Nursing Assessment For Pediatric cases

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Assessment

• History

– Present complaints

–  past medical

–  presence of any chronic illnesses

– birth history

– H/O growth and development

– H/O contact with communicable diseases

– Family History of diseases- Thalassemia, SCA, G6PD, Cystic fibrosis

– Dietary history

 

• Physical examination

– Head to foot examination

– Measurement of vital signs

• Growth measurement

– Height

– Weight

– Head circumference

– Chest circumference

– Mid-arm circuference

•Developmental assessment

 

Age Specific Approach to Physical Examination

Age and Position

Age and Position

Sequence

Preparation

Infant before sits alone:

Supine or prone. Can place on the examining table or in parent’s lap.

If quiet, auscultate heart, lungs, abdomen. Record heart and respiratory rates.

Palpate and percuss same areas.

Proceed in head to toe direction.

Completely undress if room temperature permits.

Leave diaper.

Gain cooperation with distraction – bright objects or talking.

Let old infant hold something in hands.

After sits alone:

Use sitting in parent’s lap

Perform traumatic procedures last (eyes, ears, mouth)

Elicit reflexes as body parts are examined.

Elicit moro reflex last

Smile at infant, use soft gentle voice.

Pacify with feeding or bottle of sugar water.

Ask parent’s help in restraining.

Avoid sudden, jerky movements.

Toddler

Sitting or standing on/by parent.

Prone or supine in parent’s lap.

Inspect body area through play: “Count fingers or tickle toes”

Use minimum physical contact initially.

Introduce equipment slowly.

Auscultate, percuss and palpate whenever quiet.

Perform traumatic procedures last (eyes, ears, mouth)

Have parent remove outer clothing.

Remove underwear as body parts examined.

Allow to inspect equipment.

Perform procedures quickly.

Use restraint when appropriate. Ask parent’s help in restraining.

Talk about examination if cooperative.

Praise for cooperative behavior.

Preschool child

Prefer standing or sitting.

Usually cooperative prone or supine.

Prefer parent’s closeness.

If cooperative proceed in head to toe direction.

If uncooperative, proceed same as with toddler.

Request self-undressing.

Allow to wear underpants if shy.

Offer equipment for inspection, briefly demonstrate the use.

Make up a story about the procedure or use paper doll technique.

Give choices when possible.

Expect cooperation, Use positive statements e.g. “Open your mouth”.

School-age child

Prefer sitting.

Usually cooperative in most positions.

Younger children prefer parent’s closeness while older children may prefer privacy.

Proceed in head to toe direction.

Examine genitalia last in older child

Respect need for privacy

Request self-undressing.

Allow to wear underpants.

Give gown to wear.

Explain purpose of equipment and significance of procedure.

Teach about body functioning and care.

 

Equipment

• Weighing scale

• Tape measure

• Thermometer

• Stethoscope

• Sphygmomanometer

• Ophthalmoscope

• Otoscope

• Tongue depressor

• Torch

• Knee hammer

• Tuning fork

 

Physical Assessment

Area

How and what to look for

Age and General appearance Observe acute distress, cleanliness, alertness, mood color, size, proportions.
Vital signs Temperature, apical pulse, respiration, and BP
Height, weight Should be plotted on a chart and relationship to percentiles noted
Crown-rump measurement Measure from vertex of head to point at which the child’s buttocks touch the table when in a sitting position.
Head circumference Measure over occiput and supra-orbital ridges
Head Observe for symmetry, growths, bruises, hair patterns, cradle cap, etc. Auscultate with bell of stethoscope for continuous or systolic bruits over orbital or temporal areas. All bruits should be referred to the doctor. Most bruits heard after four years of age are pathological.
Fontanels Anterior fontanel is diamond shaped, 3-4 cm long and 2-3 cm wide in a newborn, refer to doctor if larger and sutures are widely separated. It closes by 12-18 months.

Posterior fontanel is triangular in shape and 1 cm long. Refer to doctor, if larger. Closes by 4-6 weeks. Fontanels must be checked while infant is not crying.

Fontanels should not be indented or bulging.

Face Observe for shape, symmetry, facial expression, color, cyanosis, jaundice, pallor, edema, dark circles under eyes.
Eyes Observe eyelids, lashes, and orbital area, conjunctiva, sclera, iris, pupils. Look for ptosis, color of sclera and conjunctiva – redness, yellow or bluish discoloration, hordeolum (sty), and sun-set-sign. Palpate eye globe for tension.

Check pupil equality, accommodation and reaction to light (PEARL).

Eye movements and symmetry of movements should be noted. Look for strabismus, esotropia or exotropia.

Vision testing may be done with snellen chart.

Ears Observe for low set ears, cysts, evidence of dried drainage, erythema of canal.
Neck Examine for stiffness, tilting, rigidity, enlarged nodes
Chest

circumference

Place tape across nipple line and measure half way between inspiration and expiration.
Chest Note shape, symmetry of respiratory movements, symmetry of clavicles or node enlargement at axilla. Observe for retractions, grunting or wheezing.

When evaluating breathe sounds, a young child may be asked to blow on an object to elicit deep breathing through his mouth.

Breasts may be in inspected for size, symmetry, dimpling, discharge. Engorgement is common in newborns of both sexes.

Apical pulse The apex beat is located in the 4th intercostal space lateral to the left nipple before 4 years. It is in the 5th intercostal space at the midclavicular line below the left nipple between 4-6 years and in the 5th intercostal space between the midsternal and midclavicular line after 6 years of age.
Heart sounds Listen to the heart beat for normal sounds and for presence of any murmurs.
Abdomen The infant can be fed to relax the abdominal muscles. The older child can be asked to breathe through his mouth and flex his knees. The examining hands must be warm. Observe for convex or concave shape abdomen, umbilical protrusion, visible peristaltic waves, hernias.
Genetalia Note distribution pattern of pubic hair. Check for signs of discharges, infection, phimosis, placement of urethral opening on penis, presence of testes,size of scrotal sac.
Extremities And spine Palpate joints during range of motion, to observe for crepitus or “catching”. To measure length of legs, measure from anterior superior iliac spine to level of medial malleolus. Observe for symmetry of extremities, deformities, range of motion; note especially hip symmetry and range of motion. Observe curvature of spine in sitting, standing, and lying positions
Skin Examine for color, abrasions, cuts, petechiae, burns, scars. Observe for rashes, birthmarks, turgor, edema, acne. Check hair, nails, skin hygiene.

 

General rules for accurate developmental assessment

• Short testing periods are essential, as infants tire easily and young children have short attention spans

• Vigorous activity after eating can cause vomiting and discomfort in infants. Young children should be tested one to two hours after meals to best use high energy levels.

• The school-age child should be tested early in the day to counteract fatigue and the need for creative play later in the day.

• The testing environment should be comfortable and free from distractions.

• The child should be relatively well and free from drugs if being tested for developmental abilities.

 

Milestones of Development

Milestone Age of attainment Milestone Age of attainment
Social smile 4-6 weeks Drinking from cup by holding it 15-18 months
Head control 3-4 months Talking 2 or 3 words sentence 18-24 months
Sitting 6-8 months Eating by self 18-24 months
Talking

“ma ma”, “da da”

7-9 months Dressing by self simple 24 months
Standing 9-11 months Holding pen and writing 36 months
Talking 2 or 3 words 12 months Performance in school 5 year and above

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