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Geriatric Pediatric Assessment.pdf
- 1. Pediatric & Geriatric Assessment Shaista Meghani MScN, BScN, RN, RM Senior Instructor AKUSONAM
- 2. Objectives • Describe the common structural changes brought on by aging in various body systems • Recognize the geriatric syndrome • Discuss the variations in history taking for an elderly client. • Examine elderly client by modifying examination techniques • Describe assessment abnormalities in elderly clients. • Describe how communication should be varied to communicate with elderly clients. • Describe the component of a thorough pediatric history, including differences for developmental levels. • Applying general principles of examination • Identify common examination techniques/skills for pediatric health assessment. • Describing the components thorough pediatric, assessment, history, noting the difference between infant, young, children and adolescent • Identify common examination techniques/skills for pediatric health assessment
- 3. Preparation • Positive relationship • Therapeutic communication • Patience • Encourage client to participate
- 4. History Pediatric Client Geriatric Client Biographical information Demographic information Chief complain Chief complain History of present illness History of present illness Past history (Prenatal, Birth & Postnatal history) Past history (any comorbid) Developmental information (milestones) Nutrition information Nutrition Information Activity daily living
- 5. General Principles • Wash Hands • Warm environment • Expose body parts as necessary • All intrusive procedure should be performed last • In newborn/pediatrics: • Complete head to toe assessment within 24 hours • Examine the circulator and respiratory systems when the newborn/child is quite • Assess newborn/child in parents’ presence • Position during examination (mummy restraint)
- 6. Pediatric Assessment • Measurements • Vital signs (Temperature, Pulse, respiration, BP) • < 3 years : length, weight, head circumference) • > 3 years : standing height & weight
- 7. General Appearance • Changes is face, posture and body shape • Hygiene • Gait • Child’s behavior (quite, shy, active, restless)
- 8. Skin, Hair & Nail • Skin color, texture, temperature, moisture, turgor, rashes or lesion • Hair color, texture and distribution • Nail color, shape, texture • Newborn & infant skin : • Smooth & soft • • Lanugo (fine soft hair covering fetus body & limbs) • • Superficial vessels are prominent • • Nails well formed and firm
- 10. Cont.. • Nevus flammeus – may be present over occipit, forehead, upper eyelids (small reddish papular patch), malenocytic nevus • Birth marks • Hemagiomas • Diaper Rash •
- 11. Older child and adolescents • Changes at the onset of puberty. • Acne Vulgaris (At the age of 13 or 14, papules and small pustules) • Hair growth becomes heavier
- 12. Head, Face and Neck • Head shape is asymmetrical in newborn. • Caput succedaneum or Cephalhematoma • Palpate fontanels – Assess for tenderness (bulging) and depression • Inspect for crusting • Inspect shape of face • Facial paralysis
- 13. Lymph Nodes • Inspect and palpate for size, mobility, temperature and tenderness • The lymphoid tissues increase b/w 8-10 years and decrease in adolescence • Spotty, discrete movable small and non tender nodes are common
- 14. Older child and adolescent • Examine frontal and maxillary sinuses for children over 2-3 years of age as in adults • Examine the neck • Palpate the lymph nodes, thyroid glands, and trachea • Palpate the Sternocleidomastoid muscle----torticollis (Wry neck) • Mobility of neck
- 15. Eyes • Color, inflammation, any deviation • Test vision by pupillary response to light • Assess blink reflex • At 5-6 weeks-child, fixate and follows bright toy or light • At 3-4 months of age, infant begins to reach for object
- 16. Cont.. • Fundoscopic examination at 6-7months • Appearance of red reflex • Children 3-6 years of age, use Snellen E chart or Allen picture cards. • Test for strabismus ( corneal reflex test and cover uncover test)
- 17. Ears • Inspect and palpate the external ear and posterior mastoid for obvious deformities and canals for redness • Note the position of the ears (down set ears in Down’s syndrome) • Restrain the child during otoscopic examination
- 18. Cont.. • Infants <3yrs: pull pinna down and back. • Older child >3yrs: pull pinna up and backward • Inspect the tympanic membrane for color, light reflex, landmarks of the bony prominences. • Assess the hearing (hand clap, whispered voice)
- 19. Nose • Assess for purulent secretions, redness and crusting. • Watery nasal secretions indicate foreign body, common cold, allergies • Note shape of nose, flaring of nostril. • Examine the septum
- 20. Mouth and Oropharynx • Examine last • See for inflammation, thrush, membranes • Sucking reflex , cleft lip and palate • 20 deciduous teeth and eruption is completed by the age of 2 ½ years • The 1st permanent molar and lower incisor erupt at 6 years of age • Tonsils are larger than adults
- 21. Chest • Inspect chest shape and circumference. • In infancy, chest is round and AP diameter = transverse diameter. • Chest circumference is same as or slightly less than head circumference in new born until 2 years of age. • Respiration is abdominal and by 7 years is thoracic. • Breath sounds are louder almost all broncho- vesicular.
