Family, Social, Cultural, and Religious Influences on Child Health Promotion

Family, Social, Cultural, and Religious Influences on Child Health Promotion 150 150 Tony Guo

Family, Social, Cultural, and Religious Influences on Child Health Promotion

  • Family Systems Theory
    • A change in any part of a family system affects all other parts of the family
  • Family Stress Theory
    • Stress is an inevitable part of family life and any event can be stressful on the family
  • Developmental Theory 
    • Families develop and change over time in similar and consistent ways


Assumptions Strengths Limitations Applications
Family Systems Theory
  • A change in any one part of a family system affects all other parts of the family system (circular causality).
  • Family systems are characterized by periods of rapid growth and change and periods of relative stability.
  • Both too little change and too much change are dysfunctional for the family system; therefore, a balance between morphogenesis (change) and morphostasis (no change) is necessary.
  • Family systems can initiate change, as well as react to it.
  • Applicable for family in normal everyday life, as well as for family dysfunction and pathology.
  • Useful for families of varying structure and various stages of life cycle.
  • More difficult to determine cause-and-effect relationships because of circular causality.
  • Mate selection, courtship processes, family communication, boundary maintenance, power and control within family, parent-child relationships, adolescent pregnancy, and parenthood.
Family Stress Theory
  • Stress is an inevitable part of family life, and any event, even if positive, can be stressful for the family.
  • Family encounters both normative expected stressors and unexpected situational stressors over life cycle.
  • Stress has a cumulative effect on family.
  • Families cope with and respond to stressors with a wide range of responses and effectiveness.
  • Potential to explain and predict family behavior in response to stressors and to develop effective interventions to promote family adaptation.
  • Focuses on positive contribution of resources, coping, and social support to adaptive outcomes.
  • Can be used by many disciplines in health field.
  • Relationships between all variables in framework not yet adequately described. Not yet known if certain combinations of resources and coping strategies are applicable to all stressful events.
  • Transition to parenthood and other normative transitions, single-parent families, families experiencing work-related stressors (dual-earner family, unemployment), acute or chronic childhood illness or disability, infertility, death of a child, divorce, and adolescent pregnancy and parenthood.
Developmental Theory
  • Families develop and change over time in similar and consistent ways.
  • Family and its members must perform certain time-specific tasks set by themselves and by people in the broader society.
  • Family role performance at one stage of family life cycle influences family’s behavioral options at next stage.
  • Family tends to be in stage of disequilibrium when entering a new life cycle stage and strives toward homeostasis within stages.
  • Provides a dynamic, rather than static, view of family.
  • Addresses both changes within family and changes in family as a social system over its life history.
  • Anticipates potential stressors that normally accompany transitions to various stages and when problems may peak because of lack of resources.
  • Traditional model more easily applied to two-parent families with children. 
  • Use of age of oldest child and marital duration as marker of stage transition sometimes problematic (e.g., in stepfamilies, single-parent families).
  • Anticipatory guidance, educational strategies, and developing or strengthening family resources for management of transition to parenthood; family adjustment to children entering school, becoming adolescents, leaving home; management of “empty nest” years and retirement.



Family roles

  • All family members have designated roles within the family unit
  • Many cultural & societal influences on family roles— however, this is slowly changing


Family stress theory

  • Families encounter stressors (events that cause stress and have the potential to effect a change in the family social system), including 
    • Predictable (e.g., parenthood)
    • Unpredictable (e.g., illness, unemployment)
  • They are cumulative, involving simultaneous demands from work, family, and community life.

Developmental theory

  • An outgrowth of several theories of development.
    • Duvall’s Developmental stages of the Family
      • Stage I: Marriage and an Independent Home: The Joining of Families
        • Re-establish couple identity.
        • Realign relationships with extended family.
        • Make decisions regarding parenthood.
      • Stage II: Families with Infants
        • Integrate infants into the family unit.
        • Accommodate to new parenting and grand-parenting roles.
        • Maintain marital bond.
      • Stage III: Families with Preschoolers
        • Socialize children.
        • Parents and children adjust to separation.
      • Stage IV: Families with Schoolchildren
        • Children develop peer relations.
        • Parents adjust to their children’s peer and school influences.
      • Stage V: Families with Teenagers
        • Adolescents develop increasing autonomy.
        • Parents refocus on midlife marital and career issues.
        • Parents begin a shift toward concern for the older generation.
      • Stage VI: Families as Launching Centers
        • Parents and young adults establish independent identities.
        • Parents renegotiate marital relationship.
      • Stage VII: Middle-Aged Families
        • Reinvest in couple identity with concurrent development of independent interests.
        • Realign relationships to include in-laws and grandchildren.
        • Deal with disabilities and death of older generation
      • Stage VIII: Aging Families
        • Shift from work role to leisure and semiretirement or full retirement.
        • Maintain couple and individual functioning while adapting to the aging process.
        • Prepare for own death and dealing with the loss of spouse and/or siblings and other peers.


