Transcript The complete Pediatric Assessment

The Comprehensive
Pediatric Health
Assessment
What do I need to know…
And how do I get it?
Jessica Keester, MSN, C-PNP, RN
Objectives
1. Review the pediatric-focused assessment:
1. In accordance with Family-Centered Care
2. Based on developmental stage
3. Chronicity/ Special Needs
2. To understand the components of a comprehensive assessment
1. Subjective information: History
2. Objective information: Physical Exam
3. Discuss system-specific focused assessments; that vary most
significantly in pediatrics
4. Handouts- referral tools to use in practice
Components of a Comprehensive Assessment
1. Patient History: (Subjective information)
Obtained from..
a. The client/ parent interview
b. Chart, Medical Records
Includes:
a.
Family History
b.
Past Medical History; medications;
allergies
c.
History related to current need for care or
treatment
d.
Report of current issues or concern
1. Physical Exam (mostly objective information)
a.
Vital Signs, height, weight
b.
Focused exam by system: Inspection,
Auscultation, Percussion, palpation
c.
Subjective information related to each physical
exam!
Subjective vs. Objective
Heart Rate?
Objective
Medications?
Subjective
Pain?
Subjective
Skin Breakdown?
Both!
Medical
History?
Subjective
Where do I start?
Where my
EMR tells me
to..?
Client history
…AS important as the physical exam
Client History:
Obtaining The Initial History
Preparation:
Review information do we have before the client interview:
1.
2.
3.
Patient chart/medical file/ H&P
Medication list
Order set/ plan of care
Interview:
The complete health history is an opportunity to establish a
relationship with the patient/family, gain insight into the
family environment and dynamic, as well obtain health
information
(Richardson, 2013)
Client History:
Obtaining The Initial History
Obtaining the initial History
When you are the first person in your organization to assume care for this
patient
Subjective information:
1. Family history
For example: Incidence of chronic conditions/ disability/ psychosocial
diagnoses, serious illness, early death
-Maternal history of high risk pregnancy, drug/ alcohol use, prenatal
history(s)
-Social History
2. Past Medical History of Patient
a) Diagnoses (chronic and acute)
b) Medical/ Surgical (ED visits, hospitalizations, etc)
c) Allergies; Medication List
3. Dynamic family situation
4. What their goal is for your services
(Richardson, 2013)
Client History:
The Interval History
Re-admission/ Re-cert
When your organization is RE-assuming care of this patient/ OR 60 day update on plan of care
Subjective:
1.
Any information above that is not previously documented in chart, or
unable to obtain.
*Who did the previous assessment? Is it as detailed as you would make it?
* “To get started I’m just going to review some information with you that we
already have in your chart”
2.
Any Changes since last Comp Assessment was done
1.
2.
3.
4.
ED Visits, Hospitalizations
Office Visits: Changes to Plan of care or Medications
Significant Growth, changes in Developmental Status
Changes Relevant to Plan of Care
(Richardson, 2013)
“Other” Subjective information
Some examples from Devero:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Home Assessment (layout, sanitary, electrical)
Language
Psychosocial
Spiritual/ cultural
Neurological status
Emergency/ safety measures; Supplies
Advanced Directives
Neurological status
Supplies
 Ultimately the goal is to work these answers into a narrative; guide the
conversation without reading question by question. Answer as much
as you can by observation
 PLEASE do not stare at the EMR while interviewing your client
Tips for the interview
1.
2.
3.
4.
5.
6.
7.
The first impression can set a precedence for the duration of care;
approach accordingly
*What impression is given if you have not read their chart/ medical
record yet?
Be fully present with the client/ family during this time: Active Listening
1. Greet the patient/ family by name
2. Sit
3. Maintain eye contact with historian
4. Do NOT babysit the EMR
Allow time for the historian to recall, or decide how to word things
*Silence is ok!
Take the history in chronological order
1. prenatal  Infant toddler pre-school/ school age 
adolescent
Clarify when needed!
1. It’s better to do this immediately than to go back later
“Is there anything else I have not addressed that you would like to
discuss?”
Use your instincts!
(Henderson, Tierney, and Smetana, 2012.)
The interview helps establish a
relationship with the client before
moving into the invasive physical
exam
Physical
Assessment
…It’s a big deal too.
