unit VII Pediatric Assessment.ppt

unit VII Pediatric Assessment.ppt
Unit VII PEDIATRIC ASSESSMENT Hidayat Khan, MSN,MPH, DCH, BSN, RN, CHPE, IP&C KMU-INS
Pediatric Nursing Skills • 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
Equipment • Thermameter • Stethoscope & Sphygmomanometer • Pen Light • Pulse Ox & Cardiac Monitor • Otoscope / Opthalmoscope • Weight machine • Measuring tap • Reflex hammer
History 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?
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
History: Review of Systems • Skin • HEENT • Neck • Chest & Lungs / Respiratory • Heart & Cardiovascular • GI • GU Musculoskeletal & Extremities • Neuro • Endocrine
THIS OLD CARTS O____ L_______ D_______ C______________ A__________ _______ R________ _______ T________ S_________
• 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
Components of a Focused Pediatric Assessment • Always ABCs! • PAT: Pediatric Assessment Triangle • Ongoing Triage – • Minor vs. • Serious vs. Life-Threatening • Problem- Focused Examination Appearance Includes LOC & Behavior PAT Breathing Changes Skin Circulation
PAT General Appearance Work of Breathing Circulation to the Skin
Initial Assessment (s) • Primary • A = Airway • B = Breathing • C = Circulation • D = Disability • Secondary • E = Exposure • F = Full Set of Vitals • G = Give Comfort Measures including Pain Assessment & Tx. • H = Head –to-Toe assessment & history • I = Inspect posterior surfaces – rashes, bruising
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 • Facial expression • Posture / movement • Hygiene • Behavior • Developmental Status General Appearance & Behavior
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 • Heart Rate 80-150 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 Infant Toddler School-Age Adolescent
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
Physical Assessment • Four Basic Skills: 1. Inspection 2. Palpation 3. Percussion 4. Auscultation • Sequence for abdominal: 1.inspection, 2.auscultation, 3.percussion, 4.palpation
Inspection • Use all your senses • The essential First Step of the Physical Exam
Palpation • Use of your fingers and palms to determine: • Temperature • Hydration • Texture • Shape • Movement • Areas 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
Percussion Use of tapping to produce sounds that are characterized according to: • Intensity • Pitch • Duration • Quality Direct vs. Indirect
• Listening for body sounds • Bell: low-pitched • - heart • Diaphragm: high-pitched • – lung & bowel Auscultation LUNGS: Listen to all lung fields FRONT AND BACK! auscultate for breath sounds and adventitious sounds
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: “NormoCephalic – 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
Neuro Assessment • LOC / Glasgow coma scale • Confusion, Delirium, Stupor, Coma • Pupil size • CNS grossly intact: II – XII • Vital Signs • Pain • Seizure Activity • Focal Deficits
Neurological Key Points • Cranial Nerves • Cerebral Function: • Mental status, appearance, behavior, cooperation • LOC, language, emotional status, social response, attention span • Cerebellar Function • Balance, gait & leg coordination, ataxia, posture, tremors • Finger to nose (fingers to thumb) 3-4 yrs • Finger to examiner's finger 4-6 yrs • Ability to stand with eyes closed (Romberg) 3-4 yrs • Rapid alternations of hands (prone, supine) school age • Tandum walk 4-6 yrs • Walk on toes, heels school age • Stand on one foot 3-6 yrs • Motor Function: Gross motor & Fine motor movements • Sensory function • Reflexes
Cranial Nerves C1 - Smell C2 - Visual acuity, visual fields, fundus C3, 4, 6 - EOM, 6 fields of gaze C5 - Sensory to face: Motor--clench teeth, C5 & C7 - Corneal reflex C7 - Raise eyebrows, frown, close eyes tight, show teeth, smile, puff cheeks, taste--anterior 2/3 tongue C8 - Hearing & equilibrium C9 – say "ah," equal movement of soft palate & uvula C10 - Gag, Taste, posterior 1/3 tongue C11 - Shoulder shrug & head turn with resistance C12 - Tongue movement
Reflexes Deep tendon: • Biceps C5, C6 • Triceps C6, C7, C8 • Brachioradialis C5, C6 • Patellar L2, L3, L4 • Achilles S1, S2 Superficial: • Cremasteric T12, L1, L2 • Abdominal T7, T8, T9, T10, T11 Infant Automatisms: • Primitive Reflexes
