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Comparison Of The Physical Assessment Of Children By A Pediatric Nurse


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Comparison Of The Physical Assessment Of Children By A Pediatric Nurse

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Comparison Of The Physical Assessment Of Children By A Pediatric Nurse

  1. 1. This report is an evaluation of the ability of pediatric nurse practitioners to perform accurate, comprehensive physical examinations by comparing their appraisal with that made by pediatricians. The study demon- strates the competence of the nurse practitioners trained in this program. COMPARISON OF THE PHYSICAL ASSESSMENT OF CHILDREN BY PEDIATRIC NURSE PRACTITIONERS AND PEDIATRICIANS Burris Duncan, M.D.; Ann N. Smith, R.N., M.S.; Henry K. Silver, M.D. THE pediatric nurse practitioner pro- practitioners. A pediatrician from a gram developed by Silver et all2 pre- three-man private office was available pares nurses to assume a significantly one-half day per week to see patients in expanded role in meeting the health consultation and to provide medical needs of children. The program consists supervision. Periodic evaluation of all of a four-month course of intensive children was carried out by a physician. theory and practice in pediatrics at a When a physician was not available in medical center. Nurses increase their the office, a physician could be reached skills and become capable of assessing by telephone for consultation. Children and managing the total care of the well could also be referred to a neighborhood child, as well as a variety of acute and health center several miles away for chronic disorders which together make further evaluation and care by pediatri- up the majority of the problems seen in cians. the office practice of pediatrics. This re- All initial assessments of children com- port evaluates the ability of pediatric ing to the health station were performed nurse practitioners to perform accurate by nurse practitioners. In the year of the and comprehensive physical assessments study, there were 4,600 patient visits to by comparing the nurse's appraisal of the the health station; slightly over half of physical status of children with that of the visits were for well child care and in pediatricians. approximately one-half of the remaining visits, the child was brought in for a Method minor illness or other medical problem which was managed by the nurse without The children in this study were seen referral to a physician. Physicians and at Denver's Stapleton Health Station nurses recorded the pertinent and sig- located in a remodeled apartment in a nificant physical findings of all children low-income housing project in a medically seen at the health station or in consulta- isolated area with no readily accessible tion at some other facility. These became physicians or health facilities. The health a part of the child's health record. station was staffed by two pediatric nurse To determine the accuracy of the 1170 VOL. 61. NO. 6. A.J.PFH.
  2. 2. PHYSICAL ASSESSMENT OF CHILDREN pediatric nurse practitioner's assessment, those where a significant difference ex- a comparison of the nurse's assessment isted between the assessment of a condi- with that of a pediatrician was made by tion by the physician and a nurse, and reviewing clinic charts. In an unselected those where a difference in assessment consecutive series of charts that were was present, but where the difference reviewed, 182 children were first seen was not considered to be significant. Sig- by the nurse and subsequently by a nificant difference was defined as apply- pediatrician. Each of the 182 children ing to an incorrect assessment or a failure had one or more physical "conditions" to recognize a condition which could be which could and should have been noted favorably affected by treatment. by the nurse. Wellness, any significant deviation from normal, or any illness or Results injury were all considered as "condi- tions". Many children were found to There was total agreement in the find- have more than one condition on a single ings of the pediatric nurse practitioner examination; a total of 278 conditions and the consulting pediatrician in 239 were noted by the nurses and/or physi. of the 278 conditions noted in the 182 cians in the 182 children in this study. children in this study (Tables 1 and Chronic or static conditions or deviations 2A). There was a difference in assess- were counted only once. The ability to ment of 39 conditions (Table 2B). In obtain historical information or to 37, the difference in assessment was not evaluate subjective complaints or labora- considered to be significant. These in- tory results was not evaluated in this cluded