Transcript PEDIATRIC ASSESSMENT

PEDIATRIC
ASSESSMENT
ESSENTIAL PEDIATRIC NURSING SKILLS
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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.
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PHYSICAL EXAM
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.
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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.
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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.
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HISTORY
Personal Hx., Life styles,
Health Hx. (past and current), and Family Hx.
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?
EQUIPMENT
WHAT’S IN YOUR SETTING?
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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
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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.
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HISTORY: REVIEW OF SYSTEMS
Skin
 HEENT
 Neck
 Chest & Lungs /
Respiratory
 Heart &
Cardiovascular
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GI
 GU
 Musculoskeletal
& Extremities
 Neuro
 Endocrine
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Sleep & Activity
 Appetite
 Bowel & Bladder
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PHYSICAL ASSESSMENT
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The approach is:
 Orderly
 Systematic
 Head-to-toe
But FLEXIBILIY is essential
 And be kind and gentle
 but firm, direct and honest
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PHYSICAL ASSESSMENT
General Appearance & Behavior
 Facial expression
 Posture / movement
 Hygiene
 Behavior
 Developmental Status
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 ____ ?
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PEDIATRIC VITAL SIGNS – NORMAL
RANGES
Infant
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Toddler
School-Age
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
Heart Rate
100- 150
Adolescent
PHYSICAL ASSESSMENT
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General
Skin, hair, nails
Head, neck,
lymph nodes
Eyes, ears, nose,
throat
Chest, Tanner Scale
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Heart
Abdomen
Genitalia
Rectal
Musculoskeletal: feet,
legs, back, gait
PALPATION
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Use of your fingers
and palms to
determine:
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Temperature
Hydration
Texture
Shape
Movement
Areas of
Tenderness
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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
Head
Eyes
Ears
Nose
Neck
Throat
HEENT: HEAD & NECK, EYES, EARS, NOSE,
FACE, MOUTH & THROAT
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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
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Shape:
“NormoCephalic –
ATraumatic”
Lesions
? Edema
HEAD: KEY POINTS
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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
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LOC / Glasgow coma scale
Pupil size
Vital Signs
Pain
Seizure Activity
Focal Deficits
EYES
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Red Reflex
Corneal Light Reflex
Strabismus:
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Alignment of eye important due to
correlation with brain development
May need to corrected surgically
Preschoolers should have vision
screening
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Refer to ophthalmologist is there
are concerns
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EYES: KEY POINTS
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Vision: Red reflex & blink in neonate
Examine external structure of the:
1- Conjunctiva
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.
Irritations & infections
EARS: KEY POINTS
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Ask about hearing concerns
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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.
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EAR EXAM
Pinna is pulled down and back to straighten ear canal in
children under 3 years.
NOSE & THROAT / MOUTH
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Exudate
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Pharynx
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Tonsils
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Signs & Symptoms of Allerg
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Assess for symmetry,
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deformity, skin lesion.
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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
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MOUTH & PHARYNX: KEY POINTS
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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
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.
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NECK: KEY POINTS
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√ 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
Chest Assessment
•How does the child look?
•Color
•Work of Breathing: Effort
used to breathe
Auscultation
All 4 quadrants
 Front and back
 Take the time to listen
 Be sure about “lungs CTAB”
(clear to auscultation bilaterally)
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LUNGS & RESPIRATORY: KEY POINTS
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Clubbing
Snoring (expiratory): upper airway obstruction, allergy,
Dullness to percussion: fluid or mass
Increased or Decreased Respirations
Stridor
Wheezing
CHEST ASSESSMENT
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Auscultation
Wheezing
Retractions
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Subcostal
Intercostal
Sub-sternal
Supra-clavicular
Red Flags:
 grunting
 nasal flaring
 stridor
ALL THAT WHEEZES
ISN’T ALWAYS ASTHMA…
Think:
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Infection
Foreign body aspiration
Anaphylaxis
 Insect bites/stings,
medications, food
allergies
AND ALL ASTHMA
DOESN’T ALWAYS WHEEZE!
 Cough
 Fatigue
 Reduced
tolerance
exercise
COUGH - CHARACTERISTICS
Dry, non-productive
 Mucousy – productive
 Croupy
 Acute – less than 2-3 weeks
 Chronic – more than 2-3 weeks
 Associating Symptoms
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Circulatory
•AUSCULTATING HEART SOUNDS
The Auscultation Assistant – Hear Heart Murmurs, Heart Sounds,
and Breath Sounds. http://www.wilkes.med.ucla.edu/inex.htm
Pillitter
•Perfusion – capillary refill
•“Warm to touch”
Gastro-Intestinal
ABDOMINAL ASSESSMENT
Pillitteri
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.
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ABDOMEN: KEY POINTS
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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
BOWEL SOUNDS
Normal: every 10 to 30 seconds.
 Listen in each quadrant long enough to hear at
least one bowel sound.