Family Structure and Function

  • A family’s structure affects the direction of nursing care
    • Traditional Nuclear family
      • Married couple and their biological children
      • Children live with both biological parents
      • No other people live in the household
    • Nuclear family
      • Two parents and their children
      • Children can be biological, step, adoptive, or foster
      • Parents are not necessarily married
    • Blended family
      • Reconstituted family
        • Includes at least one stepparent, stepsibling, or half-sibling.
    • Extended family
      • Includes at one parent, one or more children, and one or more members (related or unrelated) other than a parent or sibling
      • They follow the rules of nuclear family but also include other members
      • The grandparents often find themselves rearing their grandchildren.
      • The older relatives often hold the authority and makes decisions in consultation with the younger parents
    • Single-Parent family
      • Estimated 24.6 million children live in single-parent family in the US
      • They emerged partially because of the women’s rights movement 
      • Also, because of more women (and men) establishing separate households because of divorce, death, desertion, or single parenthood.
      • With women’s increased psychologic and financial independence and the increased acceptability of single parents in society, more unmarried women are deliberately choosing mother-child families. 
      • Frequently, these mothers and children are absorbed into the extended family.
    • Binuclear family
      • Parents continuing the parenting role while terminating the spousal unit
      • The degree of cooperation between households and the time the child spends with each can vary
        • Joint custody
        • Co-parenting
    • Polygamous family
      • Either multiple wives (polygyny) or, rarely, husbands (polyandry).
    • Communal family
      • Relatively uncommon today, communal groups share common ownership of property. 
      • In cooperatives, property ownership is private, but certain goods and services are shared and exchanged without monetary consideration. 
      • There is strong reliance on group members and material interdependence. Both provide collective security for nonproductive members, share homemaking and childrearing functions, and help overcome the problem of interpersonal isolation or loneliness.
    • LGBTQI (Lesbian, Gay. Transgender, Queer, Questioning, and Intersex) Family
      • A same-sex, homosexual, or LGBTQI family is one in which there is a legal or common-law tie between two people of the same sex who have children
  • Qualities of Strong Families
    • A belief and sense of commitment toward promoting the well-being and growth of individual family members, as well as the family unit
    • Appreciation for the small and large things that individual family members do well and encouragement to do better
    • Concentrated effort to spend time and do things together, no matter how formal or informal the activity or event
    • A sense of purpose that permeates the reasons and basis for “going on” in both bad and good times
    • A sense of congruence among family members regarding the value and importance of assigning time and energy to meet needs
    • The ability to communicate with one another in a way that emphasizes positive interactions
    • A clear set of family rules, values, and beliefs that establishes expectations about acceptable and desired behavior
    • A varied repertoire of coping strategies that promote positive functioning in dealing with both normative and nonnormative life events
    • The ability to engage in problem-solving activities designed to evaluate options for meeting needs and procuring resources
    • The ability to be positive and see the positive in almost all aspects of their lives, including the ability to see crisis and problems as an opportunity to learn and grow
    • Flexibility and adaptability in the roles necessary to procure resources to meet needs
    • A balance between the use of internal and external family resources for coping and adapting to life events and planning for the future


Types of discipline

  • During reprimanding children,
    • Focus only on the misbehavior, not on the child
    • The use of “I” messages rather than “you” messages express personal feelings without accusation or ridicule
      • “I” message attacks the behavior (“I am upset when Johnny is punched; I don’t like to see him hurt”) not the child.
    • Positive and negative reinforcement is the basis of behavior modification theory
      • Behaviors that are rewarded will be repeated
      • Behaviors that are not rewarded will be extinguished
    • Consistently ignoring behavior will eventually extinguish or minimize the act, although sometimes parents frequently “give in” and resort to previous patterns of discipline.
    • Consequently, the behavior is reinforced because the child learns that persistence gains parental attention. For ignoring to be effective, parents should
      • Understand the process
      • Record the undesired behavior before using ignoring to determine whether a problem exists and to compare results after ignoring is begun
      • Determine whether parental attention acts as a reinforcer
      • Be aware of “response burst”
        • This is the phenomenon that occurs when the undesired behavior increases after ignoring is initiated because the child is “testing” the parents to see if they are serious about the plan.
    • The strategy of consequences involves allowing children to experience the results of their misbehavior. It includes the following three types:
      • Natural: 
        • Those that occur without any intervention, such as being late and having to clean up the dinner table
      • Logical: 
        • Those that are directly related to the rule, such as not being allowed to play with another toy until the used ones are put away
      • Unrelated: 
        • Those that are imposed deliberately, such as no playing until homework is completed or the use of time-out
  • Using Time-Out
    • Select an area for time-out that is safe, convenient, and unstimulating, but where the child can be monitored, such as the bathroom, hallway, or laundry room.
    • Determine what behaviors warrant a time-out.
    • Make certain children understand the “rules” and how they are expected to behave.
    • Explain to children the process of time-out:
      • When they misbehave, they will be given one warning. If they do not obey, they will be sent to the place designated for time-out.
      • They are to sit there for a specified period.
      • If they cry, refuse, or display any disruptive behavior, the time-out period will begin after they quiet down.
      • When they are quiet for the duration of the time, they can then leave the room.
      • A rule for the length of time-out is 1 minute per year of age; use a kitchen timer with an audible bell to record the time rather than a watch.