several cases where the nurse felt study. that the tympanic membranes were sig- The assessments by nurses and phy- nificantly injected while the physician sicians of the 278 conditions were di- did not; two instances where the nurse vided into (1) those where the assess- reported hearing a heart murmur which ment was in total agreement by both was not heard by the physician; and health professionals, and, (2) those that four occasions where the physician heard were assessed differently by the two. an innocent murmur which was not re. The latter were further subdivided into ported by the nurse. In only two in- stances (0.7%o) was the difference be- Table I-Comparison of the assessment tween the nurse's and physician's assess- of the physical findings in 182 children ment considered to be significant. One with 278 "conditions"* recorded by case involved a twelve-month-old boy both pediatric nurse practitioners who had fever, cough and lethargy. The (PNPs) and pediatricians (Peds) pediatric nurse practitioner noted ery- Incidence Percentage thema of the throat and believed this to be the primary site of his illness; she PNP and Ped agree in felt the infant was sick enough to be re- their assessment 239/278 86% ferred to a physician for further evalua- PNP and Ped disagree tion and therapy. The physician agreed in their assessment 39/278 14% with the nurse regarding the severity of Disagreement- disease but felt the site of the disease significant 2/278 0.7% primarily affected the lower respiratory Disagreement- tract; a roentgenogram revealed patchy not significant 37/278 13% infiltration of the left lung. The other case with a significant difference in * Wellness, any significant deviation of a physical finding from niormal, or any illness or injury were all assessment involved a thirteen-month-old considered to be "conditions". boy who had fever and erythema of the JUNE, 1971 1171
  3. 3. Table 2A-"Conditions" present on physi- throat when evaluated by the nurse prac- cal examination of 182 children seen titioner. At that time, the nurse did not by pediatric nurse practitioners and feel that the child was sufficiently ill to pediatricians Conditions noted both by nurse and physician need immediate referral to a physician; she recommended that he be brought Number of back to the health station the following Condition times noted day. During the night, he developed in- creased irritability and neck stiffness. He Well child 63 was seen by a physician who diagnosed Middle ear abnormality 35 Erythematous inflamed throat 21 meningitis. Examination of the cerebro- Skeletal abnormality (fracture 2) 18 spinal fluid revealed one white cell; Visual loss 11 sugar, 70 mg. per 100 ml.; protein, 19 Developmental retardation 9 mg. per 100 ml.; LDH, 20 units; and Heart murmur 9 a negative culture. Blood culture was Anemia 7 also negative but a throat culture was Upper respiratory infection 6 positive for Group A beta hemolytic Rashes-Allergic 6 streptococcus. Despite the absence of Diaper 3 Infected 6 cerebrospinal fluid findings, the infant was treated with combined antibiotic Strabismus 3 therapy for possible meningitis. He made Lower respiratory infection an uneventful recovery except for the (pneumonia) 3 Hearing loss 3 neck stiffness which persisted for several Caries 2 days. Conjunctivitis 2 Fever of unknown etiology 2 Discussion Significant short stature 2 Laceration 2 Certain segments of the medical and. Ringworm 2 nursing professions have resisted the ex- Bronchitis 2 pansion of the nurse's role and this new Sprained ankle 2 method of delivering health services be- Umbilical hernia 2 cause of a fear that the pediatric nurse Adenopathy 1 practitioner, in performing a physical Asymmetry of the skull 1 examination and making an assessment Bleeding right ear 1 of the physical status of the child, might Cellulitis 1 Contusion 1 miss significant problems or deviations from the norm which would have been Croup 1 recognized by a pediatrician. Excessive skin on hands and feet (hyperkeratosis) 1 This study demonstrates that pediatric Fontanell bulging 1 nurse practitioners trained by Silver Hypotonia 1 et al are highly competent health pro. Large scrotal sac (hydrocele) 1 fessionals in assessing normal and ab- Lethargy I normal physical findings in children. In Nevus 1 only 0.7% of all "conditions' occurring Ptosis 1 in a group of 182 children who were Stomatitis 1 seen within a short time of each other Sty 1 Teeth mottling 1 by pediatric nurse practitioners and Trauma to tympanic membrane 1 pediatricians was there a significant Weak abdominal musculature 1 * Wellness any significant deviation of a 239 physical finding from normal, or any illness or injulry vere all considered to be "conditions". 1172 VOL. 61, NO. 6, A.J.P.H.
