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NURS323 – Foundational Skills and Competencies for Clinical Practice III (FSCPIII)
Pediatric Head to toe assessment
1. INTRODUCTION
Assessment of children's health covers several assessment areas and requires a wide variety of skills.
It is essential that assessment be incorporated during family visits in the community and in the daily
care of hospitalized children. Screening for normal growth and development contributes to an
accurate evaluation of a child's health status.
The purpose of this lab is to assist the student to appreciate child-specific assessment findings and
adapt physical assessment skills to children in a developmentally appropriate way. This will support
the student to develop and apply history-taking and communication skills in the paediatric setting.
2.
LEARNING OBJECTIVES
Upon completion of this module, you will be able to:
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Understand concepts basic to the focused and comprehensive assessment of children.
Identify major anatomical and physiological differences between infants, children, and adults.
Apply specific facts about children's growth and development in history taking and examination.
Learn about appropriate communication with children and their parents while taking a history
and performing a physical examination.
Use ABCDs and the Pediatric Assessment Triangle to immediately identify urgent red flags in
assessment. Use the focused assessment approach to systematically collect objective data
pertinent to a child’s health status.
RESOURCES
Preparation for the Lab:
Review module objectives and pre-lab preparation.
Growth & Development
Read relevant NURS346 class readings and lecture material for pediatric assessment, and Growth &
Development lectures.
Pediatric Foundations Online Module (via LearningHub)
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NB: While this is to be completed prior to the first practice learning day it is invaluable to complete
prior to the scheduled pediatric assessment lab.
READ
Hockenberry, M. J. & Wilson, D. (2019). Wong’s nursing care of infants and children, (11th ed.).
Chapter 4: Communication, Physical and Developmental Assessment. St Louis: Mosby.
Communication, Physical and Developmental Assessment
• Establishing a setting for communication
Communicating with Families
• Communicating with Children
• Communication Techniques
• Box 4-3: Creative Communication Techniques with Children
• Performing a health History
• Box 4-4: Outline of a pediatric Health History
• General Approaches toward examining the child
• Physical Examination
• General Appearance
• Skin
• Head and Neck
• Mouth and Throat
• Chest and Lungs
• Heart
• Abdomen
• Back and Extremities
• Neurological Assessment
SUPPLEMENTAL RESOURCES
Bates’ Visual Guide to Physical Examination, 5th edition (Streaming Videos). Wolters Kluwer available through the UBC Library – on the Library homepage search Bates under Indexes and
Databases to locate the link to the resources.
https://resources.library.ubc.ca/page.php?details=bates-visual-guide-to-physical-examination-5thedition&id=2421
1. Head-to-toe Assessment: Infant
2. Heat-to-toe Assessment: Child
OPEN Pediatrics Videos (available on You Tube or through OPEN Pediatrics at
https://learn.openpediatrics.org Search “Videos and Courses for Nursing Students”
Examples include
- Recognizing Respiratory Distress
- Pain Assessment
- Cardiovascular Assessment
- Common pediatric respiratory problems
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4.
KEY CONCEPTS RELATED TO THIS LAB
When working with children, the basic skills of assessment must be adapted. For example, when
interviewing, the informant will often be the parent or when completing the physical examination,
new approaches are required. In addition, knowledge regarding different normal values for children
is necessary to accurately interpret the findings.
Students are expected to be familiar with the normal parameters for children of different ages. The
orientation to assessment of children will be introduced in NURS346 and will be reinforced by
demonstration, practice, and discussion during lab, and clinical practice in the community and the
hospital experience.
4.1
Paediatric Assessment Triangle (PAT)
Review PAT in the Pediatric Foundations online module. Your initial assessment can be
framed using the PAT. The PAT should give you a sense of how your client is doing. This is the
time to complete any immediate interventions.
Video: https://youtu.be/Hv3Bi3o5UmU
General Appearance
Gives the nurse insight into basic neurological function and how well the body is compensating
for illness
- Does the child look ill?
- Is the child playful?
- Is the child alert, crying, sleepy or unresponsive?
- How is the child interacting with the environment and caregiver?
- Is the child’s behaviour appropriate for their developmental age?
Work of Breathing
- Are there audible airway sounds?
- Is the child coughing or drooling?
- How is the child’s breathing (i.e. rapid, laboured, shallow)?
- What is the respiratory rate and is it normal for their age?
- Are they using any accessory muscles?
Circulation to the Skin
Remember good perfusion is indicative of vital functions - What is the skin colour? (i.e. pale, cyanotic, mottled)
- Are they flushed?
- Are they diaphoretic?
- Are there overt signs of bleeding?
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If the PAT reveled a stable client, then you can progress to a full systems assessment head-to-toe
including:
- Vital signs
- Cardiovascular
- Pain
- Gastrointestinal (GI)
- Neurological
- Genitourinary (GU)
- Respiratory
- Skin
Refer to documents available on ePOPS http://policyandorders.cw.bc.ca/:
Pediatric Inpatient Nursing Assessment
Instructions for use of BCCH & SHHC Inpatient flowsheet - provides standardized instructions for
the use of the inpatient flowsheet at BC Children’s Hospital and Sunny Hill Health Centre
4.2
Obtaining the Child’s History
General areas essential in a nursing assessment of a pediatric client.
