|Prompts as an adjunct to routine questions asked during nursing assessment
||What to ask & why?
|Maintaining a Safe Environment
||Does the child appear to be more clumsy or prone to falling?
||Being prone to falling may be due to joint or muscle pathology.Often the history of trauma may draw attention to the previously existing pathology. Be aware of non-accidental injury.‘Clumsiness’ is a non-specific term but may mask significant musculoskeletal or neurological disease.
||Take a pain history and focus on locality, exacerbating / relieving factors, timescale and patternIs there variation in the day?What is the child like in him or herself?
||Young children may have difficulties verbalising pain but behavioural changes or avoidance of activities previously enjoyed may occur.Asymmetrical persistent pain is a cause for concern. Referred pain from the hip may present as non-specific pain in the thigh or knee.Pain on waking or daytime symptoms suggestive of stiffness or gelling (after periods of inactivity) are indicative of inflammatory joint / muscle disease.A change in mood may be a feature of being unwell or in pain. Denial of pain may be due to fear of additional treatment (such as a joint injection or the need for blood tests).Trauma is a common cause of musculoskeletal pain but be aware that trauma is common and may be a ‘red herring’ as other pathologies may co-exist.
|Breathing & voice
||Does the child seem breathless?Has their voice become weaker or changed?
||Some chronic conditions e.g. Juvenile Dermatomyositis, may involve the muscles of the voice, breathing or swallowing and increase the risk of aspiration / choking. Infection may be increased due to treatment
|Eating & Drinking
||Has appetite changed?Ask about weight gain or loss.Does the child have difficulty in eating or swallowing?
||Often children with undiagnosed chronic illness can have loss of appetite or are more “picky”.Gain in weight could be linked to inactivity or medication (steroids)Juvenile Dermatomyositis, may involve the muscles of the voice, breathing or swallowing and increase the risk of aspiration / choking
||Ask about bowel symptoms and patterns
||Some types of arthritis are associated with inflammatory bowel disease (IBD). Recurrent diarrhoea, passing of blood/mucus, recurrent abdominal pain may indicate IBD.
||Have there been any skin or nail changes?
||Psoriatic arthritis may affect small joints and nailsRashes are indicative of a variety of conditions. ExamplesButterfly rash (cheeks) - Systemic Lupus Erythematosis.Blotchy, salmon pink rash on trunk, arms and legs – Systemic Juvenile Idiopathic Arthritis.Purplish rash on knuckles, elbows, eyelids – Juvenile Dermatomyositis
|Maintaining Hygiene & Dressing
||Does the child have difficulty in fastening buttons or getting dressed?Do they need assistance with personal hygiene?
||Inflammation of the finger joints will affect dexterity and ability to dress, brush teeth and hair
||Has there been any change in activities? Walking, sport or school activities?Does the child struggle to get up off the floor?
||Regression of achieved milestones, functional impairment, avoidance of activity or being more clumsy during play, sport or writing may suggest inflammatory joint or muscle disease.Difficulty on stairs or getting up from a chair or the floor can suggest muscle weakness or joint disease.
||Have there been any recent vision changes?Have parents noticed a change in pupil shape, different shaped pupils?Does the child complain of headaches?
||Uveitis in Juvenile Idiopathic Arthritis (JIA) is usually symptom free and affected eyes may not look or feel different. Headaches, blurring, floaters and discomfort are often absent or can be a later feature. Irregular pupils are a late feature of uveitis.Speech problems (weak or hoarse voice) may occur with Juvenile Dermatomyositis.Hearing problems can occur with some multisystem diseases (periodic fevers).Developmental delay or regression needs further assessment.
||Does he / she wake at night with pain?
||Night waking is a common feature of growing pains (usually intermittent and often predictable after periods of activity). Conversely persistent night waking, especially if there are other concerns (such as limping, fever, malaise) is a red flag and needs further investigation.
|Leisure & Social Activities
||How is he / she at school?Is school attendance good?How many days has he / she had off school in the last three months?Is he / she performing at school as expected? Have there been any changes?
||Behavioural / mood problems may occur.Poor school attendance / regular time off / being late may be indicative of poor disease control.Often children with early morning stiffness struggle to get washed and dressed.Deterioration in school performance (e.g sport, handwriting) is always significant.
|Concerns Worries & Beliefs
||What are their concerns?
||Family history of muscle disease, arthritis or autoimmune disease may indicate a predisposition to muscle or joint disease. Observed ‘abnormalities’ (such as flat feet, curly toes) may be part of normal development but cause concern. The parent or carer, child or young person, may have anxieties and concerns about severe illness and investigations.