PEDIATRIC ASSESSMENT. ESSENTIAL PEDIATRIC NURSING SKILLS Knowledge of Growth and Development ...

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 1st year. Every 3 month of the 2nd and 3rd year. Each 6 month of 4th and 5th year. Yearly after the 6th 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.

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

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?

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

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

Facial expression Posture /

movement Hygiene Behavior Developmental

Status

General Appearance & Behavior

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 – NORMAL RANGES

Heart Rate 80-150 70-110 60-110 60-

100

Respiratory Rate 24-38 22-30 14-22 12-

22

Systolic blood pressure 65-100 90-105 90-120 110-

125

Diastolic blood pressure 45 - 65 55-70 60-75

65-85

Infant Toddler School-Age Adolescent

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

Warm hands and short nails

Palpate areas of tenderness / pain last

Talk with the child during palpation to help him relax

Be observant of reactions to palpation

Move firmly without hesitation

H E E N T

HeadEyes

EarsNose

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: “NormoCephalic –

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 MENINGITISClinical 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 (check for blanching) “Looks Sick”

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

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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

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

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

Auscultation

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 RespirationsStridorWheezing

CHEST ASSESSMENT

Auscultation Wheezing Retractions

Subcostal Intercostal Sub-sternal Supra-clavicularRed 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

• AUSCULTATING HEART SOUNDS

Pillitter

Circulatory

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

• Perfusion – capillary refill• “Warm to touch”

ABDOMINAL ASSESSMENT

Pillitteri

Gastro-Intestinal

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 umbilicusWhenever 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?

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

Stomachaches and Abdominal Pain

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

Medline.com

Key Points:

• Barefoot• Feet Together• Bend Over –”Diving Of a Diving Board”• Check Hips

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 Home life Emotions /

Depression or Education

Activities Drugs /

Alcohol / Substance Abuse

Sexuality activity or Suicide

SHADESS• School• Home• Activities• Drugs / Substance Abuse

• Emotions / Depression

• Sexuality• Safety

COMMON SCHOOL HEALTHFOCUSED 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 Stomachach

es 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