Transcript The complete Pediatric Assessment

The Comprehensive
Pediatric Health
Assessment
What do I need to know?
Jessica Keester, MSN, C-PNP, RN
Objectives
1. Review the pediatric-focused assessment:
2. To understand the components of a
comprehensive assessment
3. Discuss system-specific focused assessments;
that vary most significantly in pediatric
4. To be able to demonstrate complete
documentation of patient assessment
5. Handouts- 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.
Chief Complaint
- Current issue being cared for
 Do I need to ask this
every shift?!
 Where o I find it if I am
new to the case?!
Components of a Comprehensive Assessment
2. Physical Exam (mostly objective
information)
a. Objective Information:
a.
Vital Signs, ht, wt (if applicable)
b.
Head to Toe assessment
a.
c.
Focused Assessments
a.
b.
Should include focused exams by
system: Inspection, Auscultation,
Percussion, palpation
What systems? How often?
Subjective information:
a.
Symptoms r/t system assessing
(Ie. pain, tenderness)
Subjective vs. Objective
Heart Rate?
Objective
Medications?
Subjective
Pain?
Subjective
Skin Breakdown?
Both!
Medical
History?
Subjective
Nausea?
Subjective
Where do I start?
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.
Any Previous medical records
available on the patient
Order set/ plan of care
1.
1.
2.
Medication List
Treatment schedule
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 to Plan of Care
(Richardson, 2013)
“Other” Subjective information
Some examples from Devero:
1. Home Assessment (layout, sanitary, electrical)
2. Language
3. Psychosocial
4. Spiritual/ cultural
5. Neurological status
6. Emergency/ safety measures; Supplies
7. Advanced Directives
8. Neurological status
9. 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
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
Exam by system
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…)
 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 .
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
Moving on.
What makes a pediatric patient different
than an adult?
•Gathering information
•Explanation of procedure
•Cooperation during the exam
•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
PHYSICAL EXAM
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
Vital Signs
Your
Assessment
•How
do these
trend with age?
Heart rate- lowers with age
BP- raises with age
RR- Lowers with age
Sp02- Does not change- “norm” is always 95-100%
How do vital signs reflect compensation in Pediatrics?
Trend ___first, then trend ____  once this change
occurs prognosis is OMINOUS
General Impression
“General”
Your Assessment
What your assessing..
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
HEENT
Head
•Shape, Symmetry, Molding,
circumfererence?
•Strength (head lag), ROM, scalp, hair
•Fontanelles
Eyes
•Placement
•Lids- observe placement, movement
•Conjunctiva
Palpebral/ Bulbar
•Discharge?
Ears:
•Placement/ development
•Note presence of any abnormal
openings, tags of skin, or sinuses.
• Inspect hygiene (odor, discharge,
color).
What body system develops the
same time as ears?
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
Inspection:
Auscultation:
http://www.practicalclinicalskills.com/auscultatio
n-course-contents.aspx?courseid=201
Your Assessment
Trach? Add:
•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
“normal”?
Appreciate dullness of the left anterior
chest due to heart and right lower chest due
to liver.
Note the hyper-resonance of the left lower
anterior chest due to air filled stomach.
Inspection:
•Tracheostomy Site- ties in place, skin
condition, secretions
•Connected to source of O2/ vent
settings?
Auscultation:
•Diaphragm of stethoscope
•Needs to be really quiet!
•Coarse breath sounds likely to be
patient norm
•Vent: Differentiate self-initiated
breaths/ vs. vent “breaths”
**This is when knowing pt baseline is
critical!
Respiratory…
Tracheostomy…
Inspection:
•Tracheostomy Site- ties in place, skin
condition, secretions
•Connected to source of O2/ vent
settings?
Auscultation:
•Diaphragm of stethoscope
•Needs to be really quiet!
•Coarse breath sounds likely to be
patient norm
•Vent: Differentiate self-initiated
breaths/ vs. vent “breaths”
**This is when knowing pt baseline is
critical!
Suction?
-Pre-assessment
-Amount , consistency, color of
secretions
-Post-assessment! (…Did it work?!)
Cardiac
Inspection
• Heaves, lifts
Palpation
• Thrills
Auscultation
Paleness
Pulses
SOB
“bluing”
Tires easily
*think feedings
for infants
•Where do you listen?
•What position should the child
be in?
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.
S1/S2
http://www.easyauscultation.com/cases?coursecaseorder=1&courseid=22
3rd Heart tone (physiologic)
http://www.easyauscultation.com/cases?coursecaseorder=4&courseid=22
Innocent Murmur
http://www.easyauscultation.com/cases?coursecaseorder=5&courseid=22
Abdomen/ G.I
Your Assessment
What tells us most about the G.I tract and it’s functioning?
Inspection
Size, contour, shape, umbilicus
-> GT? Location? Patent?
-> Ostomy site?
Auscultation
What is normal?
Palpation
• Location of internal organs
important to interpret findings
Percussion
• Which anatomy produces which
sounds?
•*Subjective information, Pain
Documentation
How does this compare
to the head to toe
assessment you learned
in school?
What indicates more
information is needed?
•Any chronically effected
system
•Changes to previous
assessment/ baseline
• ANY documented
“abnormal”- regardless of
history
I think of physical assessment as 3 components …
1. Head to Toe
1.
To be completed at the beginning of shift (1st hour)
2.
Comprehensive- every system
2. On-Going Assessment/ “Progress note”
1.
System specific re-assessment based on systems that are affected (see
previous slide)
2.
About every 2hours- based on patient condition
3. Intervention based Assessment
1.
Re-evaluation based on interventions, medications
2.
Pre-assessment, intervention assessment, Post-assessment (see
suctioning example 
Shift head to toe
assessment
On-Going Assessment/
“Progress note”
Procedural
Case Studies
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.