Pediatric Primary Care: Practice Guidelines for Nurses, 2nd Ed.

CHAPTER 2

Obtaining an Interval History

Donna Hallas

I. THE INTERVAL HISTORY

A. Definition.

1. Interval history: data collection that occurs at subsequent visits to one in which comprehensive history and physical examination were completed.

2. Amount of information reviewed and collected for interval history depends on child's age and length of time since either comprehensive history was obtained and/or prior appointments in which interval history was updated.

3. General guideline for obtaining interval history: review and update data every 6 months for infants, toddlers, preschool-age children and every year for school-age children, adolescents.

B. Significance of interval history.

1. Although comprehensive history is used to establish initial health promotion plan, analysis of data collected during interval history is often used in one of four ways:

a. To continue established health promotion plan.

b. To identify new healthcare problems.

c. To make changes to health promotion plan based on new data.

d. To establish new health promotion plan.

C. Preparation for obtaining interval history.

1. Prior to beginning data collection for interval history, review comprehensive history and any prior interval histories available on medical record.

a. Helps nurse practitioner focus questions that will elicit data needed to complete interval history.

b. Sample data contained in comprehensive history that may need further exploration during interval history are listed in Table 2-1.

Table 2-1 Focusing the Interval History from Details in the Comprehensive History

Comprehensive history

Interval history

 

Past medical history

Any data in past medical history that is significant and requires further clarification.

 
 

Consider previous acute illnesses including hospitalizations, injuries, accidents, surgeries, chronic illnesses.

 
 

Review problem list.

 
 

If all prior problems are listed as resolved, then no further data should be elicited at this visit.

 
 

If problems still exist, then ask questions specific to identified problem.

 

Allergies

Always obtain update on allergies to foods, medications, environmental pollutants.

 

Developmental history

Review results of prior DDST or the Ages and Stages Questionnaires.

 
 

Note achievement of developmental milestones at each interval visit.

 
 

If delays are noted, question status of intervention services (early intervention for children 5 years old, OT, PT, speech, special education services for all children).

 

Social history

Exercise and activity.

 
 

Wellness behaviors.

 
 

Behavior issues at home or at school.

 

Family history

Review family structure and family support systems.

 
 

If data contained in comprehensive history suggest dysfunctional family, ask about present family structure and function.

 
 

Review genogram.

 
 

Review significant family history prior to interview.

 
 

Pay particular attention to strong family history of conditions in which family lifestyle modifications can have significant impact (e.g., cardiovascular conditions, hypertension, diabetes, obesity).

 
 

Implementing lifestyle modifications in early childhood years may significantly affect health throughout lifetime.

 

Medication history

Prescription.

 
 

Over the counter.

 
 

Homeopathic remedies.

 

Nutritional history

Timing and frequency of meals.

 
 

Ethnic and cultural considerations in food choices.

 

Immunization history

Immunization records should be reviewed at each visit.

 

Mental health

Assess mental health status for school age and adolescence at each interval visit.

 
 

Anxiety and depression frequently occur in these populations.

 

D. Elements of an interval history.

1. Elements included in interval history should be related to the age of the child.

2. Major focus for interval history for each age child and adolescent should include questions concerning eating, sleeping, bladder and bowel patterns, and any unusual behaviors or changes in behaviors. Additional questions are then age related.

3. Infant, toddler, and preschool-age children.

a. Ask questions related to achievement of developmental milestones.

b. Denver Developmental Screening Test (DDST) may be used as a guide for questioning patterns concerning achievement of developmental milestones.

c. Toddlers and preschoolers: Assess information regarding speech and language development and development of social skills.

d. Use the Surveillance and Screening Algorithm: Autistic Spectrum Disorders for toddlers at the 18, 21, and/or 24 month old episodic visit if it had not been completed at a maintenance health visit.

Table 2-2 Review of System (ROS) in an Interval History

System

ROS—gathering the interval history*

On a regular basis, do you have problems with:

 

Head and neck

Headaches

 

Blurred vision or any vision problems

 

Earaches

 

Nosebleeds

 

Sore throats

 

Diffi culty swallowing

 

Any lumps in head or neck area

Chest and lungs

Chest pain

 

Heart beating fast in chest (palpitations)

 

Shortness of breath

 

Fainting

 

Frequent cough

Abdomen

Nausea

 

Vomiting

 

Diarrhea

 

Urinating or bowels

 

Menstruation

 

Testicular pain

Musculoskeletal

Leg pain or cramps

 

Stiffness, swelling, bone deformities

Skin, hair, and nails

Rashes

 

Moles

 

Darkened or discolored areas

 

Abnormal hair growth

 

Clubbing of nails

 

Bruising easily

Sexual history

History of sexually transmitted infections

*This information is gathered in addition to the details related to eating, sleeping, bladder, and bowel patterns.

4. School-age children.

a. Should also include questions related to sociobehavioral development with peers and progress in school.

b. If female school-age child has secondary sex characteristics, then ask about menstrual cycle: Age of onset, frequency, length of cycle, any discomfort prior to or during menstruations.

c. Children older than10 years of age should be asked: Have they or their friends tried alcohol or drugs? Use a brief alcohol/drug screening tool at each episodic visit.

