Pediatric Assessment

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Pediatric Assessment
2013-10-26 20:54:39
Pediatric Assessment

Pediatric Assessment Guide
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  1. Pediatric Assessment:Children are NOT small adults
    Body surface area= large for weight->infants susceptible to hypothermia 

    • Anterior fontanelle palpable until about 18m
    • Posterior fontanelle palpable until about 2-3 m
    • Tongue is large
    • Short, narrow trachea under 5 years of age
    • Cardiac output is rate dependent not strove volume
    • Susceptible to trauma due to poor protection of liver and spleen
  2. Pediatric Assessment:Children are NOT small adults
    Kidneys dont concentrate urine effectively until 12-18 months of age

    • Nerve fibers continue to develop during the 1st year
    • Head is proportionally larger--->risk for head injury
    • Higher metabolic rate
    • Cartilage in ribs is higher

    • Until 10 years, faster resp rate 
    • Tidal volume is proportional to weight (7-10ml/kg)
  3. Pediatrics Assessment:Children are NOT small adults
    Diaphragm is primary breathing muscle

    C02 is not effectively expired when the child is distressed

    Bones are soft and more easily bent and fractures until puberty

    Muscles are 25% of weight in infants vs 40% in adults

    Blood volume is weight dependent (80ml/kg)--->dehydration hits them sooner
  4. Communication: Build rapport with family
    • Make a self introduction 
    • Explain the purpose  of nursing history
    • Provide privacy
    • Question appropriately 
    • Involve child in interview
    • Be honest
    • Choose a common language
    • Use interpreter when appropriate
  5. Communication: Build rapport with family
    • Careful listening
    • Complete attention
    • Pay attention to the parents attitudes
    • Pay attention to the parents tone of voice
    • Be alert to underlying themes
    • Observe nonverbal behaviors
  6. Building Trust with Child
    • Follow through on promises
    • Smile, be friendly
    • Be silly
    • Use humor-cautiously-with teens
  7. Culturally sensitive interactions:Nonverbal strategies
    Invite family members to choose where they would like to sit or stand

    Observe interactions to determine which body gestures are acceptable and appropriate

    Avoid appearing rushed

    Be an active listener

    Observe for cues regarding appropriate eye contact

    Ask for clarification if nonverbal meaning is unclear
  8. Culturally sensitive interactions: Verbal strategies
    Use positive tone of voice to convey interest

    Speak slowly and carefully, not loudly, when families have poor language comprehension

    Encourage questions

    Learn basic words and sentences of families language if possible 

    Give reason or purpose for a treatment or RX

    Use information written in families language

    Offer services of interpreter
  9. Developmental approach to the examination: Newborns
    Newborns and infants<6 months of age

    Keep parent present 

    • Provide physical comfort
    •    Pacifier
    • Distractions
    •    Rocking or clicking nose
    • Keep sequence flexible

    Take advantage of when is quiet to or asleep for auscultation 

    Palpate abdomen muscles when they are relaxed 

    Anything thing that might irritate done at the end
  10. Developmental approach to the examination: Infants >6 months
    • Keep with parent
    •    can examine on parents lap 
    • Smile and talk soothingly during procedure 
    • Use toys to distract
    • Use pacifier to quiet them 
    • Begin with feet and hand first before moving to trunk 
    • Auscultate lungs and heart sounds while they are sleeping or resting
  11. Developmental approach to the examination:Toddlers
    Keep toddlers with parents--->stranger anxiety

    Neurological and developmental assessment can be done observing the child play and walk

    Allow them to hold security objects 

    • Begin exam with touching feet then move to body and head 
    •    Ears, eyes and mouth= most feared---> do it end of exam
  12. Developmental approach to the examination: Preschoolers
    • Assess willingness to be separated from parent
    •   Younger children--->parents lap 
    •   Older children-------> patient table
    • Leave underpants  on until time to examine genital area
    • Allow child to touch and play with equipment
    • Give simple explanations
    • Offer choices when possible
    • Use distractions when needed
    •   Ask them to count or name colors
    • Give positive feedback when they cooperate
  13. Developmental approach to the examination: School Age
    • Willing to cooperate and it on exam table
    • Developing modesty
    •    Offer a gown
    • Allow choice to older children if parents will be present or they want privacy
    • Head to toe sequence done at this age 
    • Explain what you are doing and why
    • Offer choices so they can feel empowered
    • Teach the child how the body works--let them listen to heart and lung sounds
  14. Developmental approach to the examination: Adolescents
    • Protect modesty--> private place to undress
    •    Offer gown
    •    Cover body parts up that arent being            assessed 
    • Use head to toe sequence

