PEDIATRIC ASSESSMENT ESSENTIAL PEDIATRIC NURSING SKILLS Knowledge of

PEDIATRIC ASSESSMENT

ESSENTIAL PEDIATRIC NURSING SKILLS � � � Knowledge of Growth and 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 1 st year. � Every 3 month of the 2 nd and 3 rd year. � Each 6 month of 4 th and 5 th year. � Yearly after the 6 th year.

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.

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 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? Stethoscope & Sphygmomanometer Pen Light Otoscope / Opthalmoscope Scale

REVIEW OF SYSTEMS � Ask questions about each system � Measurements: weight, 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 GI HEENT GU Neck Chest & Lungs / Respiratory Heart & Cardiovascular & 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 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 ____ ?

PEDIATRIC VITAL SIGNS – NORMAL RANGES Infant � � Heart Rate 80 -150 Toddler 70 -110 School-Age Adolescent 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

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 Shape Areas Texture Movement 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 Head Eyes Ears Nose 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: “Normo. Cephalic – 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 MENINGITIS Clinical 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 o

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 �

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)

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 Respirations Stridor Wheezing

CHEST ASSESSMENT Auscultation Wheezing Retractions Subcostal Intercostal Sub-sternal Supra-clavicular Red 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

Circulatory • AUSCULTATING HEART SOUNDS The Auscultation Assistant – 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.

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 umbilicus Whenever 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?

Stomachaches and Abdominal Pain Appendicitis Bowel obstruction - Hernia Intussusception Cholecystitis with or without Kidney gallstones Food poisoning (salmonella, shigella) Inflammatory Bowel Disease – Ulcerative colitis stones Pancreatitis Sickle cell crisis Ulcers Urinary tract infections

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 Key Points: • Barefoot • Feet Together • Bend Over –”Diving Of a Diving Board” • Check Hips Medline. com

ASSESSMENT � The Five P’s: � Pain � Paresthesia � Passive stretch � Pressure � Pulse-less-ness

SKIN, NAILS & HAIR Rashes Lesions Lacerations Lumps Bruises Bites Infections

COMMON SKIN LESIONS Macule Papule Vesicle, bulla Pustule Cyst Patch Plaque Wheal Striae Scale Crust Keloid Fissure Ulcer Petechiae Purpura Ecchymosis n. 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 HEALTH FOCUSED 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 Stomachaches 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