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
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.
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.
Examine on parent lap.
Leave diaper on.
Comfort measures such as pacifier or bottle.
Start with heart and lung sounds. Ear and throat exam last.
Examine on parent lap if uncooperative.
Use play therapy.
Distract with stories.
Let toddler play with equipment / BP.
Call by name.
Quickly do exam.
Personal Hx., Life styles, Health Hx. (past and current), and Family Hx.
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?
Stethoscope & Sphygmomanometer
Otoscope / Opthalmoscope
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
Inspection- eye only.
Palpation- tip of finger.
Percussion- use. . .
Dullness (solid organ), resonance (over solid organ or filled air), tympanic (hollow organ).
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
The approach is:
Orderly Systematic Head-to-toe
But FLEXIBILIY is essential And be kind and gentle but firm, direct and honest
General Appearance & Behavior
Facial expression Posture / movement Hygiene Behavior Developmental Status
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 ____ ?
Heart Rate 80-150
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
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
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
Head Eyes Ears Nose Neck Throat
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
” Lesions ? Edema –
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
Clinical Manifestations in an Older Child
High fever Headache LOC Changes / GCS
/ stiff neck + Kernigs = inability to extend legs + Brudzinski sign = flexion of hips when neck is flexed
Purple rash “Looks Sick”
(check for blanching)
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
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
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).
Pinna is pulled down and back to straighten ear canal in children under 3 years.
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.
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
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
Fever Purulent rhinorrhea Facial Pain – cheeks, forehead Breath odor Chronic cough – could be day and night (+) Post-nasal drip
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
Is it strept or is it viral or could it be mono?
Lymph nodes & ROM
√ 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
• How does the child look? • Color • Work of Breathing: Effort used to breathe
All 4 quadrants Front and back Take the time to listen Be sure about “lungs CTAB” (clear to auscultation bilaterally)
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.
Clubbing Snoring (expiratory): upper airway obstruction, allergy, Dullness to percussion: fluid or mass
Increased or Decreased Respirations Stridor Wheezing
Auscultation Wheezing Retractions Subcostal Intercostal Sub-sternal Supra-clavicular Red Flags: grunting nasal flaring stridor
Think: Infection Foreign body aspiration Anaphylaxis Insect bites/stings, medications, food allergies
AND ALL ASTHMA DOESN’T ALWAYS WHEEZE!
Dry, non-productive Mucousy – productive Croupy Acute – less than 2-3 weeks Chronic – more than 2-3 weeks Associating Symptoms
•AUSCULTATING HEART SOUNDS The Auscultation Assistant – and Breath Sounds. Hear Heart Murmurs, Heart Sounds, http://www.wilkes.med.ucla.edu/inex.htm
– capillary refill
“Warm to touch”
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.
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 should be measured over the umbilicus Whenever possible.
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.
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?
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
Appearance –color, facial, ROM, gait, position Pain – get your pain scales out Nausea Vomiting Diarrhea Bloating Vomiting Inability to pass gas or stool
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.
Lateral curvature of spine
Key Points: • Barefoot • Feet Together • Bend Over –”Diving Of a Diving Board” • Check Hips Medline.com
The Five P’s: Pain Paresthesia Passive stretch Pressure Pulse-less-ness
Rashes Lesions Lacerations Lumps Bumps Bruises Bites Infections
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
Bacterial infections Abscess formation Severity varies with skin integrity, immune and cellular defenses Examples: impetigo cellulitis
Privacy and modesty. Explain procedures and equipment.
Interact with child during exam.
Privacy issues – first consideration HEADS: home life, education, alcohol, drugs, sexual activity / suicide GAPS Guidelines for Adolescent Preventive Services Bright Futures
H ome life
E E motions / Depression or ducation A ctivities
D rugs / Alcohol / Substance Abuse S S exuality activity or uicide SHADESS
rugs / Substance Abuse
motions / Depression
COMMON SCHOOL HEALTH FOCUSED ASSESSMENTS
The “I don’t feel good”
– where do I begin?
Behavioral / Mental Health Concerns Chronic Conditions & Special Needs
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