Pediatric Physical Assessment Summer 2010 Susan Beggs, RN MSN CPN Chapter 33 in your book (2007) pp.810-849

Common considerations Communication strategies Identifiers Questioning of the child or parent Strategies to gain cooperation Introductions Removing distractions Privacy Awareness of growth and development milestones When you enter the room, two identifiers must be used: name, birthdate, hospital record number, etc. Introduce yourself to the parent as well, asking only one questions at a time. Many parents become confused and interject unnecessary information about the child. Try to keep them focused on the questions by repeating, “what I hear you say is…..” Don’t hurry! Allow yourself time Explain the purpose of the interview; use open-ended questions; ask one question at a time.

Data to be collected Data from birth to current status (the complete history) Well history Problem-oriented history Psychosocial data Physiologic data Daily routines, issues that impact daily living Physiologic data to be obtained: history of present illness, birth history, familial diseases, chief complaint, etc. (965) Psychosocial data: (966) composition, employment, housing and home environment, childcare or school, changes in family or lifestyle since last seen Daily routines, issues that impact daily living All data: immunizations, nutrition, medications, allergies, birth history, sleep and rest patternsj Well history: data from the last well child check-up Problem-oriented history: the current problem. “what brought you to the hospital?”

Pediatric Assessment vs. Adult Assessment Developmental approach Order of the exam Differences in findings in pediatric client Assessments for congenital anomalies Documentation of findings Assistance by parent Before beginning the exam, the nurse must be aware of the developmental milestones expected in the child at their age. In an adult, the assessment is from head to toe…in pedi, it might be toe to head depending on the age. In children, many of the systems may be immature…liver, spleen, etc., so findings may be different from an adult. Secondly, skin texture, eye movement, ear placement, are imp. To document bec. They may be suggestive of underlying problems. The parent, esp in a small child or infant, is encouraged to assist wih

Beginning the assessment Exam begins with the 1st mtg All measurements are taken: wt, ht, head circumference Should be plotted to obtain the percentile At the first meeting, you have an opportunity to observe the child, the family, and the developmental tasks for the child that you not only expect, but observe…is he delayed? Advanced? Vital signs: temp (99 degrees until >36 months). Temp taken axillary or tympanick. Pulses: apical (SEE page 817 for normal vital signs by age) Respirations: rate, depth, ease of respiration. Resp. should be non-labored, quiet. Remember: infants are abdominal breathers, nose breathing begins from 4 wks to 4 months. By age 7 costal breathers Blood pressure: size of cuff important. One time per shift in the hospital; monitor closely in children with renal disease or cardiac problems. We are seeing more and more children that are hypertensive and obese! Weight should double in 3-5 months, triple by the end of the first year

Pediatric Assessment vs. Adult Assessment Developmental approach Order of the exam Differences in findings in pediatric client Assessment for congenital anomalies Documentation of findings Assistance by the parent present Before beginning the exam, the nurse must be award of the developmental milestones expected in the child according to their age In an adult, the assessment is from head to toe..in pedi, it might be toe to head, depending on the ge In children, many of the systems may be immature…liver, spleen, etc., so findings may be different from an adult. Secondly, skin texture, eye movement, ear placement, are important to document because they may be suggestive of underlying problems. The parent, esp in a small child or intant, is encouraged to assist with the exam

Review of symptoms Developmental approach to the exam Young child: foot to head Older child: head to toe Sequence imp. to a young child because they are not undressed untill the least distsressing part of the exam is completed.

Exam techniques Vary by the age of the child Build rapport with the family Develop cultural competence Involve the child in the interview if age appropriate Be honest with the child when answering questions Utilize “careful listening” Small infants may be held in the parent’s lap;; adolescents need to be examined alone, unless they request that the parent is present Strategies to build rapport with the family: make sure the parents understand the purpose of the interview and that the information will be confidential only to healthcare members involved in the childl’s care. Make a self-introduction: name, title, role, ask all family members presnet what name they prefer you to use when talking with them Explain the purpose of the interview and why the nursing history is different from the information collected by other health professionals. Provide privacy and remove as many distraction as possible during the interview. Direct the focus of the interview with open-ended questions. “Tell me what brought you to the hospital?” Ask one question at a time so that the parent or child understands what piece of information is desired and so that it is clear which questions the parent is answering. Ask, “does any member of your family have diabetes?” instead of compiling all diseases together. Some cultural groups, particularly Asians, try to anticipate the answers you want to hear, or say yes even if they do not understand the question. This is done in an effort to please you or as an expression of politeness. In some cultures, eye contact is avoided: Asian, Natyive American, and Middle Eastern patienst. Europeans, such as the French and Spanish, use firm eye contact and look for a response or impact regarding what has been said. Some American may make brief eye contact and then let the eyes wander. “Careful listening”: being alert to any underlying themes. Paying attention to parent’s attitudes or tone of voice with the child’s problems. Observing the parent’s nonverbal behavior (posture, gestures, body movements, eye contact, and facial expression)

