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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 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