Components of the Physical
Assessment:
Vitals:
1.
a)
b)
c)
d)
e)
Pulse/ hr
Respirations
Blood pressure
Pulse ox (?)
**PAIN
a)
b)
c)
d)
e)
f)
g)
h)
General (……?)
Skin (throughout whole exam)
“HEENT” (+Mouth)
Neurological (reflexes?, developmental status..)
Respiratory
Gastrointestinal
MSK (motor skills, some neuro)
Genitalia (often PD for therapists..Nurses should NOT
defer this if possible…)
Exam by system
 Subjective Data
**Be aware for MIX of subjective and OBJECTIVE data: For example: endocrine
section- you as a therapist or nurse can not “assess” hypothyroid. That is a Medical
Diagnosis. Devero groups together relative subjective findings of ROS and exam .
Nutrition: ROS
Development: Subjective
Physical “Exam” vs. “Assessment”…..
“Assessment” data is information you can
gather. Subtle differences between fields. You
can “assess” data that is given to you as a
subjective assessment; or you can assess
data that you collect based on your training
and scope of practice
“Exam” data includes only the information
you can collect independently; based on
training and scope of practice.
Ie….. MEDICAL Practice/ Diagnosis
NURSING Practice/ Diagnosis
THERAPY Practice/ Diagnosis
“MID- LEVEL” Practice/ Diagnosis …….
RECAP
1.
Receive Assignment
2.
Review patient information:
a)
medical record
b)
chart
c)
orders
Initial visit:
1.
Introductions
2.
Interview
3.
Physical Exam
4.
Document
What makes a pediatric patient different
than an adult?
•Gathering information: Who do I ask?
•Explanation of procedure; What is “age appropriate”?
•Cooperation during the exam; increased anxiety
•Concept of invasive vs. non-invasive
•Relationship with the family is as important as the client
themselves.
•….. Medications, compensating, anatomy changes with phase of
development, etc. …..
Developmentally Appropriate
Care
Infant: Birth – 12 months
Development:
Dependent to parent, will look to parents for security,
reacts to parents anxiety levels
Interview:
Full interview taken with parent. “white coat” anxiety
less of a factor, Least invasive first is most important
(you never when they will get irritated with being
touched!)
Position:
Before 4-6 months: can be on table, make sure parent is
in view After 6 months: Best in parent arms, or laying on
parent lap encourage parents to be an active part of the
exam *great time to assess parent attachment to infant
Sequence:
If quiet, auscultate heart, lungs, abdomen. Heart and
respiratory rates. Perform traumatic procedures last
(eyes, ears, mouth [while infant is crying]). Elicit reflexes
as body part examined.
(Richardson, 2013; Duderstadt, 2006)
Provider
Tip:
What is
“invasive” to
infants/ kids??
Thermometers
Mouth, nose, ears…think
orrifaces
Under their clothes
COLD
Toddlers: (12mo-3yo)
Development:
Still utilizes parent as safety; but begins to explore in sight of parent
Interview:
Full interview taken with parent. Should have some anxiety to new
faces/ caregivers. Begin communication with child based on their
growing vocabulary
Position:
Best to begin in parent arms, or on parent’s lap. A good approach is
to assess on parent first than the child
Sequence:
Attempt to warm child up to you first, involving toys/ play, let them
touch equipment before use. Attempt to auscultate heart, lung,
abdomen first, get RR heart rate they may cooperate very well at
first related to curiosity..this will not last long! Invasive assessments
LAST!
(Richardson, 2013; Duderstadt, 2006)
Preschool: 3 yo-5yo
Development:
Increased exploring; intentional limit pushing
Interview:
Full interview taken with parent. Should have some
anxiety to new faces/ caregivers. Begin
communication with child based on their growing
vocabulary; If they are timid try averting eye contact
Position:
Child may want to begin on parent’s lap or holding
parents hand, A successful approach is to assess on
parent first than the child
Sequence:
Use play and toys to become acquainted and nonthreatening; Inspect body through counting fingers;
using minimal contact initially. Introduce equipment
through play, let them feel and touch equipment.
Auscultate as soon as possible–busy age group!
(Richardson, 2013; Duderstadt, 2006)
School age: (5yo-12yo)
Development:
Seeking autonomy; exploring (self-exploration/
stimulation common) Still prefers parent closeness
Interview:
Include child in interview/ subjective information.