EYES Does not open eyes Opens eyes in response to painful stimuli Opens eyes in response to voice Opens eyes spontaneously N/A N/A VERBAL Makes no sounds Incomprehen sible sounds Utters inappropri ate words Confused, disorientated Oriented, converses normally N/A MOTOR Makes no movements Extension to painful stimuli Abnormal flexion to painful stimuli Flexion / Withdrawal to painful stimuli Localizes painful stimuli Obeys commands Glasgow Coma Scale 1 2 3 4 5 6 The lowest possible GCS is 3 (deep coma or death) while the highest is 15 (fully awake person). Source :Wikipedia
Eyes • PERRL & EOM • 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 • Visual following at 5-6 weeks • 180 degree tracking at 4 months • Pictures or Tumbling E charts & strabismus check for preschool child • Snellen chart for older children • Irritations & infections • PERRL • Amblyopia (lazy eye): Corneal light reflex, binocular vision, cover-uncover test • EOMs: tracking 6 fields of vision • Fundoscopic exam of internal eye & retina
Conjunctivitis Viral – most common cause • Very contagious • 8 day incubation period • Pinkish-red eyes • Watery or serous discharge • Crusty eyelids on awakening • c/o “gritty sensation in eye • May c/o URI symptoms • Can be either unilateral or bilateral • Vesicles around eye could be herpes lesions Immediate referral to ophthalmologist Bacterial – more common in school-age children Symptoms: • Red eyes • Purulent or mucopurulent discharge, matted eyelids upon awakening • c/o “gritty” sensation • Usually starts unilaterally and then progresses to bilateral • Often concurrent otitis media • Culture if < 1 month of age
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
Nose & Throat / Mouth • Turbinates • Exudate • Pharynx • Tonsils • Signs & Symptoms of Allergic 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: Variations • Allergy: “allergic salute” - line across nose. • Infection • Foreign body: • Foul odor or unilateral discharge • Structure variations • Bell’s palsy
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 • Range of Motion (ROM) • Check clavicle in newborn • Head control in infant • Trachea & thyroid in midline • Carotid arteries (bruits) • Torticollis • Webbing • Meningeal irritation
• All 4 quadrants • Front and back • Take the time to listen • Be sure about “lungs CTAB” (clear to auscultation bilaterally) Chest Assessment •How does the child look? •Color •Work of Breathing: Effort used to breathe Auscultation
Lungs & Respiratory: Key Points • Quality of Respirations: • Symmetry, Expansion, Effort, Dyspnea • S & S Respiratory Distress: • Color: cyanosis, pallor, circumoral cyanosis, mottling • Tachypnea • Retractions • Nasal flaring • Grunting (expiratory) • Stridor - inspiratory • Adventitious sounds
Lungs & Respiratory: Key Points • Clubbing • Snoring (expiratory): upper airway obstruction, allergy, • Fremitus: • Increased in pneumonia, atelectasis, mass • Decreased in asthma, pneumothorax or FB • Dullness to percussion: fluid or mass
Work of Breathing • Increased or Decreased Respirations • Stridor • Wheezing
Chest Assessment • Auscultation • Wheezing • Retractions • Subcostal • Intercostal • Sub-sternal • Supra-clavicular Red Flags: • grunting • nasal flaring • stridor
•Auscultating Heart Sounds Pillitter Circulatory The Auscultation Assistant – Hear Heart Murmurs, Heart Sounds, and Breath Sounds. http://www.wilkes.med.ucla.edu/inex.htm •Perfusion – capillary refill •“Warm to touch”
Murmurs: • may be systolic, diastolic or continuous • timing, location, quality -course, harsh, blowing, high pitched • Apical pulse
Abdominal Assessment Pillitteri Gastro-Intestinal
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
Bowel Sounds • Normal: every 10 to 30 seconds. • Listen in each quadrant long enough to hear at least one bowel sound. • Absent • Hypoactive • Normoactive • Hyperactive
Musculo-Skeletal • 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 • Reflexes
Skin, Nails & Hair • Rashes • Lesions • Lacerations • Lumps • Bumps • Bruises • Bites • Infections
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 • Behavioral / Mental Health Concerns • Chronic Conditions & Special Needs
Common School Health Focused Assessments • 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
The Frequent Fliers • Headaches • Stomachaches • Nosebleeds • Chest Pain • Coughs • & Fevers
Behavioral / Mental Health Concerns • Developmental Delays • Depression • Aggressive Behaviors • Suicide Risks • Other Mental Health Issues

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