Nursing Practice techniques for physical assessment Inspection Palpation Auscultation Percussion Inspection: purposeful observation of the child’s physical features and behaviors. Size, shape, color, movement, position, location. Detection of odors is also a part of inspection Palpation: use of touch to identify characteristics of the skin, internal organs, and masses, Characteristics include texture, moistness, tenderness, temperature, position, shape, consistency, and mobility of masses and organs. The palmar surface of the fingers and finger pads helps determine position size, consistency and masses. Auscultation: listening to sounds produced by the airway, lungs, stomach, heart, and blood vessels to identify their characteristics. Auscultation is usually performed with a stethoscope to enhance the sounds heard. Percussion: striking the surface of the body, either directlyy or indirectly to set up vibrations that reveal the density of underlying tissues and borders of internal organs.

Normal findings in children Small, firm, nontender, and shotty lymph nodes may be palpable Tonsils of varying sizes; often larger in young children Pupils of equal size, round and reactive to light and accommodation Pulses in upper and lower extremities; bilaterally symmetric SHOTTY: freely palpable and very small

Terminology for head shape Normocephalic Microcephalic Macrocephalic Bossing Bossing: frontal enlargement Head movement is evaluated by observing the child move the head. Head control is also observed

Physical exam Skin: perfusion, turgor, color, lesions Hair: distribution, loss, lice, pubic areas Head/skull: symmetry, circumference, sutures in infants Eyes/ears: *red reflex, TM, muscles of the eye, lacrimal glands, conjunctiva Red reflex: imp to assess in the neonate. Moms may come into the hospital/doctor office stating that in photographs their child has a white spot instead of the red. This is a sign of retinoblastoma which is a serious malignant tumor arising from the retina. Many times the absence of the red reflex can save the eye if diagnosed early.

Physical exam, cont. Lips, tongue, gums, palate, teeth Neck: movement, nodes, thyroid Chest: shape, movement, effort, function A B Funnel chest (Pectus excavatum) pigeon chest (pectus carinatum) Tongue for coating, lips for color and hydration status, gums, palate Chest: inspect for simultaneous chest expansion and abdominal rise. Retractions? “funnel chest” “pigeon chest” Auscultation of the chest: breath sounds, vesicular breath sounds are low-pitched, swishing, soft, short sound. They are usualy heard in older children, but not in infants and young children. Bronchovesicular breath: medium pitched, hollow, blowing sounds heard equally on inspiration and expiration in all age grouops. The location of these sounds on the chest is r/t child’s developmental status. Bronchial/tracheal breath sounds are hollow and higher pitched than vesicular breath sounds. Be aware of tactile fremitus…placing your hands on the chest to evaluate the quality and distribtuion of these vibrations. Decreased sensations indicate that air is trapped in the lungs as occurs with asthma. Increased sensations indicate lung consolidation, as occurs with pneumonia.

