PEDIATRIC ASSESSMENT

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PEDIATRIC ASSESSMENT

ESSENTIAL PEDIATRIC NURSING SKILLS

           Knowledge of Growth and Development Development of a Therapeutic Relationship Communication with children and their parents Understanding of family dynamics and parent-child relationships: IDENTIFY KEY FAMILY MEMBERS Knowledge of Health Promotion & Disease Prevention Patient Education and Anticipatory Guidance Practice of Therapeutic and Atraumatic Care Patient and Family Advocacy Caring, Supportive & Culturally Sensitive Interactions Coordination and Collaboration CRITICAL THINKING

INTRODUCTION

 Key elements.

 Times:  Every month in the 1 st year.

 Every 3 month of the 2 nd and 3 rd year.

 Each 6 month of 4 th and 5 th year.

 Yearly after the 6 th year.

PHYSICAL EXAM

 Avoid touching painful areas until confidence has been gained.

 Begin exam without instruments.

 Allow child to determine order of exam if practical.

 Use the same format as adult physical exam.

INFANT EXAM

 Examine on parent lap.

 Leave diaper on.

 Comfort measures such as pacifier or bottle.

 Talk softly.

 Start with heart and lung sounds.  Ear and throat exam last.

TODDLER EXAM

 Examine on parent lap if uncooperative.

 Use play therapy.

 Distract with stories.

 Let toddler play with equipment / BP.

 Call by name.

 Praise frequently.

 Quickly do exam.

HISTORY

Personal Hx., Life styles, Health Hx. (past and current), and Family Hx.      

Bio-graphic Demographic

Name, Date of Birth, Age Parents & siblings info Cultural practices Religious practices Parents’ occupations Adolescent – work info

Past Medical History

•Allergies •Past illness •Trauma / hospitalizations •Surgeries •Birth history •Developmental •Family Medical/Genetics

Current Health Status

•Immunization Status •Chronic illnesses or conditions •What concerns do you have today?

EQUIPMENT

WHAT’S IN YOUR SETTING?

Stethoscope & Sphygmomanometer

Pen Light

Otoscope / Opthalmoscope

Scale

REVIEW OF SYSTEMS

 Ask questions about each system  Measurements: weight, height, head circumference, growth chart, BMI  Nutrition: breastfed, formula, favorite foods, beverages, eating habits  Growth and Development: Milestones for each age group

PHYSICAL EXAM TECHNIQUE

 Inspection- eye only.

 Palpation- tip of finger.

 Percussion- use. . .

 Dullness (solid organ), resonance (over solid organ or filled air), tympanic (hollow organ).

 Auscultation- stethoscope.

HISTORY: REVIEW OF SYSTEMS

     Skin HEENT Neck Chest & Lungs / Respiratory Heart & Cardiovascular      GI GU & GYN Musculoskeletal & Extremities Neuro Endocrine

 Sleep & Activity  Appetite  Bowel & Bladder  In a time crunch, these three questions should give you enough insight into the child’s general functioning –  Can get more detailed if any (+) responses

PHYSICAL ASSESSMENT

 The approach is:   

Orderly Systematic Head-to-toe

   But FLEXIBILIY is essential And be kind and gentle but firm, direct and honest

PHYSICAL ASSESSMENT

General Appearance & Behavior

 Facial expression  Posture / movement  Hygiene  Behavior  Developmental Status

VITAL SIGNS

 Temperature: rectal only when absolutely necessary  Pulse: apical on all children under 1 year  Respirations: infant use abdominal muscles  Blood pressure: admission base line  And the “Fifth” Vital Sign is ____ ?