  4. 4. PHYSICAL ASSESSMENT OF CHILDREN Table 2B-"Conditions" present on physical examination of 182 children seen by pediatric nurse practitioner and pediatricians Conditions noted by either nurse or physician where there was a difference in assessment that was not considered to be significant* Assessment by Age in pediatric nurse practitioner Assessment by pediatrician years Cardiac murmur Heart murmur No murmur heard 4 0/12 Heart murmur No murmur heard 4 5/12 No murmur Grade ii/vi systolic murmur (no organic disease) 5 5/12 No murmur Innocent murmur (no organic disease) 2 4/12 No murmur Grade ii/vi vibratory nonradiating murmur (no organic disease) 5 2/12 No murmur Grade i/vi murmur not transmitted (no organic disease) 9 8/12 Abnormal lower respiratory findings Diffuse wheezing No wheeze, congested upper airway 5/12 Diffuse wheezing *No pathology 4/12 Wheeze, rhonchi, rales with otitis U.R.I., otitis, transmitted sounds 1 6/12 Questionable infection Lungs clear 2 8/12 Rhonchi Lungs clear 1 10/12 Skeletal abnornalities Asymmetric gluteal folds "Normal" (seen one month later) 3/12 Asymmetric gluteal folds "Normal" (seen one month later) 1/12 Questionable bowing of legs "Normal" (seen one month later) 3/12 Normal extremities Left foot eversion and pronation (no therapy necessary) 1 11/12 Normal skull Flattened right occiput 1 4/12 Abnormality of middle ear Resolving infection U.R.I. 1 0/12 Tympanic membranes injected Retracted, no infection 3 5/12 Tympanic membranes injected, dull No infection 1 3/13 Developmental lag Lag in gross motor development Within normal limits 5/12 Lag in fine motor development Within normal limits (seen one month later) 3/12 Abnormality of throat Erythematous inflamed throat "Clear" 9 9/12 Erythematous inflamed throat U.R.I. 3 4/12 Strabismus Strabismus No strabismus 2 8/12 Strabismus Strabismus diagnosed by pediatrician (Ophthalmologist found no strabismus; only prominent epicanthic folds) 1 Anal abnormality Normal anus (rectal bleeding, pain Anal fissure (seen 3 days later) 14 7/12 on defecation) Normal anus (constipation) Anal fissure (seen 2 days later) 1 4/12 (Continued on following page.) JUNE, 1971 1173
  5. 5. Table 2B-(Continued) Miscellaneous U.R.I. Parotitis (seen 1 day later) 13 11/12 Brawny edema over rt. mandible, "Doubt mumps" 4 6/12 ( ?) parotitis Thrush not noted Thrush (seen 1 day later) 9/12 Vomiting, probably gastroenteritis Viral pharyngitis, conjunctivitis 5 3/13 Weight loss (anorexia) Viral gastroenteritis 4 6/12 Rash (?) measles Heat rash (cleared in 1 day) 4/12 Failed screening test for hearing Normal hearing (audiologist) 13 0/12 Small cyst left nipple Supernumary nipple 2 7/'12 Well child, no hernia noted Small umbilical hernia 1 11/12 Well child, (liver down 1/2 cm.) Liver down 21/2 cm. 4 4/12 Conditions noted by either nurse or physician where the difference in assessment was considered to be significant* Assessment by Age in pediatric nurse practitioner Assessment by pediatrician years Red throat (?) infection Pneumonia (confirmed by x-ray) 1 Red throat (?) infection "Meningitis" (CSF negative on examination and culture) 1 1/12 * Significant was defined as an incorrectly or unrecognized condition which could have been favorably affected by treatment. difference between the assessment made practitioners, it was emphasized that by the nurses and those made by the they should refer not only all children physicians. whom they felt definitely should be The pediatric nurse practitioners seen by a physician, but also those in evaluated in this study were graduate whom any question existed as to the nurses with a baccalaureate degree in normalcy or significance of a particular nursing who had received a four months finding. It was recognized that this would course of study in Silver et al's pediatric result in over-referral of patients to nurse practitioner program.12 They were physicians and that this would increase skilled in taking complete pediatric his- the number of instances where there tories and performing comprehensive would be a difference in assessment by physical examinations including the the nurse and the