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Pediatric assessment

This document discusses the importance of assessment and triage in pediatric care. It outlines the essential components of a focused pediatric assessment, including evaluating the child's appearance, breathing, and skin circulation. The document also provides guidance on performing a thorough physical exam and neurological assessment of children.

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PEDIATRIC ASSESSMENT Prepared by: Puan Kurniati Solehan
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?
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
Equipment What’s in Your setting? • Airway support equipment, Ambu-bags • Stethoscope & Sphygmomanometer • Pen Light • Pulse Ox & Cardiac Monitor • Nebulizer • Otoscope / Opthalmoscope • O2
The single most important part of the health assessment is…… the
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?
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
History: Review of Systems • Skin • GI • HEENT • GU & GYN • Neck • Musculoskeletal • Chest & Lungs / & Extremities Respiratory • Neuro • Heart & • Endocrine Cardiovascular
THIS OLD CART O____ L_______ D_______ C______________ A__________ _______ R________ _______ T________
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
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
PAT General Appearance Work of Breathing Circulation to the Skin
APPEARANCE Tone Interactiveness Consolability Look/gaze Speech/cry
Work of Breathing • Increased or Decreased Respirations • Stridor • Wheezing
Circulation to the Skin • Inadequate perfusion of vital organs • Leads to compensatory mechanisms in non- essential functions • Ex: vasoconstriction in the skin.
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
Physical Assessment • The approach is: • Orderly • Systematic • Head-to-toe • But FLEXIBILIY is essential • And be kind and gentle • but firm, direct and honest
Physical Assessment General Appearance & Behavior • Facial expression • Posture / movement • Hygiene • Behavior • Developmental Status
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 ____ ?
Pediatric Vital Signs – Normal Ranges Infant Toddler School-Age Adolescent • Heart Rate 80-150 70-110 60-110 60-100 • Respiratory Rate 24-38 22-30 14-22 12-22 • Systolic blood pressure 65-100 90-105 90-120 110-125 • Diastolic blood pressure 45 - 65 55-70 60-75 65-85
Physical Assessment • General • Heart • Skin, hair, nails • Abdomen • Head, neck, • Genitalia, Tanner Scale, lymph nodes • Rectal • Eyes, ears, nose, • Musculoskeletal: feet, throat legs, back, gait • Chest, Tanner Scale
Physical Assessment • Four Basic Skills: 1. Inspection 2. Palpation 3. Percussion 4. Auscultation • Sequence for abdominal: 1.inspection, 2.auscultation, 3.percussion, 4.palpation
Inspection • Use all your senses • The essential First Step of the Physical Exam
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
Palpation • For the ticklish child: place her hands over your hands and have the child do the pressing down.
Percussion Use of tapping to produce sounds that are characterized according to: • Intensity • Pitch • Duration • Quality Direct vs. Indirect
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
“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!
H E E N T Head Eyes Ears Nose Neck Throat
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
Head • Shape: “NormoCephalic – ATraumatic” AT • Lesions • ? Edema
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
Neuro Assessment • LOC / Glasgow coma scale • Confusion, Delirium, Stupor, Coma • Pupil size • CNS grossly intact: II – XII • Vital Signs • Pain • Seizure Activity • Focal Deficits
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
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
Reflexes Deep tendon: • Biceps C5, C6 • Triceps C6, C7, C8 • Brachioradialis C5, C6 • Patellar L2, L3, L4 • Achilles S1, S2 Superficial: • Cremasteric T12, L1, L2 • Abdominal T7, T8, T9, T10, T11 Infant Automatisms: • Primitive Reflexes
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
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”
HEAD INJURY • Very common in pediatrics • Most often not serious • requires observation only • Symptoms - headache - vomiting - lethargy - altered behavior •Altered mental status: GCS
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
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
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
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)
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
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
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
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
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
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
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?