  • Parenting and Divorce
    • The Divorce process
      • Acute phase
        • The married couple makes the decision to separate.
        • This phase includes the legal steps of filing for dissolution of the marriage and, usually, the departure of the father from the home.
        • This phase lasts from several months to more than 1 year and is accompanied by familial stress and a chaotic atmosphere.
      • Transitional Phase
        • The adults and children assume unfamiliar roles and relationships within a new family structure.
        • This phase is often accompanied by a change of residence, a reduced standard of living and altered lifestyle, a larger share of the economic responsibility being shouldered by the mother, and radically altered parent-child relationships.
      • Stabilizing Phase
        • The post-divorce family re-establishes a stable, functioning family unit.
        • Remarriage frequently occurs with concomitant changes in all areas of family life.
    • Feelings and Behaviors of Children Related to Divorce
      • Infancy
        • Effects of reduced mothering or lack of mothering
        • Increased irritability
        • Disturbance in eating, sleeping, and elimination
        • Interference with attachment process
      • Early Preschool Children (2 to 3 Years of Age)
        • Frightened and confused
        • Blame themselves for the divorce
        • Fear of abandonment
        • Increased irritability, whining, tantrums
        • Regressive behaviors (e.g., thumb sucking, loss of elimination control)
        • Separation anxiety
      • Later Preschool Children (3 to 5 Years of Age)
        • Fear of abandonment
        • Blame themselves for the divorce; decreased self-esteem
        • Bewilderment regarding all human relationships
        • Become more aggressive in relationships with others (e.g., siblings, peers)
        • Engage in fantasy to seek understanding of the divorce
      • Early School-Age Children (5 to 6 Years of Age)
        • Depression and immature behavior
        • Loss of appetite and sleep disorders
        • May be able to verbalize some feelings and understand some divorce-related changes
        • Increased anxiety and aggression
        • Feelings of abandonment by departing parent
      • Middle School-Age Children (6 to 8 Years of Age)
        • Panic reactions
        • Feelings of deprivation: loss of parent, attention, money, and secure future
        • Profound sadness, depression, fear, and insecurity
        • Feelings of abandonment and rejection
        • Fear regarding the future
        • Difficulty expressing anger at parents
        • Intense desire for reconciliation of parents
        • Impaired capacity to play and enjoy outside activities
        • Decline in school performance
        • Altered peer relationships: become bossy, irritable, demanding, and manipulative
        • Frequent crying, loss of appetite, sleep disorders
        • Disturbed routine, forgetfulness
      • Later School-Age Children (9 to 12 years of age)
        • More realistic understanding of divorce
        • Intense anger directed at one or both parents
        • Divided loyalties
        • Ability to express feelings of anger
        • Ashamed of parental behavior
        • Desire for revenge; may wish to punish the parent they hold responsible
        • Feelings of loneliness, rejection, and abandonment
        • Altered peer relationships
        • A decline in school performance
        • May develop somatic complaints
        • May engage in aberrant behavior, such as lying, stealing
        • Temper tantrums
        • Dictatorial attitude
      • Adolescents (12 to 18 years of Age)
        • Able to disengage themselves from parental conflict
        • Feelings of a profound sense of loss: of family, childhood
        • Feelings of anxiety
        • Worry about themselves, parents, siblings
        • Expression of anger, sadness, shame, embarrassment
        • May withdraw from family and friends
        • Disturbed concept of sexuality
        • May engage in acting-out behaviors


Mass Media

Media Effect Potential Consequences
  • Government, medical, and public health data show exposure to media violence as one factor in violent and aggressive behavior. 
  • Both adults and children become desensitized by violence witnessed through various media, including television (including children’s programming), movies (including G-rated movies), music, and video games. In addition, cyber-bullying and harassment via text messages are a growing concern among middle school and high school students.
  • A significant body of research shows that sexual content in the media can contribute to beliefs and attitudes about sex, sexual behavior, and initiation of intercourse. 
  • Teen’s access sexual content through a variety of media: television, movies, music, magazines, Internet, social media, and mobile devices. 
  • Current issues receiving attention for the role they play in adolescent sexual behavior include sending of sexual images via mobile devices (i.e., sexting), impact of violent media on youth views of women and forced sex/rape, and cyber-bullying LGBTQI youth.
  • Media can also serve as a positive source of sexual information (i.e., information, apps, social media about sexually transmitted infections, adolescent pregnancy, and promoting acceptance and support of LGBTQI youth).
Substance use and abuse
  • Although the causes of adolescent substance use and abuse are numerous, media plays a significant role. 
  • Alcohol and tobacco are still heavily marketed to adolescents/young adults. 
  • Television and movies featuring the use of these substances can influence initiation of use. 
  • Media also shows substance use to be pervasive and without consequences. 
  • Finally, content shared over social networking sites can serve as a form of peer pressure and can influence likelihood of use.
  • Obesity is a highly prevalent public health issue among children of all ages, and rates are increasing around the world. Several studies have demonstrated a link between the amount of screen time and obesity.
  • Advertising of unhealthy food to children is a long-standing marketing practice, which may increase snacking in the face of decreased activity. In addition, both increased screen time and unhealthy eating may also be related to unhealthy sleep.
Body image
  • Media may play a significant role in the development of body image awareness, expectations, and body dissatisfaction among young and older adolescent girls.
  • Their beliefs may be influenced by images on television, movies, and magazines.
  • New media also contributes to this through Internet images, social network sites, and websites that encourage disordered eating (e.g., pro-Ana sites)


  • Actions to promote positive media
    • Parents
      • Follow American Academy of Pediatrics recommendations for 2 hours (total) of screen time daily for children 2 years of age and older.
      • Establish clear guidelines for Internet use and provide direct supervision. Have frank discussions of what youth may encounter in viewing media. Be mindful of own media use in the home.
      • Encourage unstructured play in the home, and plan to help kids readjust to this change in family dynamic. Consider planned, deliberate use of media to experience the benefits (i.e., watching a television show together to bond or start a sensitive discussion).
    • Nurses/Health Care Providers
      • Dedicate a few minutes of each visit to provide media screening and counseling. 
      • Discourage presence of electronic devices in children’s rooms.
      • Be sensitive to the challenges that parents face in carrying this out.
    • Schools
      • Offer timely, accurate sexuality and drug education.
      • Promote resilience.
      • Develop programs to educate youth on wise use of technology.
      • Develop and implement policies on dealing with cyber-bullying and sexting.