Physical Assessment Heart sounds: murmurs, apical rate, arrhythmias, blood pressure, and rhythm Abdomen: shape, bowel sounds, underlying organs Genitals: Preparation for the exam crucial! Include the anus and rectum, assessment for pubertal development and sexual maturity Takes a trained ear, but you are listening for S1 (closure of the tricuspid and mitral valves) they close almost simultaneously, so only one sound is normally heard. S2 is produced by the closure of the aortic and pulmonic valves. Once blood has reached the pulmonic and aortic arteries, the valves close to prevent leakage back into the ventricles during diastole. Inspection of the abd: from the front and side with good lighting. A sunken abd is abnormal and indicates dehydration. Dullness is percussed over the liver, spleen, and full bladdder. Typany (like a watermelon) over thestomach or intestines when as obstruction is present.May also be percussed in infants that are swallowing a lot of air. Light palpation: gentle touch that slightly depresses the abd. Liver edge descends with inspiration, and you feel a flat, narrow ridge. The liver is enlarged when the edge is more than 3cm (1 inch) below the right costal margin. Genitals: hymen (use the thumb and forefinger of one gloved hand to separate the labia minora for viewing structures in the vestibule. Hymen is just inside the vaginal opening. Sexually active adolescents may have a vaginal opening with irregular edges. In males, palpate the scrotum for descended testicles. The urethra should be visualized as well . Stroke the inner thigh of each leg to stimulate the cremasteric reflex. The testicle and scrotum normally rise on the stroked side. The response indicates intact function of the spinal cord at the T12, L1 and L2 levels. Rectal exams are not routinely performed on children. It is indicated for sx of intr-abd, rectal bowel, or stool abnormalities

Physical Assessment, cont. Musculo/skeletal system: one and joints, ROM, strength, posture, spinal alignment Inspection of the limbs Nervous system: cognition, balance, CN function, language, reflexes Inspect the child’s posture when standing from a front, side and back view. After beginning to walk, young children often have a pot-bellied stance bec. of lumbar lordosis. The spine has normal convex and lumbar concave curves after 6 years of age. The school-age child should be assessed for scoliosis…a lateral spine curvature. Stand behind the child, observing the height of the shoulders and hips To assess the CN in infants and young children, modify the procedures used for school age children. IV: (trochlear)moves eyes on objects VII (facial) acoustic testing for sound near the child IX ( glossopharyngeal)observe swalloinwg X: (vagus) all ages elicit gag reflexj XII (hypoglossal) observe feeding sucking and swallowing are coordinated Neurologic “soft signs” are findings that indicate the child’s inability to perform certain activities r/t to the child’s age. They may provide subtle clues to an underlying central nervous system deficit or neurologic maturation delay

Physical exam of dark-skinned children Erythema: dusky red or violet Cyanosis: black or dusky Jaundice: diffusely darker than the child’s normal color May also look at the sclera. Vitiligo: areas of depigmentation

Psychosocial Assessment Home environment Employment and education Eating Activities Drugs (substance use) Sexuality Suicide/depression Safety H: who lives with you? Where do you live? Do you have your own room? Whom are you closest to? E: are you currently in school? Whatare your favorite subjects? Tell me about your friends at school E: wht do you like and not like about your body? Recent changes in weight? Exercise? What do you think is a healthy diet? A: what do you and your friends do for fun? Sports? Hx or ETOC or drug in your family? Tabacco? Do you use any drugs or tobacco? S: have you had a romantic relationship? Tell me about the people that you?ve date. OR tell me about your sex life. Have you been in a sexual relationship? What does the term “safe sex: mean to you? Are you interested in boys? Girls? Both? S: do you fell sad or down more than usual? Crying moe than usual? “bored” all the time? Have you ever thought about hurting yourself or someone else? S: have you even been seriously injured/ wear a seat belt in the care? Have you ever ridden with a driver who was drunk or high? Violences in your school? Neighborhood? Home? Have you ever been physically or sexually abused? Raped, or a date or at any other time?

Suspicions of child abuse/neglect detected during assessment Dress Grooming and personal hygiene Posture and movements Body image Speech and communication Facial characteristics and expressions Psychologic state Dress: appropriate for the weather; ragged or excessively dirty Grooming and hygiene: dirty teeth, broken and dirty fingernails, matted and dirty hair Posture and movements: crouching in a corner; slow,k concentrated movements Body image: distorted, being think but describing self as fat Speech and communication: answering questions in words of one syllable; looking to others to respond first; seeking approval for answers Facial characteristics and expressions: fearful, anxious, tearful, sad, or angy expressions Psychologic state: labie, demanding, bizarre, overly dramatic, or condescending

Concluding the exam What questions should be asked at the end of every interview? “Is there anything more about your child that we should know?” “Is there anything I did not mention that you want to ask about?” “What questions do you have about the treatments? Did you understand everything that the dr. said?

