1. Pediatric Physical Assessment Fall 2009 Susan Beggs, RN MSN CPN

2. 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

3. 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

4. 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

5. Beginning the assessment  Exam begins with the 1 st mtg  All measurements are taken: wt, ht, head circumference  Should be plotted to obtain the percentile

6. Review of symptoms  Developmental approach to the exam  Young child: foot to head  Older child: head to toe

7. 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”

8. Nursing Practice techniques for physical assessment  Inspection  Palpation  Auscultation  Percussion

9. 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

10. Terminology for head shape  Normocephalic  Microcephalic  Macrocephalic  Bossing

11. 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

12. Physical exam, cont.  Lips, tongue, gums, palate, teeth  Neck: movement, nodes, thyroid  Chest: shape, movement, effort, function  AB  Funnel chest  (Pectus excavatum) pigeon chest (pectus carinatum)

13. 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

14. 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

15. Physical exam of dark- skinned children  Erythema: dusky red or violet  Cyanosis: black or dusky  Jaundice: diffusely darker than the child’s normal color

16. Psychosocial Assessment  H ome environment  E mployment and education  E ating  A ctivities  D rugs (substance use)  S exuality  S uicide/depression  S afety

17. 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

18. Concluding the exam  What questions should be asked at the end of every interview?

19. 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?

20. 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?

21. Another challenge….  Kelly, aged 15 months, comes in for a well child check. How would the nurse assess height and weight?

22. 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

23. 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”

24. Let’s Have a Great Rotation!