  • Exploring a Family’s Culture, Illness, and Care
    • What do you think caused your child’s health problem?
    • Why do you think it started when it did?
    • How severe is your child’s sickness? Will it have a short or long course?
    • How do you think your child’s sickness affects your family?
    • What are the chief problems your child’s sickness has caused?
    • What kind of treatment do you think your child should receive?
    • What are the most important results you hope to receive from your child’s treatment?
    • What do you fear most about your child’s sickness?
  • Cultural practices the Dominant culture may consider abusive
    • Coining: 
      • A Vietnamese practice may produce welt-like lesions on the child’s back when the edge of a coin is repeatedly rubbed lengthwise on the oiled skin to rid the body of disease.
    • Cupping: 
      • An Old-World practice (also practiced by the Vietnamese) of placing a container (e.g., tumbler, bottle, jar) containing steam against the skin to “draw out the poison” or other evil elements. When the heated air in the container cools, a vacuum is created that produces a bruise-like blemish on the skin directly beneath the mouth of the container.
    • Burning: 
      • A practice of some Southeast Asian groups whereby small areas of skin is burned to treat enuresis and temper tantrums.
    • Female genital mutilation (female circumcision): 
      • Removal of or injury to any part of the female genitalia; practiced in Africa, the Middle East, Latin America, India, Asia, North America, Australia, and Western Europe.
    • Forced kneeling: 
      • A child discipline measure of some Caribbean groups in which a child is forced to kneel for a long time.
    • Topical garlic application: 
      • A practice of Yemenite Jews in which crushed garlic cloves of garlic–petroleum jelly plaster is applied to the wrists to treat infectious disease. The practice can result in blisters or garlic burns.
    • Traditional remedies that contain lead: 
      • Greta and azarcon (Mexico; used for digestive problems), paylooah (Southeast Asia; used for rash or fever), and surma (India; used as a cosmetic to improve eyesight).


Communication and Physical Assessment of the Child and Family

Communicating with Children

  • Importance of creating a safe environment
    • Introduce yourself
    • Involve the child from the beginning of the interaction
    • Get eye level
    • Take your time
    • Explain the purpose of the exam in age-appropriate terms
    • Provide privacy
    • Direct the focus 
    • Ask one question at a time
    • Be honest
    • Keep language and understanding as a focus
  • Careful listening
    • Pay attention to how information is expressed
    • Observe behaviors during the interaction
      • Pay attention to the tone of voice
        • Anxiety, fear, anger
      • Be alert to underlying themes
      • Observe non-verbal behavior
        • Posture, gestures, eye contact


Communication Related to Development of Thought process

  • Infancy: 
    • nonverbal communication, gentle handling, quiet environment, calm speech
  • Early Childhood:
    • Under 5 are egocentric, focus the communication on them; include them in the exam, unable to think abstractly
      • Use simple direct language
  • School Age:
    • They want explanations and reasons for everything; heightened concern about body integrity; encourage communication
  • Adolescence:
    • Thinking fluctuates between child and adult thinking; be prepared to be flexible 
      • Interviewing poses special considerations regarding parental involvement.


Facilitating examination of Infants

  • Promote physical comfort and relaxation
  • Distract infant with colorful toys
  • Use gentle, warm hands 
  • Do procedures that provoke crying at end of exam

Facilitating examination of Toddlers

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

Facilitating 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
  • Reassure adolescents of normalcy


Blocks to communication

  • Communication Barriers (Nurse)
    • Socializing
    • Giving unrestricted and sometimes unsought advice
    • Offering premature or inappropriate reassurance
    • Giving over-ready encouragement
    • Defending a situation or opinion
    • Using stereotyped comments or clichés
    • Limiting expression of emotion by asking directed, closed-ended questions
    • Interrupting and finishing the person’s sentence
    • Talking more than the interviewee
    • Forming prejudged conclusions
    • Deliberately changing the focus
  • Signs of Information Overload (Patient)
    • Long periods of silence
    • Wide eyes and fixed facial expression
    • Constant fidgeting or attempting to move away
    • Nervous habits (e.g., tapping, playing with hair)
    • Sudden interruptions (e.g., asking to go to the bathroom)
    • Looking around
    • Yawning, eyes drooping
    • Frequently looking at a watch or clock
    • Attempting to change the topic of discussion


Communicating with Children

  • Allow children time to feel comfortable
  • Avoid sudden or rapid advances, broad smiles, extended eye contact, and other gestures that may be threatening.
  • Talk to the parent if the child is initially shy.
  • Communicate through transition objects (such as, dolls, puppets, and stuffed animals) before questioning a young child directly.
  • Give older children the opportunity to talk without the parents’ present.
  • Assume a position that is at eye level with the child 
  • Speak in a quiet, unhurried, and confident voice.
  • Speak clearly, be specific, and use simple words and short sentences.
  • State directions and suggestions positively.
  • Offer a choice only when one exists.
  • Be honest with children.
  • Allow children to express their concerns and fears.
  • Use a variety of communication techniques.