Ask yourself… What if a 14 year old girl weighs 93 lbs. Would the nurse be concerned? What if she weighed 110 lbs 6 months earlier? What if a year earlier she had weighed 105 lbs? pp. 1613-1617 93 lbs puts her in the 10th percentile. A year ago her weight was in the 50th percentile. Growing children should not go back in growth. Her weight loss of 17 pounds needs to be investigated…is she dieting, or has she developed an eating disorder, or is it a sign of illness?

Ask yourself…. A 2 yr old child being seen for well check is resistant to the exam. What techniques would be helpful for the nurse to use with a toddler? Very challenging to exam bec. They are not usually cooperative. Sit or stand next to the parent. Provide a few toys that encourage the child to explore. Use age-appropriate words to describe what is about to be done. Order of the exam should be flexible. Any painful procedures should be left to last. Parent is the best assistant. (May need to assess the anxiety level of the parent) See pp. 812-813

Another challenge…. Kelly, aged 15 months, comes in for a well child check. How would the nurse assess height and weight? Remember this age child has stranger anxiety! Distracting a child of this age with a toy or object may be useful. Talking calmly in a soft voice, distracting with a toy and leaving uncomfortable procedures to last. In a child this age, measurements may be able to be done lying down. See pg. 819

Critical thinking after the exam Compiling the data Describing the elements of the health history Modifying assessments based on ages Determining the sexual maturity Recognizing 5 important signs of a serious alteration that require urgent attention Five imp signs of a serious alteration in health condition: Altered level of consciousness, bradycardia, tachypnea(greater than 60), pain, signs of dehydration (no tears, dry mucous membranes, doughy skin turgor, sunken fontanelle, increased urine concentration), stridor, retractions, cyanosis

Critical thinking exercise Leah, 17 years old, is a single mother who brings her 6 month old child to the clinic. Leah has not kept her appointments the last two months. She reports, “I hate to take time off work when she is well but my supervisor said it was important for her to get a checkup; I guess I messed up” What assumptions could the nurse make about Leah? She does not provide adequate care; teenage mothers lack information about parenting responsibilites, Leah may not know what the needs of an infant are and how imp. well checks are for early detection of problems. Checkups also provide a time of the nurse to teach the young mother How should the nurse respond to her comments? Avoid displays of disapproval. She could state, “children do take a lot of our time and it is a hard balance when you are working outside the home. Let’s look today at your schedule and how we can help you” How can the nurse best act as an advocate for both the daughter and Leah? By determining, through the assessment, the health of Leah’s baby girl. The nurse will want to focus on anticipatory guidance r/t nutrition, immunizations, safety, and any age-related growth and developmental issues.

Part II: Medications for the pediatric patient Small, very accurate dosages All medications ordered must be calculated by the nurse (and you!) All weights based on kilograms/milligram This will be covered more in detail in orientation at the hospital; however, we will review some of the key concepts that you will employ at the hospital

Calculations of the medications Nurse is responsible for the accurate ADMINISTRATION of the medication The most accurate ADMINISTRATION is performed by the nurse calculating the dosage before giving to the patient Since the children’s hospital is a teaching one, many doctors will see the patient….man will order meds for the child. Therefore, we must calculate and scrutinize every order. At this time, the dr. orders are still a hard copy, found in the pt. notebook at the door of the pt.

Let’s calculate John weighs 8.2 kg. The dr. orders Ampicillin 200 mg. q 6 hrs. (dosage is 25mg/kg) Is this an appropriate amount? Sarah, age 12 and weighing 44 kg, has a temp of 102. the dr. has ordered tylenol 81 mg q 6 for fever above 101.8. Is this an appropriate dose for Sarah? Ampicillin 205 mg per dose; it is appropriate. Sarah weighs 44 kg and therefore can have an adult dose. This order is less than appropriate for her weight

Syringe pump vs. Plum® How do you make the decision about the type of pump to use? All meds given IV are administered on a pump Making the decision…. Explain the difference between the amt of fluid that an infant, toddler, etc. can absorb vs. an adolescent. The syringe pump is used for all amounts of fluid, from 1 ml to 20 ml. It is never wrong to use the syring pump, but on an older child, es one who is mobile, the Plum may be used. We will go over the settings when we get to the hospital.

Let’s Have a Great Rotation! I am glad to say that there have been changes at Dell Children’s Hospital and we now are able to do some things we could not do before. I am hoping that each of you enjoys the rotation with children and will consider pediatrics as an option for employment when you graduate!