• What is their diet?

• Happy with appearance/weight?

• Thought about harming themselves or others?

• Sexually active?

5. Adolescents.

a. Use the HEADSSS assessment (home, education/employment, activity, drugs/alcohol, sexuality, suicide/depression, safety and exposure to violence).

b. Adolescent female: Ask questions related to menstrual cycle.

c. Ask about high-risk social behaviors (smoking; alcohol/drug use; sexual activity, including diagnosis and treatment of sexually transmitted infections [STIs]; driving motor vehicle in reckless manner; use of guns; etc.).

E. Review of systems (ROS).

1. Age-appropriate ROS: Conduct in head-to-toe manner as identified in comprehensive physical examination (Table 2-2).

II. INTERVAL HISTORY FOR ATHLETIC CHILD OR ADOLESCENT

A. Pre-participation sports history and physical have well-established guidelines; follow explicitly.

B. Interval history is integral part of assessment.

1. Question parent and child about significant family history changes (e.g., sudden death of relative who was 50 years old from cardiovascular condition). Include questions that elicit information about significant episodes (red flags) of chest pain, dyspnea, syncope, palpitations, loss of consciousness, history of concussions (Table 2-3).

Table 2-3 Red Flags: The Interval History for the Athletic Child or Adolescent

Interval history questions that may elicit red flag data

System

Red flag data

Any relatives < 50 years of age die as result of sudden unexpected cardiac death?

Cardiovascular

Change in family history Sudden death of relative < 50 years of age

Child report chest pain or palpitations, syncope during or after exercise?

 

Chief complaint from child:

  Chest pain

  Palpitations

   

  Syncope

Child report any breathing problems during or after exercise?

Respiratory

Chief complaint from child:

  Dyspnea

   

  Wheezing

Child had any episodes of dizziness, syncope, fainting, concussion?

Neurologic

Chief complaint from child:

  Syncope

   

  Loss of consciousness

III. FOCUSED HISTORY

A. Focused history: Used to collect data about a specific problem, usually chief complaint identified by parent/child (Tables 2-4 and 2-5).

B. Focus all questions on eliciting data about chief complaint.

C. Focused history usually limited to one or two systems.

IV. APPLYING DATA OBTAINED IN INTERVAL HISTORY TO CLINICAL PRACTICE

A. After completing interval history and physical examination, compare findings in comprehensive history to data obtained in interval history.

1. If no significant changes found in interval history, advise parent, infant/ child to continue to follow established health promotion plan.

Table 2-4 Sample Focused History: Medical

Subjective data

Questions to focus the history

 

''My child has a chronic cough.''

What do you mean by a chronic cough?

 

“My child begins coughing each night. I cannot remember the last time he didn't cough at night.”

Does child cough during day or just at night?

 
 

What time of night does child begin coughing?

 
 

Describe the cough.

 
 

Is cough productive or nonproductive?

 
 

Does cough affect child's sleeping pattern?

 
 

Any products currently being used in household that weren't being used before child began having this “chronic” cough?

 
 

Pets in your household?

 
 

Did you change pillow your child uses?

 
 

Use any over-the-counter or prescription medications to treat this cough?

 
 

Has child been evaluated for asthma or allergies?

 
 

Anything make cough better or worse?

 

Table 2-5 Sample Focused History: Mental Health

Subjective

Questions to focus the history

 

“My child's behavior has become so difficult at home.”

Describe what you mean by “difficult behavior.”

 
 

Does anything trigger these behaviors?

 
 

What do you do when this behavior becomes “so difficult?”

 
 

What is your child's response?

 
 

Does this behavior pattern occur at school or outside the home, such as at a friend's house or relative's home?

 
 

Has there been a change in your family lifestyle—such as parents arguing at home, parental separation, new family member living in the home?

 
 

Has there been any change in your child's physical abilities–such as change in cognitive or psychomotor skills?

 
 

Does your child complain of headaches?

 

2. If significant changes are found in interval history, revise health promotion plan.

a. Example: If interval family history reveals family members have diabetes mellitus, evaluate and modify family/child exercise and dietary patterns.

3. If significant changes are found in interval history in relation to child's health, establish new health promotion plan with parent and child/adolescent active participation.

a. Example: If interval history reveals significant change in frequency of coughing and upper respiratory symptoms, complete a detailed focused history and establish a new health promotion plan.

BIBLIOGRAPHY

Bickley LS, Hoekelman RA. Bates' Guide to Physical Assessment. 10th ed. Philadelphia, PA: Lippincott; 2008.

Burns CE, Dunn AM, Brady MA, et al. Pediatric Primary Care. 4th ed. St. Louis, MO: Saunders; 2009.

Duderstadt KG. Pediatric Physical Examination: An Illustrated Handbook. St. Louis, MO: Mosby; 2006.

Johnson CP, Myers SA, and the Council on Children with Disabilities. Identification and evaluation of children with autistic spectrum disorders. Pediatrics. 2007;120:1183-1215. American Academy of Pediatrics website: http://www.aap.org/pressroom/AutismID.pdf. Accessed June 1, 2011.



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