Communicating with Adolescents

  • Build a Foundation
    • Spend time together.
    • Encourage expression of ideas and feelings.
    • Respect their views.
    • Tolerate differences.
    • Praise good points.
    • Respect their privacy.
    • Set a good example
    • Communicate Effectively
  • Give undivided attention.
    • Listen, listen, and listen.
    • Be courteous, calm, honest, and open-minded.
    • Try not to overreact. If you do, take a break.
    • Avoid judging or criticizing.
    • Avoid the “third degree” of continuous questioning.
    • Choose important issues when taking a stand.
    • After taking a stand:
    • Think through all options.
    • Make expectations clear


  • Pediatrics Health History
    • Identifying information
      • Name
      • Address
      • Telephone
      • Birth date and place
      • Race or ethnic group
      • Sex
      • Religion
      • Date of interview
      • Informant (most likely the parent)
    • Chief complaint (CC): To establish the major specific reason for the child’s and parents’ seeking of health care
    • Present illness (PI): To obtain all details related to the chief complaint
    • Past history (PH): To elicit a profile of the child’s previous illnesses, injuries, or surgeries
      • Birth history (pregnancy, labor and delivery, perinatal history)
      • Dietary history
      • Previous illness, injuries, and operations
      • Allergies
        • Has your child ever taken any prescription or over-the-counter medications that have disagreed with him or her or caused an allergic reaction? If yes, can you remember the name(s) of this medication(s)?
        • Can you describe the reaction?
        • Was the medication taken by mouth (as a tablet or syrup), or was it an injection?
        • How soon after starting the medication did the reaction happen?
        • How long ago did this happen?
        • Did anyone tell you it was an allergic reaction, or did you decide for yourself?
        • Has your child ever taken this medication, or a similar one, again?
        • If yes, did your child experience the same problems?
        • Have you told the physicians or nurses about your child’s reaction or allergy?
      • Current medications
      • Immunizations
      • Growth and development
        • Developmental milestone:
          • Age of holding up head steadily
          • Age of sitting alone without support
          • Age of walking without assistance
          • Age of saying first words with meaning
          • Age of achieving bladder and bowel control
      • Habits
        • Behavior patterns, such as nail biting, thumb sucking, pica (habitual ingestion of nonfood substances), rituals (“security” blanket or toy), and unusual movements (head banging, rocking, overt masturbation, walking on toes)
        • Activities of daily living, such as hours of sleep and arising, duration of nighttime sleep and naps, type and duration of exercise, regularity of stools and urination, age of toilet training, and daytime or nighttime bedwetting
        • Unusual disposition; response to frustration
        • Use or abuse of alcohol, drugs, coffee, or tobacco
    • Review of systems (ROS): To elicit information concerning any potential health problem
Body systems
Constitutional Integument Eyes Ears/nose/mouth/throat
Neck Chest Respiratory Cardiovascular
Gastrointestinal Genitourinary Gynecologic Musculoskeletal
Neurologic Endocrine


  • Family medical history: 
    • To identify genetic traits or diseases that have familial tendencies and to assess exposure to a communicable disease in a family member and family habits that may affect the child’s health, such as smoking and chemical use
  • Psychosocial history: 
    • To elicit information about the child’s self-concept
  • Sexual history: 
    • To elicit information concerning the child’s sexual concerns or activities and any pertinent data regarding adults’ sexual activity that influences the child
  • Family history: 
    • To develop an understanding of the child as an individual and as a member of a family and a community
      • Family composition
      • Home and community environment
      • Occupational and educational
      • Occupation and education of family members
      • Cultural and religious traditions
      • Family function and relationships
  • Nutritional assessment: 
    • To elicit information on the adequacy of the child’s nutritional intake and needs
      • Dietary intake
      • Clinical examination
  • Sexuality
    • 12 to 14 Years of Age
      • Have adolescent identify a supportive adult with whom to discuss sexuality issues and concerns.
      • Discuss the advantages of delaying sexual activity.
      • Discuss making responsible decisions regarding normal sexual feelings.
      • Discuss the roles of gender, peer pressure, and the media in sexual decision making.
      • Discuss contraceptive options (advantages and disadvantages).
      • Provide education regarding sexually transmitted infections (STIs), including human immunodeficiency virus (HIV) infection; clarify risks, and discuss condoms.
      • Discuss abuse prevention, including avoiding dangerous situations, the role of drugs and alcohol, and the use of self-defense.
      • Have the adolescent clarify his or her values, needs, and ability to be assertive.
      • If the adolescent is sexually active, discuss limiting partners, use of condoms, and contraceptive options.
      • Have a confidential interview with the adolescent (including a sexual history).
      • Discuss the evolution of sexual identity and expression.
      • Discuss breast examination or testicular examination.
    • 15 to 18 Years of Age
      • Support delaying sexual activity.
      • Discuss alternatives to intercourse.
      • Discuss “When are you ready for sex?”
      • Clarify values; encourage responsible decision making.
      • Discuss consequences of unprotected sex: Early pregnancy; STIs, including HIV infection.
      • Discuss negotiating with partners and barriers to safer sex.
      • If the adolescent is sexually active, discuss limiting partners, use of condoms, and contraceptive options.
      • Emphasize that sex should be safe and pleasurable for both partners.
      • Have a confidential interview with the adolescent.
      • Discuss concerns about sexual expression and identity.
  • Family health history
    • Geographic location
      • This includes the birthplace and travel to different areas in or outside of the country
        • Identification of possible exposure to endemic diseases
      • Finding out if they come from urban or rural location, the age of the home, and whether there are significant threats such as molds or pests within the housing structure
        • Children are especially susceptible to parasitic infestation in areas of poor sanitary conditions and to vector-borne diseases such as, mosquitoes or ticks in humid or heavily wooded regions
  • Family structure
    • Family assessment is the collection of data about the composition of the family and the relationships among its members
    • The most common method of eliciting information on the family structure is to interview family members. 
    • The principal areas of concern are: 
      • Family composition
      • Home and community environment
      • Occupation
      • Education of family members, and cultural and religious traditions.
  • Psychosocial history
  • Review of systems
Constitutional:  Overall state of health, fatigue, recent or unexplained weight gain or loss (period for either), contributing factors (change of diet, illness, altered appetite), exercise tolerance, fevers (time of day), chills, night sweats (unrelated to climatic conditions), general ability to carry out