- 22. Cont.. • Slight inter-costal retraction is common in infants • Perform tactile fremitus while child is crying • Child chest normally more resonant than adults
- 23. Heart • Quiet child and quiet environment are necessary. • Palpate the pulses in the lower extremities esp. femoral pulses. • During infancy heart is nearly horizontal. Apex is 1 or 2 ICS above i.e. apical impulses in young children is felt in the 4th ICS to the left MCL. • By 7 years the apical impulse is found in 5th ICS at MCL. • Heart sounds are louder, high pitched and shorter duration than adults
- 24. Abdomen • Sequence: IAPP • Examine when a newborn is calm • Examine young child while seated on parent’s lap • Depressed abdomen indicates dehydration. • Umbilical hernias are common • Potbelly
- 25. Cont.. • Observe peristaltic waves and dilated veins (liver disease) • Percuss to locate boundaries of liver, spleen and any tumors
- 26. Genital • Male genitalia: (IP) • Examine penis and scrotum. • Examine fore skin of penis. • Phimosis • Hypospadias and epispadias. • Inspect scrotum for swelling and enlargement.(hydrocele) • Un-descended testes
- 28. Cont.. • Female genitalia: • Inspect by separating labia majora and observe labia minora, urethral meatus and vaginal orifice • Urethral discharge • Bloody/ Mucoid vaginal discharge
- 29. Musculo-Skeletal • Watch the child playing • Inspect the neck, extremities, hips, and spine for symmetry, reduced or increased mobility and defects • Club foot, polydactyl/ syndyctyl • Infants have bow legs until 12-18 months
- 31. Cont.. • Gait is wide based when begin walking. • Examine hip dislocation • Examine Inspect spine –in young infant and child a tuft of hair or small dimple. • Scoliosis asymmetric shoulders/ribcage
- 32. Neurological Assessment • Assess quality, pitch, loudness, and duration of cry, as well as drowsiness, irritability • Infantile reflexes disappears by 4 to 6 months of age – (Moro, palmer grasp, planter grasp, stepping, tonic neck reflex, rooting reflex, and babinski reflex) • Cranial nerves assessment (older children)
- 35. Geriatric Syndrome • Geriatric syndromes are multifactorial, and shared risk factors that includes: • Sleep problems • Delirium • Bladder control problem • Falls • Osteoporosis • Weight loss • Others
- 36. Skin • Thinning of epidermis (atrophy) : face, neck, upper part of the chest, and extensor surface of the hands and forearms. Wrinkled & Loose turgor, • Dermal collagen becomes stiffer, elastin has a higher degree of calcification. These changes cause the skin to lose its tone. Decrease vascularity cause skin looks pallor • Melanocytes destruct due to chronic sun exposure
- 37. Cardiovascular • Cardiac output decreases with age • Cardiac muscle has a decreased inotropic response to catecholamines, Increase in myocardial stiffness, Progressive stiffness of arteries • Increased risk of Coronary Artery Disease • Thickening of the walls of arteries with hyperplasia of the intima, and accumulation of calcium and phosphate in elastic fibers progressively occurs with aging
- 38. Respiratory • Elastic recoil of the lungs decreases with age and thus there is a greater tendency for airways to collapse. • Vital capacity of lungs decreases with age
- 39. Neurological • Decline in sensory perception • decreased pain perception • decreased sympathetic tone • loss of muscle tone • diminished proprioception • decreased coordination • balance problems •Intellectual ability diminishes •The speed of memory recall decreases‐‐‐Demen tia
- 40. Gastrointestinal • Decreased peristaltic response in esophagus, with age •Decreased relaxation of the lower sphincter of esophagus •A decrease in intestinal motility occurs with age leading to constipation •Loss of control of the internal and ext ernal anal sphincters in elderly, resulti ng into fecal incontinence
- 41. Genitourinary • A gradual decrease in the volume and weight of the kidneys occurs •Reduction in the total number of glomeruli per kidney •Decrease concentrating and diluting ability of the kidneys •Capacity of bladder to hold urine decreases significantly– urinary incontinence •Decrease sensation for micturition •Prostate enlargement, bladder neck obstruction urinary retention