    Provide a chaperon if they chose to not have parents in the room

    • Provide reassurance about the normal progression of secondary sexual
    • characteristic development
  15. Physical Assessment of the Child
    Use age appropriate approach

    • Younger children do better when parent is close by
    • Growth measurements:
    • Length 
    • Height 
    • Weight
    • Head circumference 
    • ***Plot on growth chart 
  16. Physical Assessment (continued)
    • Vital signs: 
    • Temperature
    • Pulse
    • Respirations
    • Blood pressure

    Need to know normal VS for different ages

    Use correct cuff size
  17. Physical Assessment continued
    General Appearance 

    • --Nurse impression of the child
    •       Overall physical appearance
    •       Hygiene
    •       Nutritional status
    •       Behavior
  18. Physical Assessment (cont)
    • Head-
    • Shape, symmetry, head control, posture and ROM 
    • Hair-Pediculosis Capitus aka Lice very common in preschool and school age children, color distribution and cleanliness of hair
    • Face- symmetry, shape and mobility 
    • Neck-edema, pulses and neck veins
    • Palpate thyroid and trachea
    • ***Always keep in mind ABCs***
  19. Physical Assessment (cont)
    Eyes- Inspect for size, symmetry, color and motility, Pupillary responses 

    • Vision tests done when appropriate such as:
    • Snellen symbol E chart
    • Snellen letter chart
    • Ishihara plates to test color vision
  20. Physical Assessment (cont)
    • Ears- 
    • Auditory canal should be pink

    Tympamic membrane should be pearly gray and translucent

    • External Ear-
    • Inspect for shape, position, placement and cleanliness
    • Top of pinna should be above the outer canthus of the eye
  21. Physical Assessment (cont) Nose, Mouth and Throat
    • Nose-
    • check for patency, no flaring

    • Mouth and throat-
    • Check mucous membranes
    • Tonsils
  22. Physical Assessment (cont) Lymph nodes
    Note size, mobility, tenderness and enlargement

    Firm, clearly defined, nontender, movable nodes up to 1cm are common in young children

    Enlarged, warm, tender, indicates local infection
  23. Physical Assessment (Chest, Lungs)
    • Chest
    • Size, shape, symmetry, and movement

    • Lungs
    • Observe respirations
    • Palpated by placing hand flat against back or chest
    • Auscultate for lung sounds
  24. Assessing an upset child
    • Soothe with pacifier
    • Wait til they take a breath
    • Blow bubbles
    • Draw attention to breathing
  25. Alterations in Respiratory system
    • Etiology: 
    • Hyperthermia/ Hypothermia
    • Anxiety
    • Pain 
    • Altered Mental Status 

    Assessment findings: Effort, Rate, Rhythm/Color/Accessory muscles/Retractions/Grunting 

    • Interventions:
    • Suctioning 
    • Oxygen
    • Breathing Treatments
  26. Physical Assessment (cont) Heart, Nails
    • Heart- 
    • Auscultate cardiac sounds
    • S3 normal in children 

    • Nails
    • Size, shape and color
    • Capillary refill should also be examined
  27. Alterations in Circulation
    • Etiology
    • Hyperthermia/Hypothermia
    • Anxiety/Pain
    • Hyperventilation
    • Congenital Heart Defects

    • Assessment findings:
    • Rate, Rhythm, Color, Murmur, Pedal pulses

    • Interventions
    • Oxygen
    • Breathing treatments
  28. Physical Assessment: Skin
    • Skin
    • Color, temp, moistness, turgor
    • Turgor best assessed on the abdomen or thigh
    • Get a good history of rash
  29. Physical Assessment: Abdomen
    • Inspect first
    • Then ausculate, percuss, palpate in all 4 quads
  30. Physical Assessment: Genitalia: Boys
    • Assess penis 
    • Glans and shaft
    • Prepuce of foreskin
    • Meatal opening
    • Scrotum and testes
    • Hair distribution
  31. Physical Assessment: Genitalia: Girls
    • Inspect and palpate external structures
    • Vulva
    • Mons pubis
    • Clitoris
    • Urethral meatus
    • Vaginal orifice
  32. Physical Assessment (cont) Anus, Back and spine, Extremities
    • Anus
    • Inspect for patency, muscle tone of sphincter and any prolapse or hemorrhoids