activities of daily living

Integument:  Pruritus, pigment, or other color changes (including birthmarks), acne, eruptions, rashes (location), bruises, petechiae, excessive dryness, general texture, tattoos or piercings, disorders or deformities of nails, hair growth or loss, hair color change (for adolescents, use of hair dyes or other potentially toxic substances, such as hair straighteners)
Eyes:  Visual problems (behaviors indicative of blurred vision, such as bumping into objects, clumsiness, sitting close to television, holding a book close to face, writing with head near desk, squinting, rubbing the eyes, bending head in an awkward position), cross-eyes (strabismus), eye infections, edema of lids, excessive tearing, use of glasses or contact lenses, date of last vision examination
Ears/nose/mouth/throat:  Earaches, ear discharge, evidence of hearing loss (ask about behaviors such as the need to repeat requests, loud speech, inattentive behavior), results of any previous auditory testing, nosebleeds (epistaxis), constant or frequent runny or stuffy nose, nasal obstruction (difficulty breathing), alteration or loss of sense of smell, mouth breathing, gum bleeding, number of teeth and pattern of eruption/loss, toothaches, tooth brushing, use of fluoride, difficulty with teething (symptoms), last visit to the dentist (especially if temporary dentition is complete), sore throats, difficulty swallowing, choking, hoarseness or other voice irregularities
Neck:  Pain, limitation of movement, stiffness, difficulty holding head straight (torticollis), thyroid enlargement, enlarged nodes or other masses
Chest:  Breast enlargement, discharge, masses; for adolescent girls, ask about breast self-examination
Respiratory:  Chronic cough, wheezing, shortness of breath at rest or on exertion, difficulty breathing, snoring, sputum production, infections (pneumonia, tuberculosis), skin reaction from tuberculin testing
Cardiovascular:  Cyanosis or fatigue on exertion, history of heart murmur or rheumatic fever, tachycardia, syncope, edema
Gastrointestinal: Appetite, nausea, vomiting (not associated with eating; may be indicative of brain tumor or increased intracranial pressure), abdominal pain, jaundice or yellowing skin or sclera, belching, flatulence, distention, diarrhea, constipation, recent change in bowel habits, blood in stools
Genitourinary: Pain on urination, frequency, hesitancy, urgency, hematuria, nocturia, polyuria, enuresis, unpleasant odor to urine, force of stream, discharge, change in size of scrotum, date, and result of last urinalysis, for adolescents, sexually transmitted infection, and type of treatment; for adolescent boys, ask about testicular self-examination
Gynecologic: For pubescent children

Female: Menses onset, amount, duration, frequency, discomfort, problems; vaginal discharge, breast development

Male: Puberty onset, emissions, erections, pain, or discharge from penis, swelling or pain in testicles

Both: Sexual activity, use of contraception, sexual transmitted infections

Musculoskeletal:  Weakness, clumsiness, lack of coordination, unusual movements, scoliosis, back pain, joint pain or swelling, muscle pains or cramps, abnormal gait, deformity, fractures, serious sprains, activity level
Neurologic: Headaches, seizures, tremors, tics, dizziness, loss of consciousness episodes, loss of memory, developmental delays, or concerns
Endocrine:  Intolerance to heat or cold, excessive thirst or urination, excessive sweating, salt craving, rapid or slow growth, signs of early or late puberty
Hematologic/lymphatic:  Easy bruising or bleeding, anemia, date and result of last blood count, blood transfusions, swollen or painful lymph nodes (cervical, axillary, inguinal)
Allergic/immunologic:  Allergic responses, anaphylaxis, eczema, rhinitis, unusual sneezing, autoimmunity, recurrent infections, infections associated with unusual complications
Psychiatric: General affect, anxiety, depression, mood changes, hallucinations, attention span, tantrums, behavior problems, suicidal ideation, substance abuse


  • Nutrition
    • Dietary intake
      • Dietary Reference Intakes (DRI) are a set of four evidence-based nutrient reference values that provide quantitative estimates of nutrient intakes for use in assessing and planning dietary intake:
        • Estimated Average Requirement: 
          • Estimated to meet the nutrients requirements of one-half of healthy individuals for a specific age and gender group
        • Recommended Dietary Allowance (RDA):
          • Sufficient to meet the nutrient requirement of nearly all healthy individuals for a specific age and gender group
        • Adequate Intake (AI)
          • Based on estimates of nutrient intake by healthy individuals
        • Tolerable Upper Intake Level (UL)
          • Highest nutrient intake level likely to pose no risk for adverse health effects
    • Clinical examination of nutrition
      • Hair, skin, mouth, eyes
    • Evaluation of nutritional assessment
      • Malnourished
      • At risk
      • Well nourished
      • Overweight or obese


Clinical Assessment of Nutritional Status

Evidence of Adequate Nutrition Evidence of Deficient or Excessive Nutrition Deficiency or Excess
General Growth
Normal weight gain, growth velocity, and head growth for age and gender Weight loss or poor weight Protein, calories, fats, and other

essential nutrients, especially vitamin A, pyridoxine, niacin, calcium, iodine, manganese, zinc

Excess weight gain  Excess calories
Sexual development appropriate for age Delayed sexual development Excess vitamins A, D
Smooth, slightly dry to touch

Elastic and firm

Absence of lesions

Color appropriate to genetic background

Hardening and scaling Vitamin A
Seborrheic dermatitis Excess niacin
Dry, rough, petechiae Riboflavin
Delayed wound healing Vitamin C
Scaly dermatitis on exposed surfaces Riboflavin, Vitamin C, Zinc
Wrinkled, flabby Niacin
Crusted lesions around orificies, especially nares Protein, calories, zinc
Pruritus Excess vitamin A, riboflavin, niacin
Poor turgor Water, sodium
Edema Protein, thiamine