The nurse should be aware of the developmental history as well as the medical history of the
child.
The developmental history includes the following:
- Family relationships and support systems
- Cultural needs that may affect care and hospital routine
- Nicknames, rituals, and routines
- Developmental level and abilities
- Communication skills
- Personality, adaptability, and coping skills
- Past experiences, divorce, new siblings, and extended family
- Previous separation experiences-vacations or hospitalizations
- Impact of current health problem on growth and development
- Preparation given the child
- Previous contact with health care personnel.
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Introduce yourself
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Explain the purpose of the interview
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Provide privacy, establish confidentiality
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Direct the focus of the interview with open-ended questions, use close-ended questions to
obtain specific information or to clarify information ie) “Tell me what problems led to
Robert’s admission to hospital?” & “How high was Tommy’s fever this morning?”
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Ask one question at a time. “Does anyone in the family have asthma, heart disease or
diabetes?” is a multiple question – ask one at a time for better accuracy.
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Involve the child in the interview by asking age-appropriate questions. “Where does it
hurt?” Offer teens/school age children the opportunity to discuss major concerns in privacy.
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Be honest, building trust is essential. Give accurate simple answers to questions.
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Choose the language style best understood by the child and parent. Request feedback to
clarify with their interpretation of information.
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Use an interpreter to improve communication when you are not fluent in family’s primary
language.
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Listen CAREFULLY: complete attention is required to “hear” and accurately interpret
information
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Listen to information provided by the parents, how it is expressed, and observe behaviour
during the interaction
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Be alert to underlying themes. For example, the parent who talks about the child’s
diagnosis but repeatedly refers to the impact of the illness on the family’s finances or on
meeting the needs of the other family members, is requesting that these issues be
addressed
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Observe the parent’s non-verbal behaviour
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Is the parent interested in and appropriately concerned about the child’s condition?
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Being supportive and respectful. If a parent or child hesitates to answer questions, clarify
with them the purpose of asking and how the information will be used (confidentiality).
5.
LAB ACTIVITIES
Ac#vity #1 Demonstra#on of a focused assessment of an infant or child
As a large group observe the lab facilitator demonstra6on of the assessment of the pediatric
client. Be prepared to ask and answer ques6ons related to the assessment.
Ac#vity #2 Prac#ce conduc#ng a pediatric assessment
Working in pairs (or groups of three if necessary) take turns comple6ng a pediatric
assessment on the child and infant simula6on mannequins. Specific differences between
adult and child anatomy and physiology will be highlighted. Discuss different approaches
one might use for different age groups. Focus on how the findings change with growth and
development.
Differences related to the Anatomy & Physiology in Children
Respiratory/Airway
- Large tongue rela6ve to small nasal and oral airways
- Short narrow trachea
- Infants 4-6 wks are obligate nasal breathers
- Smaller lung capacity
- Diaphragma6c breathing
- Higher O2 needs, higher metabolic rate
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Cardiovascular
- Smaller total circulating blood volume so even small losses may be significant
- Can maintain cardiac output for long periods
Neurological
- Unstable temperature control (high and lows)
- Large head relative to body size – more prone to head injury
- Cranial structures not fused until 18 months
Metabolic/Renal
- Larger relative body surface area (hypothermia)
- Larger % of extracellular fluid (increases susceptibility to dehydration)
- Immature kidneys (infants do not concentrate urine effectively)
- Limited glycogen storage
*** for all the above consider what the implications of these differences might be… i.e. short
and narrow trachea means that they are at significantly higher risk for airway obstruction
The “Across the Room Assessment” – The pediatric assessment triangle (PAT)
1. Notice the child’s general appearance
o Is s/he playful and energetic or lethargic and unresponsive?
o Is s/he clean?
o Do you see any rashes or bruises?
2. Behaviour
o Is the child behaving in a way that is considered normal for their stage of growth
and development of their physiological diagnosis?
3. Who is with the child?
o Are they interacting?
o How do they communicate?
o How does the child respond to their adult caregiver?
***Safety checks***
4. ABCD’s
o Airway
§ Patent?
§ Positioning
o Breathing
§ Is the child’s breathing rapid, laboured, noisy or shallow?
§ Any signs of respiratory distress?
o Circulation
§ Skin – pink? Mottled? Cyanotic? Flushed?
§ Diaphoretic?
§ Any bleeding?
o Disability
§ Neurological status
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Awake? alert? sleepy? confused? unusual behaviour? consolable?
5. RED FLAGS
o Any concerns with the above? i.e.
§ airway patency
§ respiratory distress or apnea
§ active bleeding or cyanosis
§ altered level of consciousness
STOP THE ASSESSMENT and address these issues before proceeding!
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