonates and infants, measurement of head circumference.
• Examination of the skin, hair and nails.
• Examination of the head, eyes, ears, nose and throat.
• Examination of the respiratory system.
• Examine the abdomen and the gastrointestinal system.
• Examine the musculoskeletal system.
• Examine the neurologic system.

When examining a neonate or infant, the nurse should completely undress the child. 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 should be left until the very end of the examination, as this is likely to result in the child becoming distressed.

It is important for a nurse to assess the reflexes of a neonate / infant. 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 is touched against the neonate’s / infant’s palm or sole.	The child will tightly grasp the object, or flex their toes downward.	3 to 4 months; 8 to 10 months
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. Involving an adult who the child trusts can also be important in encouraging the child’s cooperation with physical examination.

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. There are also a number of laboratory tests which are used to determine the presence of pregnancy. 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.
• As the breasts / abdomen increase in size, striae gravidarum 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.
• 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:

• Reason for presentation
• Present health status and past health history
• Family history
• Personal and psychosocial history
• Gynaecologic and obstetric history
• A review of the woman’s body systems

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.
• Vaginal discharge, minor bleeding.
• Shortness of breath.
• Palpitations.
• Oedema in the extremities.
• Orthostatic hypotension.
• 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. 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. Sexually-transmitted infection/s (STIs). Infectious disease.
Problems with current pregnancy:
Bleeding. Pregnancy-induced hypertension (PIH), pre-eclampsia, eclampsia. Foetal position breech or transverse at term. Polyhydramnios or oligohydramnios. Multiple pregnancy. Postmaturity. Premature rupture of membranes. Inadequate or excessive weight gain.

Pregnant women – physical examination

A nurse may then commence a physical examination of the woman:

• Measurement of the vital signs.
• Measurement of height and weight.
• Inspect the hands and nails for colour, surface characteristics, movement and sensation.
• Inspect and palpate the lower extremities for oedema, surface characteristics, redness, tenderness.
• Inspect the head and face for skin characteristics, pigmentation and oedema.
• Examination of the breasts (if indicated).
• Examine the musculoskeletal system.
• Examination of the neurologic system, and particularly the reflexes.
• Examination of the abdomen.
• Auscultation of the foetal heart sounds, using a Doppler or ultrasound, from 12 weeks gestation.

Nurses may also be able to determine the foetal lie, foetal presentation and foetal position by palpating the abdomen.

Observing and assessing older adults

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:

• Present health status and past health history.
• Family history.
• Personal and psychosocial history.
• A review of the person’s body systems.

Older adults – physical examination

A nurse may commence a physical examination of the person:

• Measurement of the vital signs, including height and weight.
• Examination of the skin, hair and nails.
• Examination of the head, eyes, ears, nose and throat.
• Examination of the respiratory system.
• Examination of the cardiovascular system.
• Examination of the abdomen and gastrointestinal system.
• Examination of the musculoskeletal system.
• Examination of the neurologic system.

Conclusion

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.