Excess sodium

Yellow tinge (jaundice) Vitamin B12

Excess vitamin A, niacin

Depigmentation Protein, calories
Pallor (anemia) Pyridoxine, folic acid, vitamin B12, C, E (in premature infants), iron

Excess vitamin C, Zinc

Paresthesia Excess riboflavin
Lustrous, silky, strong, elastic Stringy, friable, dull, dry, thin Protein, calories
Alopecia Protein, calories, zinc
Depigmentation Protein, calories, copper
Raised areas around hair follicles Vitamin C
Even molding, occipital prominence, symmetric facial features

Fused sutures after 18 months

Softening of cranial bones, prominence of frontal bones, skull flat and depressed toward middle Vitamin D
Delayed fusion of sutures Vitamin D
Hard, tender lumps in occiput Excess vitamin A
Headache Excess thiamine
Thyroid not visible, palpable in midline Thyroid enlarge, may be grossly visible Iodine
Clear, bright Hardening and scaling of cornea and conjunctiva Vitamin A
Good night vision Night blindness Vitamin A
Conjunctiva: pink, glossy Burning, itching, photophobia, cataracts, corneal vascularization Riboflavin
Tympanic membrane: pliable Calcified (hearing loss) Excess vitamin D
Smooth, intact nasal angle Irritation and cracks at nasal angle Riboflavin

Excess vitamin A

Lips: smooth, moist, darker color than skin Fissures and inflammation at corners Riboflavin

Excess vitamin A

Gums: firm, coral pink, stippled Spongy, friable, swollen bluish red or black, bleed easily Vitamin C
Mucous membranes: bright pink, smooth, moist Stomatitis Niacin
Tongue: rough texture, no lesion, taste sensation Glossitis Niacin, riboflavin, folic acid
Diminished taste sensation Zinc
Teeth: uniform white color, smooth, intact Brown mottling, pits, fissures Excess fluoride
Defective enamel Vitamins A, C, D, calcium, phosphorus
Caries Excess carbohydrates
In infants, shape almost circular  Depressed lower portion of rib cage Vitamin D
In children, lateral diameter increased in proportion to anteroposterior diameter Sharp protrusion of sternum Vitamin D
Smooth costochondral junctions Enlarged costochondral junction Vitamin C, D
Breast development: normal of age Delayed development Zinc
Cardiovascular System
Pulse and BP within normal limits Palpitations Thiamine
Rapid pulse Potassium

Excess thiamine

Arrhythmias Magnesium, potassium 

Excess niacin, potassium

Increased BP Excess sodium
Decreased BP Thiamine

Excess niacin

In young children, cylindric and prominent Distended, flabby, poor musculature Protein, calories
Prominent, large Excess calories
In older children, flat Potbelly, constipation Vitamin D
Normal bowel habits Diarrhea Niacin

Excess vitamin C

Constipation Excess calcium, potassium
Musculoskeletal System
Muscles: firm, well-developed, equal strength bilaterally Flabby, weak, generalized wasting Protein, calories
Weakness, pain, cramps Thiamine, sodium, chloride, potassium, phosphorus, magnesium

Excess thiamine

Muscle twitching, tremors Magnesium
Muscular paralysis Excess potassium
Spine: cervical and lumbar curves (double S curve) Kyphosis, lordosis, scoliosis Vitamin D
Extremities: symmetric; legs straight with minimum bowing Bowing of extremities, knock knees Vitamin D, calcium, phosphorus
Epiphyseal enlargement  Vitamin A, D
Bleeding into joints and muscles, joint swelling, pain Vitamin C
Joints: flexible, full range of motion, no pain or stiffness Thickening of cortex of long bones with pain and fragility, hard tender lumps in extremities Excess vitamin A
Osteoporosis of long bones Calcium 

Excess vitamin D

Neurologic System
Behavior: alert, responsive, emotionally stable  Listless, irritable, lethargic, apathetic (sometimes apprehensive, anxious, drowsy, mentally slow, confused) Thiamine, niacin, pyridoxine, vitamin C, potassium, magnesium, iron, protein, calories

Excess vitamins A, D, thiamine, folic acid, calcium

Absence of tetany, convulsions  Masklike facial expression, blurred speech, involuntary laughing Excess manganese
Convulsions Thiamine, pyridoxine, vitamin D, calcium, magnesium

Excess phosphorus (in relation to calcium)

Intact peripheral nervous system Peripheral nervous system toxicity (unsteady gait, numb feet and hands, fine motor clumsiness) Excess pyridoxine
Intact reflexes Diminished or absent tendon reflexes  Thiamine, vitamin E


