2. Objectives
• Understand the importance of Assessment and
Triage and how they interplay in the Health Care
Setting
• Identify essential components of a “focused”
Pediatric Assessment
• Utilize the assessment information to differentiate
between minor and more serious conditions (Triage)
• Identify and implement nursing interventions based
on the assessment and triage provided
Sound Familiar?
3. Essential 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
5. The single most important part of
the health assessment is……
the
6. History
Bio-graphic Demographic Past Medical History
• Name, Date of Birth, Age •Allergies
•Past illness
• Parents & siblings info
•Trauma / hospitalizations
• Cultural practices •Surgeries
• Religious practices •Birth history
• Parents’ occupations •Developmental
• Adolescent – work info •Family Medical/Genetics
Current Health Status
•Immunization Status
•Chronic illnesses or conditions
•What concerns do you have today?
7. 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
10. Patti’s Nitty Gritty Trio
• 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
11. Components of a
Focused Pediatric Assessment
• Always ABCs!
Appearance
• PAT: Pediatric Includes
Assessment LOC & Behavior
Triangle
• Ongoing Triage – PAT
• Minor vs.
• Serious vs.
Life-Threatening Breathing Changes Skin Circulation
• Problem- Focused
Examination
13. APPEARANCE
Tone
Interactiveness
Consolability
Look/gaze
Speech/cry
14. Work of Breathing
• Increased or
Decreased
Respirations
• Stridor
• Wheezing
15. Circulation to the Skin
• Inadequate perfusion
of vital organs
• Leads to
compensatory
mechanisms in non-
essential functions
• Ex: vasoconstriction in
the skin.
16. Initial Assessment (s)
• Primary • Secondary
• A = Airway • E = Exposure
• B = Breathing • F = Full Set of Vitals
• G = Give Comfort
• C = Circulation Measures including Pain
• D = Disability Assessment & Tx.
• H = Head –to-Toe
assessment & history
• I = Inspect posterior
surfaces – rashes,
bruising
17. Physical Assessment
• The approach is:
• Orderly
• Systematic
• Head-to-toe
• But FLEXIBILIY is essential
• And be kind and gentle
• but firm, direct and honest
18. Physical Assessment
General Appearance & Behavior
• Facial expression
• Posture / movement
• Hygiene
• Behavior
• Developmental Status
19. 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 ____ ?
23. Inspection
• Use all your
senses
• The essential
First Step of the
Physical Exam
24. Palpation
• Use of your fingers • Warm hands and
and palms to short nails
determine: • Palpate areas of
tenderness / pain last
• Temperature
• Talk with the child
• Hydration during palpation to
• Texture help him relax
• Shape • Be observant of
• Movement reactions to palpation
• Move firmly without
• Areas of hesitation
Tenderness
25. Palpation
• For the ticklish child: place her hands over
your hands and have the child do the
pressing down.
26. Percussion
Use of tapping to
produce sounds that
are characterized
according to:
• Intensity
• Pitch
• Duration
• Quality
Direct vs. Indirect
27. Auscultation
• Listening for body sounds
• Bell: low-pitched
• - heart
• Diaphragm: high-pitched
• – lung & bowel
LUNGS:
Listen to all lung fields
FRONT AND BACK!
auscultate for breath sounds and adventitious sounds
28. “I P P A”
• Practice, Practice, Practice
• by knowing what the norm is, you’ll be able
to pick up on the abnormal, even if you
can’t diagnose it….
• The important thing is to be able to say
“This is not right”
• and refer appropriately!
30. 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
31. Head
• Shape:
“NormoCephalic –
ATraumatic”
AT
• Lesions
• ? Edema
32. 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
33. Neuro Assessment
• LOC / Glasgow coma scale
• Confusion, Delirium, Stupor, Coma
• Pupil size
• CNS grossly intact: II – XII
• Vital Signs
• Pain
• Seizure Activity
• Focal Deficits
34. 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
35. 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
37. Glasgow Coma Scale
The lowest possible GCS is 3 (deep coma or death) while the
highest is 15 (fully awake person).