physician. However, it basic skills of inspection, palpitation, per- was felt that these over-referrals served cussion and auscultation and the use of as an added safeguard for the children. such tools as the otoscope, stethoscope Examples of over-referral included chil- and ophthalmoscope. They determined dren with asymmetric skin folds of thighs the developmental status of children and in whom the physician decided that no tested for hearing defects, speech diffi- significant abnormality existed; chil- culties, physical impairments and various dren in whom the nurse heard a slurring congenital deformities. They were capa- of the heart sounds which was in- ble of assessing the over-all status of an terpreted by the physician as being ill child in order to determine the acute- within normal limits with no significant ness and severity of disease. They also cardiac murmur; or cases where the assessed various aspects of parent-child nurse was concerned about intermittent relationships, normal growth and de- mild imbalance of the eye muscles, but in velopment, variations of growth patterns, whom the physician decided that the im- and psycho-sexual development. balance was not clinically significant. In the training of pediatric nurse Evaluation of the competency of 1174 VOL. 61. NO. 6. A.J.P.H.
  6. 6. PHYSICAL ASSESSMENT OF CHILDREN pediatric nurse practitioners has not to pediatricians for consultation and for previously been determined. Anderson3 confirmation of the nurse5' assessment. concluded that nurses or trained physi- The results of our study, therefore, apply cian's assistants could have detected 88% only to the select group of patients who of "significant abnormalities" of infants were seen by both health professionals. in the first year of life which were dis- The nurse's ability to ascertain pertinent covered by pediatricians because these findings in the history or to assess other abnormalities had inherent visibility or factors was not part of this study. susceptibility to identification by simple screening procedures. A number of surveys evaluating other Summary and Conclusions aspects of the performance of pediatric nurse practitioners have been carried This report is an evaluation of the out. Nurse practitioners have been shown ability of pediatric nurse practitioners to be capable of caring for the majority to perform accurate, comprehensive (more than three-fourths) of children physical examinations by comparing the coming to health stations in low income appraisal of the physical status of chil- areas4; they are well accepted by more dren made by pediatric nurse practi- than nine-tenths of patients and parents tioners with that made by pediatricians. and in one survey 57% of the parents A consecutive series of charts of chil- indicated that the care given jointly by a dren enrolled in a neighborhood health physician and a pediatric nurse practi- station were reviewed. Of these charts, tioner was better than the care that had 182 children had been seen first by the previously been provided by a pediatri- nurse and subsequently by the physician. cian alone.5 It has also been found that A total of 278 conditions were noted by an association with a pediatric nurse the nurses and/or physicians in these practitioner provided pediatricians in 182 children. private practice with at least one-third There was total agreement between more patients.6 The association with the the findings of the pediatric nurse prac- nurse practitioner was a definite eco- titioner and the consulting pediatrician nomic boon to the physicians.6 in 240 of the 278 conditions (86%) . No attempt was made to determine There was a difference between the as- whether the nurse practitioner or the sessment of the pediatric nurse practi- pediatrician was "right" in their assess- tioner and the pediatrician in 39 condi- ment of the conditions present in the pa- tions (14%) . In 37, the difference in tients under study. The purpose of the assessment was not considered to be sig- study was to determine the incidence and nificant. In only two instances of the con- significance of the differences without