Sequence of examination

  • Infant
    • Before able to sit alone — supine or prone, preferably in parent’s lap; before 4 to 6 months, can place on examining table
    • After able to sit alone — sitting in parent’s lap whenever possible; if on table, place with parent in full view
      • If quiet, auscultate heart, lungs, and abdomen.
      • Record heart and respiratory rates.
      • Palpate and percuss same areas.
      • Proceed in usual head-to-toe direction.
      • Perform traumatic procedures last (eyes, ears, mouth [while crying]).
      • Elicit reflexes as body part is examined.
      • Elicit Moro reflex last.
        • Completely undress if room temperature permits.
        • Leave diaper on male infant.
        • Gain cooperation with distraction, bright objects, rattles, talking.
        • Smile at infant; use soft, gentle voice.
        • Pacify with bottle of sugar water or feeding.
        • Enlist parent’s aid for restraining to examine ears, mouth.
        • Avoid abrupt, jerky movements.
  • Toddler
    • Sitting or standing on or near parent 
    • Prone or supine in parent’s lap
      • Inspect body area through play: “Count fingers,” “tickle toes.”
      • Use minimum physical contact initially.
      • Introduce equipment slowly.
      • Auscultate, percuss, palpate whenever quiet.
      • Perform traumatic procedures last (same as for infant).
        • Have parent remove outer clothing.
        • Remove underwear as body part is examined.
        • Allow toddler to inspect equipment; demonstrating use of equipment is usually ineffective.
        • If uncooperative, perform procedures quickly.
        • Use restraint when appropriate, request parent’s assistance.
        • Talk about examination if cooperative; use short phrases.
        • Praise for cooperative behavior.
  • School-Age Child
    • Prefer sitting
    • Cooperative in most positions
    • Younger child prefers parent’s presence
    • Older child may prefer privacy
      • Proceed in head-to-toe direction.
      • May examine genitalia last in older child
        • Respect need for privacy.
        • Request self-undressing.
        • Allow to wear underpants.
        • Give gown to wear.
        • Explain purpose of equipment and significance of procedure, such as otoscope to see eardrum, which is necessary for hearing.
        • Teach about body function and care.
  • Adolescent
    • Same as for school-age child
    • Offer option of parent’s presence
      • Same as older school-age child.
      • May examine genitalia last
        • Allow to undress in private.
        • Give gown.
        • Expose only area to be examined.
        • Respect need for privacy.
        • Explain findings during examination e.g., “Your muscles are firm and strong”).
        • Matter-of-factly comment about sexual development (e.g., “Your breasts are developing as they should be”).
        • Emphasize normalcy of development.
        • Examine genitalia as any other body part; may leave to end.


  • Goal of assessment
    • Minimize anxiety and foster trust
    • Preserve security of parent-child relationship
    • Prep child as much as possible
  • Performing Pediatric Physical Examination
    • Perform the examination in an appropriate, nonthreatening area:
      • Have room well-lit and decorated with neutral colors.
      • Have room temperature comfortably warm.
      • Place all strange and potentially frightening equipment out of sight.
      • Have some toys, dolls, stuffed animals, and games available for the child.
      • If possible, have rooms decorated and equipped for different-age children.
      • Provide privacy, especially for school-age children and adolescents.
      • Provide time for play and becoming acquainted.
    • Observe behaviors that signal the child’s readiness to cooperate:
      • Talking to the nurse
      • Making eye contact
      • Accepting the offered equipment
      • Allowing physical touching
      • Choosing to sit on the examining table rather than the parent’s lap
    • If signs of readiness are not observed, use the following techniques:
      • Talk to the parent while essentially “ignoring” the child; gradually focus on the child or a favorite object, such as a doll.
      • Make complimentary remarks about the child, such as about his or her appearance, dress, or a favorite object.
      • Tell a funny story or play a simple magic trick.
      • Have a nonthreatening “friend” available, such as a hand puppet, to “talk” to the child for the nurse.
        • If the child refuses to cooperate, use the following techniques:
      • Assess reason for uncooperative behavior; consider that a child who is unduly afraid may have had a traumatic experience.
      • Try to involve the child and parent in the process.
      • Avoid prolonged explanations about the examining procedure.
      • Use a firm, direct approach regarding expected behavior.
      • Perform the examination as quickly as possible.
      • Have an attendant gently restrain the child.
      • Minimize any disruptions or stimulation.
      • Limit the number of people in the room.
      • Use an isolated room.
      • Use a quiet, calm, confident voice.
    • Begin the examination in a nonthreatening manner for young children or children who are fearful:
      • Use activities that can be presented as games, such as test for cranial nerves
        • I. Olfactory Nerve
        • II. Optic Nerve
        • III. Oculomotor Nerve
        • IV. Trochlear Nerve
        • V. Trigeminal Nerve
        • VI. Abducens Nerve
        • VII. Facial Nerve
        • VIII. Auditory, Acoustic, or Vestibulocochlear Nerve
        • IX. Glossopharyngeal Nerve
        • X. Vagus Nerve
        • XI. Accessory Nerve
        • XII. Hypoglossal Nerve
      • Use approaches such as Simon Says to encourage the child to make a face, squeeze a hand, stand on one foot, and so on.
      • Use the paper-doll technique:
        • Lay the child supine on an examining table or floor that is covered with a large sheet of paper.
        • Trace around the child’s body outline.
        • Use the body outline to demonstrate what will be examined, such as drawing a heart and listening with a stethoscope before performing activity on the child.
      • If several children in the family will be examined, begin with the most cooperative child to model desired behavior
        • Provide choices, such as sitting on table or in parent’s lap.
        • Allow the child to handle or hold equipment
        • Encourage the child to use equipment on a doll, family member, or examiner.
        • Explain each step of the procedure in simple language.
        • Examine the child in a comfortable and secure position:
          • Sitting in parent’s lap
          • Sitting upright if in respiratory distress
      • Proceed to examine the body in an organized sequence (usually head to toe) with the following exceptions:
        • Alter sequence to accommodate needs of different-age children
        • Examine painful areas last
        • In an emergency, examine vital functions (airway, breathing, and circulation) and injured area first
      • Reassure the child throughout the examination, especially about bodily concerns that arise during puberty.
      • Discuss findings with the family at the end of the examination.
      • Praise the child for cooperation during the examination; give a reward such as a small toy or sticker.


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