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
Nose: Variations • Allergy: “allergic salute” - line across nose. • Infection • Foreign body: • Foul odor or unilateral discharge • Structure variations • Bell’s palsy
Nose and Throat Sinusitis: • Fever • Purulent rhinorrhea • Facial Pain – cheeks, forehead • Breath odor • Chronic cough – could be day and night • (+) Post-nasal drip
Mouth & Pharynx: Key Points • Lips: color, symmetry, moisture, swelling, sores, fissures • Buccal mucosa, gingivae, tongue & palate for moisture, color, intactness, bleeding, lesions. • Tongue & frenulum - movement, size & texture • Teeth - caries, malocclusion and loose teeth. • Uvula: symmetrical movement or bifid uvula • Voice quality, Speech • Breath - halitosis
Ears, Nose and Throat Sore Throats Is it strept or is it viral or could it be mono? Lymph nodes & ROM
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
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)
Lungs & Respiratory: Key Points • Quality of Respirations: • Symmetry, Expansion, Effort, Dyspnea • S & S Respiratory Distress: • Color: cyanosis, pallor, circumoral cyanosis, mottling • Tachypnea • Retractions • Nasal flaring • Grunting (expiratory) • Stridor - inspiratory: croup • Adventitious sounds: • Crackles / Rales • Rhonchi - course breath sounds • Wheeze – inspiratory vs. expiratory
Lungs & Respiratory: Key Points • Clubbing • Snoring (expiratory): upper airway obstruction, allergy, • Fremitus: • Increased in pneumonia, atelectasis, mass • Decreased in asthma, pneumothorax or FB • Dullness to percussion: fluid or mass
Work of Breathing • Increased or Decreased Respirations • Stridor • Wheezing
Chest Assessment • Auscultation • Wheezing • Retractions • Subcostal • Intercostal • Sub-sternal • Supra-clavicular Red Flags: • grunting • nasal flaring • stridor
All that Wheezes isn’t always Asthma… Think: • Infection • Foreign body aspiration • Anaphylaxis • Insect bites/stings, medications, food allergies
And all Asthma doesn’t always Wheeze! • Cough • Fatigue • Reduced exercise tolerance
Coughs • Allergies • Asthma • Infections – pneumonia, bronchitis, bronchiolitis • Sinusitis – Post-nasal drip • GERD • Cigarette smoking • Exposure to secondhand smoke, • Other pollutants
Cough - Characteristics • Dry, non-productive • Mucousy – productive • Croupy • Acute – less than 2-3 weeks • Chronic – more than 2-3 weeks • Associating Symptoms
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
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”
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
Gastro-Intestinal Abdominal Assessment Pillitteri
Abdomen: Key Points • Contour • Bowel Sounds & Peristalsis • Skin: color, veins • Umbilicus • Assess for Tenderness, Ridigity, Tympany, Dullness • Hernias: umbilical, inguinal, femoral • Masses - size, shape, dullness, position, mobility • Liver, Spleen, Kidneys, Bladder
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
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?
Stomachaches and Abdominal Pain • Appendicitis • Hernia • Bowel obstruction -- • Intussusception Cholecystitis with or without gallstones • Kidney stones • Food poisoning • Pancreatitis (salmonella, shigella) • Sickle cell crisis • Inflammatory Bowel • Ulcers Disease – • Urinary tract • Crohn's disease infections • Ulcerative colitis
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
Diagnostic breakdown of one year's admissions for abdominal pain in a district general hospital. Davenport, M. BMJ 1996;312:498-501 Copyright ©1996 BMJ Publishing Group Ltd.