as- ditions noted (0.7%) was the difference signing a specific value judgment to the between the nurses and physicians assess- assessments themselves. It would be of ment thought to be significant. interest to compare the differences that Evaluation of the competency of might be found between the assessment pediatric' nurse practitioners has not of physical findings by members of a been previously determined although sev- pediatric housestaff and pediatricians, or eral surveys have evaluated other aspects by two groups of pediatricians. Such of the pediatric nurse practitioners. This comparative studies are needed to de- study demonstrates that pediatric nurse termine the significance of the results practitioners trained by Silver et al are herein reported. The nurses may have highly competent health professionals in failed to recognize significant abnormali- assessing normal and abnormal physical ties in the patients who were not referred findings in children. JUNE, 1971 1175
  7. 7. REFERENCES 4. Silver, H. K. Use of New Types of Allied 1. Silver, H. K.; Ford, L. C.; Stearly, S. G. Health Professionals in Providing Care for A Program to Increase Health Care for Children. American Journal of Diseases of Children: The Pediatric Nurse Practitioner Children 116:486490, 1968. Program. Pediatrics 39(5) :756-760, 1967. 5. . The Pediatric Nurse Prac- 2. Silver, H. K.; Ford, L. C.; Day, L. R. The titioner and the Child Health Associate: Pediatric Nurse Practitioner Program. New Types of Health Professionals. Paper Journal of the American Medical Associa- presented at New York Academy of Sci- tion 204:298-302, 1968. ences seminar on Education in Health- 3. Anderson, F. P. The Yield of Hitherto Related Professions, New York, N. Y. Unrecognized Significant Abnormalities on (Mar.), 1969. Routine Physical Examination of Infants 6. Schiff, D. W.; Fraser, C. H.; Walters, H. in the First Year of Life. Paper presented L. The Pediatric Nurse Practitioner in the at 9th Annual Meeting of the Ambulatory Office of Pediatrics in Private Practice. Pediatric Association, Atlantic City, N. J. Pediatrics 44(1) :62-68, 1969. (April), 1969. Dr. Duncan is Assistant Professor of Pediatrics, Mrs. Smith is a Pediatric Nurse Practitioner and Dr. Silver is Professor of Pediatrics, University of Colorado School of Medicine, 4200 East Ninth Avenue, Denver, Colorado. The study was done in cooperation with the Denver Department of Health and Hospitals and its Neighborhood Health Program. This paper was submitted for publication in March, 1970. Key to Recycling Economics? The aluminum industry is deep into research on the recycling of solid wastes- for hard-headed reasons explained in a recent pamphlet, The Solid Waste Crisis: One Answer. "Because of its high scrap value ($200 a ton), aluminum holds the key to recycling economics," states the pamphlet. It goes on to say that, although alu- minum is only 0.3 per cent of all solid waste (household wrap, TV trays, and a few aluminum cans), it is worth ten times more in dollars and cents than any other com- ponent in the waste stream-such as paper, glass, and ferrous materials. Therefore, "the more aluminum in garbage, the more the garbage is worth," and the industry is eager to buy back all aluminum that can be reclaimed through recycling. Thus the pamphlet encourages increased use of aluminum because it is good for business; but it also puts forward a broad recycling concept that might well solve the universal solid waste crisis. Aluminum researchers have been working with other materials industries on a total system which would sort out and re-use all com- ponents of solid waste. Food waste, for example, would be burned for energy in a water-jacketed incinerator, or processed into fuel oils, or gases and charcoal in a pyrolysis unit. Paper could be made into pellets for new paper, glass ground up and re-used in bottles, and metals sorted, melted down, and reprocessed. Data on the concept is available to all groups interested in constructing an operating facility from: The Aluminum Association, 750 Third Avenue, New York, N. Y. 10017. VOL. 61. NO. 6. A.J.P.H.