Children this age generally like to answer
questions about themselves; Provider lead style of
interview
Position:
Sitting alone
Sequence:
In this time period it is appropriate to begin
proceeding through head to toe assessment;
examine genitalia last assessment, should notice
discomfort or resistance with genital assessment.
(Richardson, 2013; Duderstadt, 2006)
Adolescent (12yo-18yo)
Development:
Autonomy is very important to this age *
specific struggle for patient who are
medically dependent
Interview:
Let the adolescent patient speak for themselves;
Patient-lead style of interview. Clarify questions you
still have at the end, allow parents to add at the end.
Position:
Sitting/ Alone, may want parent to leave room during
physical assessment *without developmental delayallowing an autonomous assessment is best practice
Sequence:
Proceed in Head to toe assessment * genital area lastthis is the only particularly invasive assessment to
adolescents
Provider Tip:
EMOTIONAL DEVELOPMENTAL status
is more relevant than age!
Follow recommendations for the age
corresponding with development
Physical Development DOES NOT
equal mental/ emotional
development
General Guidelines on Physical Exam:
Other Helpful hints
•Have space well lit
•Always approach child from front
•Always ask permission; give choices
•Don’t Lie- if it’s going to hurt, find a way to
downplay it without lying “little pinch”
•Have toys/ TV/ distraction
•Involve Parents as much as possible
•Avoid long explanations, child appropriate “Let me
feel those strong muscles”
•Approach exam prepared and organized
•Limit others in room besides family members
•Maintain privacy; dignity
PHYSICAL EXAM
Vital Signs
Your Assessment
•How do these trend with age?
Heart rate:
Starts high  Lowers with age
BP:
Starts low  Gets higher with age
RR:
Starts high  lower with age
02?: <<Trick question>> should always be above 95%
(in otherwise healthy child)
What about compensation and vital signs in
Pediatrics? Increase  then trend downwards if problem is not treated
. Once vitals start to trend down prognosis is OMINOUS
General appearance
Your Assessment
What are we looking for?
What is “normal”
Observe the following:
Facies
Posture
Body movement
Hygiene
Nutrition
Behavior
Development
State of awareness
Options:
Awake
Alert
tired
Listless
Lethargic**
Ill-appearing/
well-appearing
interactive
pale
Thin
Flushed
Content
General appearance
Your Assessment
……What other system are we assessing
when we look at these things?
Neurological!
Also utilize Reflex tool and
Glaslow Scale
HEENT
Your Assessment
Subjective
Data?
(Head Eyes Ears Nose Throat)
Head:
Ears:
Shape, Symmetry, Molding**
Head Circumference up to 2yoMeasure with paper or steel tape at greatest
circumference, from top of the
eyebrows and pinna of the ear to occipital
prominence of skull.
Strength (head lag), ROM, scalp, hair
Fontanelles
Placement/ development
Note presence of any abnormal openings, tags of skin, or
sinuses.
Inspect hygiene (odor, discharge, color).
Eyes:
Inspect placement and alignment.
Placement - Note asymmetry, abnormal spacing
(hypertelorism)
Palpebral slant—Draw imaginary line through
two points of medial (inner) canthi
Epicanthal fold—Observe for excess fold from
roof of nose to inner termination of eyebrow
Lids—Observe placement, movement, and color
Palpebral conjunctiva- Pull lower lid down
while child looks up.
Bulbar conjunctiva Observe color
Nose:
Position, alignment
Turbinates- color/ swelling of mucosa?
Nares*
Throat:
Tonsils-Grade 1-4, exudate, color
Mouth:
Teeth**, gums, buccal mucosa
Pharynx
Soft/ hard palate
Respiratory
Your Assessment
Inspection:
•Shape, size, symmetry,
•Evaluate respiratory movements for rate,
rhythm, depth, quality, and character
movement
•Work of breathing
Auscultation:
•(Diaphragm of stethoscope- for HIGH
pitched sounds)
•Needs to be quiet!
•Where do you get most information?
•What is normal?
•What are abnormals?
•Percussion:
•What does it tell us? What is the
-Appreciate
dullness of the left anterior chest due to
“normal”?
heart
•- and right lower chest due to liver.
-Note the hyper-resonance of the left lower anterior
chest due to air filled stomach.