PEDIATRIC VITAL SIGNS

RANGES NORMAL

Infant

Heart Rate 80-150

Toddler

70-110

School-Age

60-110

Adolescent

60-100  Respiratory Rate 24-38 22-30  Systolic blood pressure 65-100 90-105  Diastolic blood pressure 45 - 65 55-70 14-22 90-120 60-75 12-22 110-125 65-85

PHYSICAL ASSESSMENT

 General  Skin, hair, nails  Head, neck, lymph nodes  Eyes, ears, nose, throat  Chest, Tanner Scale  Heart  Abdomen  Genitalia, Tanner Scale,  Rectal  Musculoskeletal: feet, legs, back, gait

PALPATION

 Use of your fingers and palms to determine:       Temperature Hydration Texture Shape Movement Areas of Tenderness    short nails Palpate areas of tenderness / pain last Talk with the child during palpation to   reactions to palpation Move firmly without hesitation

H E E N T

Head Eyes Ears Nose Neck Throat

HEENT:

HEAD & NECK, EYES, EARS, NOSE, FACE, MOUTH & THROAT  Head: Symmetry of skull and face  Neck: Structure, movement, trachea, thyroid, vessels and lymph nodes  Eyes: Vision, placement, external and internal fundoscopic exam  Ears: Hearing, external, ear canal and otoscopic exam of tympanic membrane  Nose: Structure, exudate, sinuses  Mouth: Structures of mouth, teeth and pharynx

HEAD

  

Shape: “N

ormoCephalic ATraumatic

” Lesions ? Edema –

HEAD: KEY POINTS

        Head Circumference (HC Fontannels/sutures: Anterior closes at 10-18 months, posterior by 2 months Symmetry & shape: Face & skull Bruits: Temporal bruits may be significant after 5 yrs Hair: Patterns, loss, hygiene, pediculosis in school aged child Sinuses: Palpate for tenderness in older children Facial expression: Sadness, signs of abuse, allergy, fatigue Abnormal facies: “Diagnostic facies” of common syndromes or illnesses

NEURO ASSESSMENT  LOC / Glasgow coma scale  Pupil size  Vital Signs  Pain  Seizure Activity  Focal Deficits

BACTERIAL MENINGITIS

Clinical Manifestations in an Older Child

  High fever Headache   LOC Changes / GCS

Nuchal rigidity

/ stiff neck     + Kernigs = inability to extend legs + Brudzinski sign = flexion of hips when neck is flexed

Purple rash “Looks Sick”

(check for blanching)

EYES

     PERRR Red Reflex Corneal Light Reflex Strabismus:   Alignment of eye important due to correlation with brain development May need to corrected surgically Preschoolers should have vision screening  Refer to ophthalmologist is there are concerns o

EYES: KEY POINTS

           Vision: Red reflex & blink in neonate Examine external structure of the: 1- Conjunctiva- glassy 2- Sclera- clear 3- Cornea- cover the iris and pupil 4- pupils- compare for size, shape, test for reaction.

5- Iris- color, size and clarity. 6-12 M.

Snellen chart for older children Irritations & infections PERRL Amblyopia (lazy eye): Corneal light reflex, binocular vision, cover-uncover test

EARS: KEY POINTS

        Ask about hearing concerns   Inquire about infant’s response to Observe an older infant’s/toddlers speech pattern Inspect the ears •Assess the shape of the ears Determine if both ears are well formed •Assess External shape and size.

Pinna: line, low set ear (retardation).

Internal structure.

EAR EXAM

Pinna is pulled down and back to straighten ear canal in children under 3 years.

COMMON EAR INFECTIONS

Otitis Media     Most common reason children come to the pediatrician or emergency room Fever or tugging at ear Often increases at night when they are sleeping History of cold or congestion     Infection can lead to rupture of ear drum.

Chronic effusion can lead to hearing loss.

OM is often a contributing factor in more serious infections: mastoiditis, cellulitis, meningitis, bacteremia.

Chronic ear effusion in the early years may lead to decreased hearing and speech problems.

NOSE & THROAT / MOUTH

        Exudate Pharynx Tonsils Signs & Symptoms of Allerg     Assess for symmetry, deformity, skin lesion.

  Palpate for septal deviation.