- 42. Endocrine • Progressive deterioration in the number and the function of insulin producing beta cells. •Greater peripheral insulin resistance with age
- 43. Musculoskeletal • Lean body mass is primarily due to loss and atrophy of muscle cells • Degeneration of cartilage, bone thickening, and remodeling of bone with formation of marginal outgrowths and bone cysts. • Degenerative changes are pronounced, pain can be severe, greatly limiting the activity status
- 44. Reproductive • Menopause • Hot flashes • Insomnia with possible physiological and psycho logical disturbances • Increased risk of development of coronary artery disease and osteoporosis
- 45. Common medical problems • Arthritis •Hypertension •Coronary Heart disease •Cataracts •Diabetes •Visual impairments •Hearing impairments •Varicose Veins •Dementia
- 46. Common Nursing Problems • •Impaired physical mobility •Self care deficit •Altered home management •Decreased nutrition •Incontinence •Social Isolation •Sensory perceptual alterations •High risk for fall / injury •Confusion and others
- 48. Communication Techniques Gain the person’s attention before beginning conversation. • Make eye contact, and touch them on the should er or hands so that they are ready and listening to you. • You can assume that they are not listening to you if they are not looking at you.
- 49. Cont.. Ask whether the old person has hearing problem. • Check if the old person is wearing a hearing aid ( if required) and that the aid is working properly. • You can ask which ear is better in functioning if the person does not wear the hearing aid (Focus on the better functioning ear side).
- 50. Cont.. • Avoid background disturbances. • Reduce background noise by moving to a quiet place. Since elderly patients may have hearing problems, it will aid in a clear communication.
- 51. Cont.. Have a correct position. • Try to be at the eye level while talking to an elderly patient so that they may lip read if they have difficulty hearing. This is in case of communication with hard of hearing people; so that they may see all your gestures properly.
- 52. Maintain eye contact. • People with hearing impairment rely on their eyes to receive information. Maintain good eye contact with elderly during communication
- 53. Cont.. • Use facial expressions. If you are asking a question, use appropriate facial expressions, so that they may understand your question appropriately. •Use other channels of communication. If something is particularly important, you may write the message down in clear, large and simple terms. You can also use gestures, diagrams, and printed materials.
- 54. Cont.. • Be understanding • Use good manners • Speak slowly and clearly • Do not chew, eat or cover your mouth or face while talking. • Speak up but not shout. • Use lower‐pitched tones ‐ older people hear more easily in • lower tones than higher ones
- 55. Examination Approach for Elderly Client
- 56. • Keep the patient and environment warm. •Select a clam and well lit environment. •Vary your positions if patient’s mobility is impaired. •Avoid fatiguing the person. •Vary the intensity of stimuli for sensory testing. •Ensure privacy •Provide a comfortable chair •Use a step stool for the examination table. •Ensure adequate support when the patient is on examination table. •Give extra time to change dress
- 57. Functional Assessment • Assessment of the level of independence of elderly is done in terms of: • •Ability to use telephone •Shopping •Food preparation •Housekeeping •Laundry •Mode of transportation •Responsibility for own medications •Ability to handle finances • others
- 58. References • Bickley, L.S, Szilagyi. P.G (2012). Bates’guide to physical examination and history taking (11th ed.). Lippincott Williams & Wilkins. • Jeong, H. (2012). The skills of communication in aged care. Retrieve d from https://www.agedcommunity.asn.au/files/studentprojects/the‐ skill‐of‐communication‐in‐aged‐care‐‐‐hoyeonjeong.pdf • Boss, G. R., & Seegmiller, J. E. (1981). Age related physiological ch anges and their significance. Geriatric Medicine, 35(6), 434440.