Bottom Line: Acute or Not Soft, non-tender, non-distended no rebound, no HSM, no mass, BS NA x 4Q Can the child hop? Ball & Bindler
Musculo-Skeletal • FROM, MAE - neck, shoulder, elbow, wrist, hip, knee, ankle, foot, digits • Alignment, contour, strength, weakness & symmetry • Limb, joint mobility: stiffness, contractures • Gait – observe child walking without shoes • Spinal alignment - Scoliosis • Muscle Strength & Tone • Hips – O & B • Reflexes • Pre-Participation Sports P.E. – • NJ’s new guidelines: http://www.state.nj.us/education/districts/ppeq.doc
Scoliosis Lateral curvature of spine Key Points: •Barefoot Medline.com •Feet Together •Bend Over –”Diving Of a Diving Board” •Check Hips
Assessment • The Five P’s: • Pain • Paresthesia • Passive stretch • Pressure • Pulse-less-ness
Skin, Nails & Hair • Rashes • Lesions • Lacerations • Lumps • Bumps • Bruises • Bites • Infections
Common Skin Lesions • Macule • Scale • Papule • Crust • Vesicle, bulla • Keloid • Pustule • Fissure • Cyst • Ulcer • Patch • Petechiae • Plaque • Purpura • Wheal • Ecchymosis • Striae Capillary bleeding: Petichiae and purpura usually indicate serious conditions
Skin Infections • Bacterial infections • Abscess formation • Severity varies with skin integrity, immune and cellular defenses • Examples: • impetigo • cellulitis
Viral Skin Infections • Most communicable diseases of childhood have characteristic rash • Examples: verruca, herpes simplex types I and II, varicella zoster, molluscum contagiosum
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
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
Miscellaneous Skin Disorders • Urticaria • Psoriasis • Alopecia • Intertrigo • Stevens-Johnson syndrome • Neurofibromatosis
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
Therapeutic Management of Atopic Dermatitis Goals: • Relieve pruritus • Hydrate skin • Reduce inflammation • Prevent or control secondary infection
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
The School-Age Child • Privacy and modesty. • Explain procedures and equipment. • Interact with child during exam.
Adolescent • Privacy issues – first consideration • HEADS: home life, education, alcohol, drugs, sexual activity / suicide • GAPS Guidelines for Adolescent Preventive Services • Bright Futures
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
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?
The “I don’t feel good”
Appearance PAT Includes LOC & Behavior PAT and Breathing Changes Skin Circulation This OLD CART
Common School Health Focused Assessments • Emergencies & Trauma – Allergic Reactions, Asthma, Head, Abdomen, Limb, Other • Skin – Rashes, Lacerations, Lumps, Bumps & Bruises • The Frequent Fliers – Headaches, Stomachaches, Chest Pain, Coughs & Fevers • Other HEENT
Emergencies & Trauma • Allergic Reactions • Asthma • Head • Abdomen • Limb • Other
The Frequent Fliers • Headaches • Stomachaches • Nosebleeds • Chest Pain • Coughs • & Fevers
Frequent Fliers If only you could cash in on those miles!
Behavioral / Mental Health Concerns • Developmental Delays • Depression • Aggressive Behaviors • Suicide Risks • Other Mental Health Issues
Chronic Conditions & Special Needs • Asthma • Diabetes • Neuro – seizures • Sickle Cell Anemia • Cerebral Palsy • ADHD
Additional “To – Do’s” • Documentation • –SOAP Notes • Quality Improvement – - chart reviews • Confidentiality – seriously!
Resources and References
• 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
We Know It’s a Jungle Out There!
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.

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Pediatric assessment

  • 1.
    PEDIATRIC ASSESSMENT Prepared by: Puan Kurniati Solehan
  • 2.
    Objectives • Understand theimportance 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 NursingSkills • 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
  • 4.
    Equipment What’s inYour setting? • Airway support equipment, Ambu-bags • Stethoscope & Sphygmomanometer • Pen Light • Pulse Ox & Cardiac Monitor • Nebulizer • Otoscope / Opthalmoscope • O2
  • 5.
    The single mostimportant 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
  • 8.