1 2 3 4 5 6
N/A N/A
EYES Does not Opens eyes Opens Opens eyes
open eyes in response eyes in spontaneously
to painful response
stimuli to voice
N/A
VERBAL Makes no Incomprehen Utters Confused, Oriented,
sounds sible sounds inappropri disorientated converses
ate words normally
MOTOR Makes no Extension to Abnormal Flexion / Localizes Obeys
movements painful stimuli flexion to Withdrawal to painful commands
painful painful stimuli stimuli
stimuli
Source :Wikipedia
38. 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”
39. HEAD INJURY
• Very common in pediatrics
• Most often not serious
• requires observation only
• Symptoms
- headache
- vomiting
- lethargy
- altered behavior
•Altered mental status: GCS
40. HEAD INJURY - Physical
Findings
• PUPILS
• PAPILLEDEMA
• CUSHING TRIAD:
• bradycardia, irregular respirations and
hypertention
• Look for signs of alcohol/drug abuse in
adolescents
• Lack of external signs of head trauma
does not rule out significant brain injury
41. CONCUSSION
• Traumatic alteration in mental status
- disturbance of vision
- loss of equilibrium
- amnesia
- headache
- cognitive function
- LOC (not necessary for diagnosis)
• Needs complete neurological exam
• Second-impact syndrome
• MRI
42. Guidelines
Grading &1st Concussion
Guidelines
Minimum time
Grade Confusion Amnesia LOC to return Time
to play asymptomatic
I Yes No No 20 min When
examined
II Yes Yes No 1 week 1 week
III Yes Yes Yes 1month 1 week
43. Time to return to contact
sports after repeat
concussion
Grade Minimum time to Time
return to play asymptomatic
I (2nd time) 2 weeks 1 week
II (2nd time) 1month 1 week
III (2nd time) Season over
I,II (3rd time)
44. 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
o
vision screening
• Refer to ophthalmologist is there
are concerns
45. 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
46. Conjunctivitis
Viral – most common cause Bacterial – more common in
• Very contagious school-age children
• 8 day incubation period Symptoms:
• Pinkish-red eyes • Red eyes
• Watery or serous discharge • Purulent or mucopurulent
• Crusty eyelids on awakening discharge, matted eyelids
• c/o “gritty sensation in eye upon awakening
• May c/o URI symptoms • c/o “gritty” sensation
• Can be either unilateral or • Usually starts unilaterally
bilateral and then progresses to
bilateral
• Vesicles around eye could be
herpes lesions • Often concurrent otitis
Immediate referral to media
ophthalmologist • Culture if < 1 month of age
47. Conjunctivitis
Allergic
• Often seasonal
• Erythema due to dilated vessels
• Itching, burning
• May be seasonal
• Tearing, watery eyes
• Eyelid swelling
• Clear or stringy eye discharge
• bilateral
48. 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
49. Common Ear Infections
Otitis Media Otitis Externa
• Most common reason • Pain –especially
children come to the when pinna is slightly
pediatrician or tugged at
emergency room • Discharge
• Fever or tugging at ear (sometimes odorous)
• Often increases at night • “Swimmer’s Ear”
when they are sleeping
• History of cold or
congestion
50. Nose & Throat / Mouth
• Turbinates • Palate
• Exudate • Gums
• Pharynx • Swallow
• Tonsils • Oral Hygiene
• Signs & Symptoms of • Condition of teeth
Allergic Rhinitis • Missing teeth
• Streaking
• Cobble stoning
• Orthodontic
• Post-Nasal Drip Appliances
• Injection
• Erythema
Or is it infection?
51. 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
52. Nose: Variations
• Allergy: “allergic salute” - line across
nose.
• Infection
• Foreign body:
• Foul odor or unilateral discharge
• Structure variations
• Bell’s palsy
53. Nose and Throat
Sinusitis:
• Fever
• Purulent rhinorrhea
• Facial Pain – cheeks, forehead
• Breath odor
• Chronic cough – could be day and night
• (+) Post-nasal drip
55. Ears, Nose and Throat
Sore Throats
Is it strept or is it viral
or could it be mono?
Lymph nodes
& ROM
56. Neck: Key Points
• √ position, lymph nodes, masses, fistulas,
clefts
• Suppleness & Range of Motion (ROM)
• Check clavicle in newborn
• Head control in infant
• Trachea & thyroid in midline
• Carotid arteries (bruits)
• Torticollis
• Webbing
• Meningeal irritation
57. Chest Assessment
•How does the child look?
•Color
•Work of Breathing: Effort
used to breathe
Auscultatio
n All 4 quadrants
•
• Front and back
• Take the time to listen
• Be sure about “lungs CTAB”
(clear to auscultation bilaterally)
65. Cough - Characteristics
• Dry, non-productive
• Mucousy – productive
• Croupy
• Acute – less than 2-3 weeks
• Chronic – more than 2-3 weeks
• Associating Symptoms
66. Chest Pain
• Call 911 if severe, acute, unremitting –
needs immediate attention - very rare
• Non-cardiac – most common
• Musculoskeletal: costochondritis
• Pulmonary
• Gastrointestinal e.g. GERD
• Psychogenic
• Often no significant physical findings
• Must rule out Cardiac origin – refer to PCP or
pedi cardiologist
67. Circulatory
•Auscultating Heart Sounds
The Auscultation Assistant – Hear Heart Murmurs, Heart Sounds,
and Breath Sounds. http://www.wilkes.med.ucla.edu/inex.htm
Pillitter
•Perfusion – capillary refill
•“Warm to touch”
68. Murmurs:
• may be systolic, diastolic or continuous
• timing, location, quality -course, harsh, blowing, high pitched
• GRADE:
• I - faint, may not be heard sitting
• II - readily heard with stethoscope
• III - loud, no thrill
• IV - loud with stethoscope, thrill
• V - loud with stethoscope barely to chest, thrill
• VI - loud with stethoscope not touching chest, thrill
• Functional Murmurs:
• Change or disappear with position change (usually loudest supine)
• Low grade, soft or musical
• Intensity range from I-III/VI
• Systolic (never diastolic)
• Do not radiate
• Occur in absence of significant heart disease or structural
abnormality
71. 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
72. Stomachaches and
Abdominal Pain
• Excessive gas • Heartburn or
• Chronic constipation indigestion
• Lactose intolerance • GERD
• Viral gastroenteritis • Food allergy
• Irritable bowel • Parasite infections
syndrome (Giardia)
What are we most concerned about?