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Absent
 Hypoactive
 Normoactive
 Hyperactive
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STOMACHACHES AND
ABDOMINAL PAIN
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Excessive gas
Chronic constipation
Lactose intolerance
Viral gastroenteritis
Irritable bowel
syndrome
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Heartburn or
indigestion
GERD
Food allergy
Parasite infections
(Giardia)
What are we most concerned about?
Stomachaches and Abdominal Pain
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Appendicitis
Bowel obstruction -Cholecystitis with or without
gallstones
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Food poisoning
(salmonella, shigella)
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Inflammatory Bowel
Disease –
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Crohn's disease
Ulcerative colitis
Hernia
 Intussusception
 Kidney stones
 Pancreatitis
 Sickle cell crisis
 Ulcers
 Urinary tract
infections
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SIGNS AND SYMPTOMS
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Appearance –color, facial, ROM, gait, position
Pain – get your pain scales out
Nausea
Vomiting
Diarrhea
Bloating
Vomiting
Inability to pass gas or stool
Diagnostic breakdown of one year's admissions for
abdominal pain in a district general hospital.
Davenport, M. BMJ 1996;312:498-501
Copyright ©1996 BMJ Publishing Group Ltd.
Bottom Line: Acute or Not
Soft, non-tender,
non-distended
no rebound, no HSM,
no mass,
BS NA x 4Q
Can the child hop?
Ball & Bindler
MUSCULO-SKELETAL
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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
Pre-Participation Sports P.E. –
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NJ’s new guidelines:
http://www.state.nj.us/education/districts/ppeq.doc
SCOLIOSIS
Lateral curvature of spine
Key Points:
•Barefoot
•Feet Together
•Bend Over –
•Check Hips
Medline.com
SKIN, NAILS & HAIR
Rashes
 Lesions
 Lacerations
 Lumps
 Bumps
 Bruises
 Bites
 Infections
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COMMON SKIN LESIONS
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Macule
Papule
Vesicle, bulla
Pustule
Cyst
Patch
Plaque
Wheal
Striae
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Capillary
Scale
Crust
Keloid
Fissure
Ulcer
Petechiae
Purpura
Ecchymosis
bleeding: Petichiae and purpura
usually indicate serious conditions
SKIN INFECTIONS
Bacterial infections
 Abscess formation
 Severity varies with skin integrity, immune and
cellular defenses
 Examples:
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 impetigo
 cellulitis
THE SCHOOL-AGE CHILD
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Privacy and modesty.
Explain procedures
and equipment.
Interact with child
during exam.
ADOLESCENT
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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 HEALTH
FOCUSED ASSESSMENTS
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The “I don’t feel good”
– where do I begin?
Behavioral / Mental
Health Concerns
Chronic Conditions &
Special Needs
What Else?
COMMON SCHOOL HEALTH
FOCUSED ASSESSMENTS
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Emergencies & Trauma –
Allergic Reactions,
Asthma, Head, Abdomen,
Limb, Other
Skin – Rashes, Lacerations,
Lumps, Bumps & Bruises
The Frequent Fliers –
Headaches, Stomachaches,
Chest Pain, Coughs &
Fevers
Other HEENT
EMERGENCIES & TRAUMA
Allergic
Reactions
 Asthma
 Head
 Abdomen
 Limb
 Other
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BEHAVIORAL / MENTAL HEALTH
CONCERNS
 Developmental
Delays
 Depression
 Aggressive
Behaviors
 Suicide Risks
 Other Mental Health Issues
CHRONIC CONDITIONS & SPECIAL
NEEDS
 Asthma
 Diabetes
 Neuro – seizures
 Sickle Cell Anemia
 Cerebral Palsy
 ADHD
References
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Jan Chandler RN, MSN, CNS, PNP Pediatric Nursing: Nursing Care of
Children and Young Adults: Pediatric Physical Assessment
Colyar, M. Well Child Assessment for Primary Care Providers. Philadelphia,
PA: F.A. Davis Company.
Duderstadt, K. Pediatric Physical Examination.
St. Louis, MO: Mosby, Inc.
Engel, J. Pediatric Assessment 5th. Ed. St. Louis, MO: Mosby, Inc.
Wong’s Essentials of Pediatric Nursing 8th ed.
AAP Preparticipation Physical Evaluation. Available @ www.aap.org
Resource Manual for the Nurse in the School Setting http://www.emsc.org/school/frameschool.htm
American Medical Association Guidelines for Adolescent Preventive
Services (GAPS) http://www.ama-assn.org/ama/pub/category/2280.html
American School Health Association http://www.ashaweb.org
The Auscultation Assistant @ http://www.wilkes.med.ucla.edu/intro.html
BMI Calculator: http://www.cdc.gov/nccdphp/dnpa/bmi /
2007 Asthma Guidelines:
http://www.nhlbi.nih.gov/guidelines/asthma/index.htm
WE KNOW
IT’S A JUNGLE OUT THERE!
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