 Smooth and moist, with pinkish color.

ic Rhinitis Palate Gums Swallow Oral Hygiene Condition of teeth Missing teeth Orthodontic Appliances

NOSE: KEY POINTS

 Exam nose & mouth after ears  Observe shape & structural deviations  Nares: (check patency, mucous membranes, discharge, turbinates, bleeding)  Septum: (check for deviation)  Infants are obligate nose breathers  Nasal flaring is associated with respiratory distress

NOSE AND THROAT

Sinusitis:

 Fever  Purulent rhinorrhea  Facial Pain – cheeks, forehead  Breath odor  Chronic cough – could be day and night  (+) Post-nasal drip

MOUTH & PHARYNX: KEY POINTS

       Lips: color, symmetry, moisture, swelling, sores, fissures Buccal mucosa, gingivae, tongue & palate for moisture, color, intactness, bleeding, lesions.

Tongue & frenulum - movement, size & texture Teeth - caries, malocclusion and loose teeth.

Uvula: symmetrical movement or bifid uvula Voice quality, Speech Breath - halitosis

EARS, NOSE AND THROAT Sore Throats

Is it strept or is it viral or could it be mono?

Lymph nodes & ROM

NECK: KEY POINTS

       √ position, lymph nodes, masses, fistulas, clefts Range of Motion (ROM) Check clavicle in newborn Head control in infant Trachea & thyroid in midline Carotid arteries (bruits) Meningeal irritation

Chest Assessment

• How does the child look? • Color • Work of Breathing: Effort used to breathe

Auscultation

 All 4 quadrants  Front and back  Take the time to listen  Be sure about “lungs CTAB” (clear to auscultation bilaterally)

CHEST

 Anatomy.  Inspection: symmetry, movement of chest wall.

 Breathing pattern- abdominal breathing.

 Palpation:  1- light palpation: in light circular motion to detect lesion and masses  2- deep palpation: palpate for internal organ like liver and spleen.

LUNGS & RESPIRATORY: KEY POINTS

 Clubbing  Snoring (expiratory): upper airway obstruction, allergy,  Dullness to percussion: fluid or mass

Increased or Decreased Respirations Stridor Wheezing

CHEST ASSESSMENT

   Auscultation Wheezing Retractions   Subcostal Intercostal   Sub-sternal Supra-clavicular Red Flags:  grunting   nasal flaring stridor

ALL THAT WHEEZES ISN’T ALWAYS ASTHMA…

Think:  Infection   Foreign body aspiration Anaphylaxis  Insect bites/stings, medications, food allergies

AND ALL ASTHMA DOESN’T ALWAYS WHEEZE!

Cough

Fatigue

Reduced exercise tolerance

COUGH - CHARACTERISTICS

 Dry, non-productive  Mucousy – productive  Croupy  Acute – less than 2-3 weeks  Chronic – more than 2-3 weeks  Associating Symptoms

Circulatory

AUSCULTATING HEART SOUNDS The Auscultation Assistant – and Breath Sounds. Hear Heart Murmurs, Heart Sounds, http://www.wilkes.med.ucla.edu/inex.htm

Pillitter •Perfusion

– capillary refill

“Warm to touch”

Gastro-Intestinal

ABDOMINAL ASSESSMENT

Pillitteri

ABDOMEN

 Use supine position with pillow under the head and knee flexed.

 Divide abd. to 4 Quadrant, and examine from button to top.

 Examination of the abdomen involve the inspection, auscultation, palpation and percussion.

ABDOMEN: KEY POINTS

        Contour Bowel Sounds & Peristalsis Skin: color, veins Umbilicus Assess for Tenderness, Ridigity, Tympany, Dullness Hernias: umbilical, inguinal, femoral Masses - size, shape, dullness, position, mobility Liver, Spleen, Kidneys, Bladder

ABDOMINAL GIRTH

Abdominal girth should be measured over the umbilicus Whenever possible.

BOWEL SOUNDS

 Normal: every 10 to 30 seconds.

