Pediatric Physical Assessment

Summer 2010Susan Beggs, RN MSN CPN

Common considerations

• Communication strategies• Identifiers• Questioning of the child or parent

• Strategies to gain cooperation• Introductions• Removing distractions• Privacy• Awareness of growth and development

milestones

Data to be collected

• Data from birth to current status (the complete history)

• Well history

• Problem-oriented history

• Psychosocial data

• Physiologic data

• Daily routines, issues that impact daily living

Pediatric Assessment vs. Adult Assessment

• Developmental approach

• Order of the exam

• Differences in findings in pediatric client

• Assessments for congenital anomalies

• Documentation of findings

• Assistance by parent

Beginning the assessment Exam begins with

the 1st mtg All measurements

are taken: wt, ht, head circumference

Should be plotted to obtain the percentile

Pediatric Assessment vs. Adult Assessment

Developmental approach Order of the exam Differences in findings in pediatric client Assessment for congenital anomalies Documentation of findings Assistance by the parent present

Review of symptoms Developmental

approach to the exam

Young child: foot to head

Older child: head to toe

Exam techniques Vary by the age of the child Build rapport with the family Develop cultural competence Involve the child in the interview if age

appropriate Be honest with the child when answering

questions Utilize “careful listening”

Nursing Practice techniques for physical

assessment

Inspection Palpation Auscultation Percussion

Normal findings in children

Small, firm, nontender, and shotty lymph nodes may be palpable

Tonsils of varying sizes; often larger in young children

Pupils of equal size, round and reactive to light and accommodation

Pulses in upper and lower extremities; bilaterally symmetric

Terminology for head shape

Normocephalic Microcephalic Macrocephalic Bossing

Physical exam Skin: perfusion, turgor, color, lesions Hair: distribution, loss, lice, pubic areas Head/skull: symmetry, circumference,

sutures in infants Eyes/ears: *red reflex, TM, muscles of

the eye, lacrimal glands, conjunctiva

Physical exam, cont. Lips, tongue, gums, palate, teeth Neck: movement, nodes, thyroid Chest: shape, movement, effort, function

A B

Funnel chest (Pectus excavatum) pigeon chest

(pectus carinatum)

Physical Assessment Heart sounds: murmurs, apical rate,

arrhythmias, blood pressure, and rhythm Abdomen: shape, bowel sounds,

underlying organs Genitals: Preparation for the exam crucial!

Include the anus and rectum, assessment for pubertal development and sexual maturity

Physical Assessment, cont.

Musculo/skeletal system: one and joints, ROM, strength, posture, spinal alignment

Inspection of the limbs Nervous system: cognition, balance,

CN function, language, reflexes

Physical exam of dark-skinned children

Erythema: dusky red or violet Cyanosis: black or dusky Jaundice: diffusely darker than the

child’s normal color

Psychosocial Assessment

Home environment Employment and education Eating Activities Drugs (substance use) Sexuality Suicide/depression Safety

Suspicions of child abuse/neglect detected

during assessment Dress Grooming and personal hygiene Posture and movements Body image Speech and communication Facial characteristics and expressions Psychologic state

Concluding the exam What questions should be asked at the

end of every interview?

Ask yourself… What if a 14 year old girl weighs 93 lbs. Would the

nurse be concerned? What if she weighed 110 lbs 6 months earlier? What if a year earlier she had weighed 105 lbs?

Ask yourself…. A 2 yr old child being seen for well

check is resistant to the exam. What techniques would be helpful for the nurse to use with a toddler?

Another challenge…. Kelly, aged 15 months, comes in for a

well child check. How would the nurse assess height and weight?

Critical thinking after the exam

Compiling the data Describing the elements

of the health history Modifying assessments

based on ages Determining the sexual

maturity Recognizing 5 important

signs of a serious alteration that require urgent attention

Critical thinking exercise

Leah, 17 years old, is a single mother who brings her 6 month old child to the clinic. Leah has not kept her appointments the last two months. She reports, “I hate to take time off work when she is well but my supervisor said it was important for her to get a checkup; I guess I messed up”

Part II: Medications for the pediatric patient

Small, very accurate dosages All medications ordered must be

calculated by the nurse (and you!) All weights based on

kilograms/milligram

Calculations of the medications

Nurse is responsible for the accurate ADMINISTRATION of the medication

The most accurate ADMINISTRATION is performed by the nurse calculating the dosage before giving to the patient

Let’s calculate John weighs 8.2 kg. The dr. orders

Ampicillin 200 mg. q 6 hrs. (dosage is 25mg/kg) Is this an appropriate amount?

Sarah, age 12 and weighing 44 kg, has a temp of 102. the dr. has ordered tylenol 81 mg q 6 for fever above 101.8. Is this an appropriate dose for Sarah?

Syringe pump vs. Plum®

How do you make the decision about the type of pump to use?

All meds given IV are administered on a pump

Making the decision….

Let’s Have a Great Rotation!