Auscultation:
http://www.practicalclinicalskills.com/a
uscultation-coursecontents.aspx?courseid=201
Inspection
Heaves lifts
Palpation
Your
Assessment
Thrills
Cardiac
Auscultation
•Where do you listen?
•Over each valve area 
•What Position should the child be
in?
•Sitting, sitting leaning forward,
laying flat, and possibly laying on left
side
Supporting Data?
Paleness
Pulses
SOB
Tires easily *think feedings for
infants
“bluing”
Valves
Aortic area—Second right intercostal space close to
sternum
Pulmonic area—Second left intercostal space close to
sternum
Erb point—Second and third left intercostal spaces close to
sternum
Tricuspid area—Fifth right and left intercostal spaces
close to sternum
Mitral or apical area—Fifth intercostal space, left
midclavicular line (third to fourth intercostal space and
lateral to left midclavicular line [MCL] in infants)
Cardiac
Your Assessment
Murmurs
-Most benign murmurs are early - mid systolic.
-Diastolic murmurs almost always indicate pathology.
-A systolic murmur is present between S1 and S2
-A diastolic murmur is present between S2 and S1
-A continuous murmur is present in systole and diastole
Mitral area
Mitral valve prolapse, regurgitation, and stenosis; Still’s murmur, aortic
stenosis
Tricuspid area
Tricuspid regurgitation, ventricular septal defect (VSD), Still’s murmur,
hypertrophic cardiomyopathy.
Pulmonary area
Pulmonary regurgitation and stenosis, ASD, TAPVR, PDA, and pulmonary
flow murmurs.
Aortic area
Aortic stenosis, benign aortic systolic murmur
Using the bell and diaphragm, you should first perform a sweep at these
locations for heart sounds and then a second sweep for murmurs.
Cardiac
Your Assessment
S1/S2
http://www.easyauscultation.com/case
s?coursecaseorder=1&courseid=22
3rd Heart tone (physiologic)
http://www.easyauscultation.com/case
s?coursecaseorder=4&courseid=22
Innocent Murmur
http://www.easyauscultation.com/case
s?coursecaseorder=5&courseid=22
Which Murmurs are you likely to see in
Infants?
Abdomen/ G.I
Your
Assessment
What tells us most about the G.I tract and it’s functioning?
Inspection
Size, contour, shape,
umbilicus
Auscultation
What is normal?
*Normoactive
Palpation
Why?
Percussion
which anatomy produces
which sounds?
Hernias
Umbilical
Inguinal—Slide little finger into external inguinal ring
at base of scrotum; ask child to cough.
Femoral—Place finger over femoral canal (located by
placing index finger over femoral pulse and middle
finger against skin toward midline).
Documentation:
Welcome to DeVero!
•EMRs are generally helpful in way of “prompting” your documentation
• Be careful not to “check boxes” that you have not actually assessed (yes, this
is actually an easy mistake)
•Do not let your EMR be your brain- it’s like multiple choice tests:
-Choosing an answer you are not familiar with is not a good choice
- “This choice is least wrong”…….wrong.
•Documentation should be done as close to “real time” as possible evidence
proves that the longer you wait to document the less accurate it will be!
• A friendly message from your state Board of Nursing:
•“If you didn’t document it…… it didn’t happen!”
•Documentation in-service in MARCH: BE THERE  !!!
References:
Allen, P., Vessey, J., & Schapiro, N. (2010). Child with a chronic condition (5th Ed.). St.Louis, MO:
Mosby Elsevier.
Burns, C., Dunn, A., Brady, M., Starr, N., & Blosser, C. (2013). Pediatric Primary Care (5th).
Philadelphia, PA: Mosby Elsevier
Craven, R., Hirnle, C., & Jenson, S. (2013). Fundamentals of nursing; Human health and function
(7th. Ed.). Philadelphia, PA: Wolters Kluwer Health/ Lippincot WIlliams & Wilkins.
Duderstadt, K.G. (2006.) Pediatric physical examination: An illustrated handbook. Philadelphia,
PA: Mosby.
Wilson, D., & Hockenberry, M. (2012). Wong's Clinical Manual of Pediatric Nursing (T. Brown, Ed.,
8th ed.). St. Louis, MO: Elsevier Mosby.