 Listen in each quadrant long enough to hear at least one bowel sound.

 Absent  Hypoactive; peritonitis, paralytic illeus  Normoactive  Hyperactive, GE, Intestestinal obs.

STOMACHACHES AND ABDOMINAL PAIN

 Excessive gas  Chronic constipation  Lactose intolerance  Viral gastroenteritis  Irritable bowel syndrome  Heartburn or indigestion  GERD  Food allergy  Parasite infections (Giardia) What are we most concerned about?

Stomachaches and Abdominal Pain

 Appendicitis  Bowel obstruction - Cholecystitis with or without gallstones  Food poisoning (salmonella, shigella)  Inflammatory Bowel Disease –  Ulcerative colitis  Hernia  Intussusception  Kidney stones  Pancreatitis  Sickle cell crisis  Ulcers  Urinary tract infections

SIGNS AND SYMPTOMS

        Appearance –color, facial, ROM, gait, position Pain – get your pain scales out Nausea Vomiting Diarrhea Bloating Vomiting Inability to pass gas or stool

MUSCULO-SKELETAL

        FROM, MAE - neck, shoulder, elbow, wrist, hip, knee, ankle, foot, digits Alignment, contour, strength, weakness & symmetry Limb, joint mobility: stiffness, contractures Gait – observe child walking without shoes Spinal alignment - Scoliosis Muscle Strength & Tone Hips – O & B Reflexes

 Bone, joints-cartilages, ligaments and muscles.

 Inspect the joint for flexion and extension, abduction, adduction, rotation.

 Inspect the symmetry and observe the edema.

SCOLIOSIS

Lateral curvature of spine

Key Points: • Barefoot • Feet Together • Bend Over –”Diving Of a Diving Board” • Check Hips Medline.com

ASSESSMENT

 The Five P’s:  Pain  Paresthesia  Passive stretch  Pressure  Pulse-less-ness

SKIN, NAILS & HAIR

       

Rashes Lesions Lacerations Lumps Bumps Bruises Bites Infections

COMMON SKIN LESIONS

         Macule Papule Vesicle, bulla Pustule Cyst Patch Plaque Wheal Striae         Scale Crust Keloid Fissure Ulcer Petechiae Purpura Ecchymosis  Capillary bleeding: Petichiae and purpura usually indicate serious conditions

SKIN INFECTIONS

 Bacterial infections  Abscess formation  Severity varies with skin integrity, immune and cellular defenses  Examples:  impetigo  cellulitis

THE SCHOOL-AGE CHILD

 Privacy and modesty.  Explain procedures and equipment.

 Interact with child during exam.

ADOLESCENT

    Privacy issues – first consideration HEADS: home life, education, alcohol, drugs, sexual activity / suicide GAPS Guidelines for Adolescent Preventive Services Bright Futures

PSYCHOSOCIAL ASSESSMENT

HEADS

H ome life

 

E E motions / Depression or ducation A ctivities

 

D rugs / Alcohol / Substance Abuse S S exuality activity or uicide SHADESS

S

chool

H

ome

A

ctivities

D

rugs / Substance Abuse

E

motions / Depression

S

exuality

S

afety

COMMON SCHOOL HEALTH FOCUSED ASSESSMENTS    

The “I don’t feel good”

where do I begin?

Behavioral / Mental Health Concerns Chronic Conditions & Special Needs

What Else?

THE

“I DON’T FEEL GOOD”

THE FREQUENT FLIERS

Headaches

Stomachaches

 

Nosebleeds Chest Pain

Coughs

& Fevers

THE POWER OF NURSING

Never doubt how vitally important you are; never doubt how important your work is – and never expect anyone to acknowledge it before you do. Every moment, in everything you do, you are making a difference. In fact, you are in the business of making a difference in other people’s lives. In that difference lies their healing and your power. Never forget it.

Leah L. Curtin, RN, MS, MA, DSC, FAAN

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