74. 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
83. Viral Skin Infections
• Most communicable diseases of
childhood have characteristic rash
• Examples: verruca, herpes simplex
types I and II, varicella zoster,
molluscum contagiosum
84. Fungal Skin Infections
• Superficial infections that live on the
skin
• Also known as dermatophytoses, tinea
• Transmission from person to person or
from infected animal to human
• Examples: tinea capitis, tinea corporis,
tinea pedis, candidiasis
85. Contact Dermatitis
• Inflammatory reaction of skin to chemical
• Initial reaction in the exposed region
• Characteristic sharp delineation between
inflamed and normal skin
• Primary irritant
• Sensitizing agent
• Examples: diaper dermatitis, reaction to
wool, reaction to specific chemical
• Poison Ivy, Oak, and Sumac - urushiol
87. Atopic Dermatitis
• A type of pruritic • Three forms:
eczema that begins • Infantile eczema:
during infancy begins at age 2-6
months
• Hereditary tendency
• Childhood eczema:
• Often associated may follow infantile
with history of food form
allergies, allergic • Preadolescent and
rhinitis, and asthma adolescent: 12 years
to early adult age
88. Therapeutic Management of
Atopic Dermatitis
Goals:
• Relieve pruritus
• Hydrate skin
• Reduce inflammation
• Prevent or control secondary infection
89. WOUND CLASIFICATION
CLINICAL NON-TETANUS- TETANUS-PRONE
FEATURES PRONE WOUNDS WOUNDS
Age of wound <6 hours >6 hours
configurations Linear wounds, Stellate, avulsion
abrasions
depth <1cm >1cm
Mechanism of injury Sharp surface Crush, burn, missile
Sings of infection absent present
Devitalized tissue absent present
Contaminants (dirt, absent present
feces, soil, saliva )
Denervated/ischemic absent present
tissue
90. The School-Age Child
• Privacy and
modesty.
• Explain procedures
and equipment.
• Interact with child
during exam.
91. Adolescent
• Privacy issues – first
consideration
• HEADS: home life,
education, alcohol,
drugs, sexual
activity / suicide
• GAPS Guidelines for
Adolescent
Preventive Services
• Bright Futures
92. Psychosocial Assessment
HEADS SHADESS
• Home life •School
• Emotions / •Home
Depression or •Activities
Education
•Drugs / Substance
• Activities
• Drugs / Alcohol / Abuse
Substance •Emotions /
Abuse Depression
• Sexuality •Sexuality
activity or •Safety
Suicide
93. 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?
104. • Jan Chandler RN, MSN, CNS, PNP Pediatric Nursing: Nursing Care of
Children and Young Adults: Pediatric Physical Assessment
• Colyar, M. Well Child Assessment for Primary Care Providers.
Philadelphia, PA: F.A. Davis Company.
• Duderstadt, K. Pediatric Physical Examination.
St. Louis, MO: Mosby, Inc.
• Engel, J. Pediatric Assessment 5th. Ed. St. Louis, MO: Mosby, Inc.
• Wong’s Essentials of Pediatric Nursing 8 th ed.
• AAP Preparticipation Physical Evaluation. Available @ www.aap.org
• Resource Manual for the Nurse in the School Setting
http://www.ems-c.org/school/frameschool.htm
• American Medical Association Guidelines for Adolescent Preventive
Services (GAPS) http://www.ama-assn.org/ama/pub/category/2280.html
• American School Health Association http://www.ashaweb.org
• The Auscultation Assistant @
http://www.wilkes.med.ucla.edu/intro.html
• BMI Calculator: http://www.cdc.gov/nccdphp/dnpa/bmi /
• 2007 Asthma Guidelines:
http://www.nhlbi.nih.gov/guidelines/asthma/index.htm
108. 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.
Editor's Notes
PRIZE!
Inspection and auscultation are performed before palpation and percussion because touching the abdomen may change the characteristics of the bowel sounds.