    • Back and spine
    • Inspect for dimples and curvature
    • Also mobility

    • Extremities: 
    • Inspect for symmetry
    • Temperature
    • Color
    • Shape of bones and any deviations
    • ROM
  33. Physical Assessment: Cognitive functioning
    • Speech
    • Behavior/LOC
    • Memory

    • Cerebellar-balance, coordination and gait 
    • Cranial nerves
    •     Sensory function and reflexes
  34. Physical Assessment: Cranial Functioning
    • "Soft signs" 
    • Neurological signs that fall into a grey area between normal and abnormal
    • May be normal in younger child but not in an older child

    • Examples of soft signs:
    • Short attention span
    • unusual body movements, mirroring
    • Poor coordination and sense of position
    • Hyperactivity
    • Hypoactivity 
    • Impulsiveness
    • Labile emotions
    • Distractability
    • No established handedness
    • Language and articulation problems
    • Perceptual deficits (space, form, movement and time)
    • Problems with learning (reading, writing, and arithmetic)
  35. Denver Developmental Screening Test
    Vital component  of a childs complete health assessment 

    • Newer standardized one is DDST II
    • If an infant was born prematurely adjust the age of the child until the child is 24 months 
    • --After that, no adjustment is needed 
    • This screening test of development, not an intelligence test 
    • Stress the child is not expected to perform each item on the test 
    • Screens infants and children to age 6 in 4 categories:
    • Personal-social
    • Fine motor-adaptive
    • Language 
    • Gross motor 
  36. Normal Respiratory Rate per minute
    Newborn-17 years old 
    • Newborn  33-55
    • 1 year      25-40
    • 3 years     20-30
    • 6 years     16-22
    • 10 years   16-20
    • 17 years   12-20
  37. Normal Heart Rates for Children of Different Ages
    • HR Range           HR average 
    • Newborn    100-170                120
    • Infants-2yr 80-130                 110
    • 2-6 yrs       70-120                 100
    • 6-10 yrs     70-110                  90
    • 10-16 yrs    60-100                  85
  38. Cranial Nerves: Cranial Nerve I- Olfactory
    • Infant- not tested
    • Child- Not routinely tested. Give familiar odors to child to sniff, one naris at a time. Identifies odors such as orange, peanut butter, and chocolate
  39. Cranial Nerve II Optic
    • Infant: Shine a bright light in eyes--A quick blink reflex and dorsal head flexion indicates light perception. 
    • Child- Test vision and visual fields if cooperative. Visual Acuity appropriate age.
  40. Cranial Nerve III Oculomotor
                        IV Trochlear
                        VI Abducens
    • Infant: Shine a penlight at the eyes and move it side to side. Focuses on and tracks the light to each side
    • Child: Move an object through the six cardinal points of gaze. Tracks objects through all fields of gaze
    • All ages: Inspect eyelids for dropping. Inspect pupillary response to light. Eyelids do not droop and pupils are equal size and briskly respond to light.
  41. Cranial Nerve V Trigeminal
    Infant: Stimulate the rooting and sucking reflex. Turns head toward stimulation at side of mouth and sucking has good strength and pattern. 

    • Child: Observe the child chewing a cracker. Touch the forehead and cheeks with cotton ball when eyes are closed. Bilateral jaw strength is good. Child points to location touched by cotton ball. 

  42. Cranial Nerve VII Facial
    All ages: Observe facial expression when crying, smiling, frowning ect. Facial features stay symmetric bilaterally. 
  43. Cranial Nerve VIII Acoustic
    Infant: Produce a loud sound near the head. Blinks in response to sound, moves head toward sound or freezes position. 

    Child: Use a noise maker near each ear or whisper words to be repeated. Turns head toward sound and repeat words
  44. Cranial Nerve IX Glossopharyngeal
                        X Vagus
    Infant:Observe swallowing during feeding. Good swallowing pattern 

    All ages: Elicit gag reflex. Gags with simulation
  45. Cranial Nerve IX Spinal Accessory
    Infant: Not tested

    Child: Ask child to raise the shoulders and turn head side to side against resistance. Good strength in neck and shoulders
  46. Cranial Nerve XII Hypoglossal
    Infant: Observe feeding. Sucking and swallowing in coordinated. 

    Child: Tell the child to stick out the tongue.  Listen to speech. Tongue is mid-line with no tremors. Words are clearly articulated.