    History: Review ofSystems • Skin • GI • HEENT • GU & GYN • Neck • Musculoskeletal • Chest & Lungs / & Extremities Respiratory • Neuro • Heart & • Endocrine Cardiovascular
  • 9.
  • 10.
    Patti’s Nitty GrittyTrio • 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
  • 12.
    PAT General Appearance Workof Breathing Circulation to the Skin
  • 13.
    APPEARANCE Tone Interactiveness Consolability Look/gaze Speech/cry
  • 14.
    Work of Breathing •Increased or Decreased Respirations • Stridor • Wheezing
  • 15.
    Circulation to theSkin • 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 • Theapproach 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 ____ ?
  • 20.
    Pediatric Vital Signs– Normal Ranges Infant Toddler School-Age Adolescent • Heart Rate 80-150 70-110 60-110 60-100 • Respiratory Rate 24-38 22-30 14-22 12-22 • Systolic blood pressure 65-100 90-105 90-120 110-125 • Diastolic blood pressure 45 - 65 55-70 60-75 65-85
  • 21.
    Physical Assessment • General • Heart • Skin, hair, nails • Abdomen • Head, neck, • Genitalia, Tanner Scale, lymph nodes • Rectal • Eyes, ears, nose, • Musculoskeletal: feet, throat legs, back, gait • Chest, Tanner Scale
  • 22.
    Physical Assessment • Four Basic Skills: 1. Inspection 2. Palpation 3. Percussion 4. Auscultation • Sequence for abdominal: 1.inspection, 2.auscultation, 3.percussion, 4.palpation
  • 23.
    Inspection • Use all your senses • The essential First Step of the Physical Exam
  • 24.
    Palpation • Use ofyour 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 theticklish child: place her hands over your hands and have the child do the pressing down.
  • 26.
    Percussion Use of tappingto produce sounds that are characterized according to: • Intensity • Pitch • Duration • Quality Direct vs. Indirect
  • 27.
    Auscultation • Listening forbody 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 PA” • 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!
  • 29.
    H E EN T Head Eyes Ears Nose Neck Throat
  • 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
  • 36.
    Reflexes Deep tendon: • BicepsC5, C6 • Triceps C6, C7, C8 • Brachioradialis C5, C6 • Patellar L2, L3, L4 • Achilles S1, S2 Superficial: • Cremasteric T12, L1, L2 • Abdominal T7, T8, T9, T10, T11 Infant Automatisms: • Primitive Reflexes
  • 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 Manifestationsin 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 alterationin 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 returnto 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
  • 54.
    Mouth & Pharynx:Key Points • Lips: color, symmetry, moisture, swelling, sores, fissures • Buccal mucosa, gingivae, tongue & palate for moisture, color, intactness, bleeding, lesions. • Tongue & frenulum - movement, size & texture • Teeth - caries, malocclusion and loose teeth. • Uvula: symmetrical movement or bifid uvula • Voice quality, Speech • Breath - halitosis
  • 55.
    Ears, Nose andThroat 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 doesthe 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)
  • 58.
    Lungs & Respiratory:Key Points • Quality of Respirations: • Symmetry, Expansion, Effort, Dyspnea • S & S Respiratory Distress: • Color: cyanosis, pallor, circumoral cyanosis, mottling • Tachypnea • Retractions • Nasal flaring • Grunting (expiratory) • Stridor - inspiratory: croup • Adventitious sounds: • Crackles / Rales • Rhonchi - course breath sounds • Wheeze – inspiratory vs. expiratory
  • 59.
    Lungs & Respiratory:Key Points • Clubbing • Snoring (expiratory): upper airway obstruction, allergy, • Fremitus: • Increased in pneumonia, atelectasis, mass • Decreased in asthma, pneumothorax or FB • Dullness to percussion: fluid or mass
  • 60.
    Work of Breathing • Increased or Decreased Respirations • Stridor • Wheezing
  • 61.
    Chest Assessment • Auscultation •Wheezing • Retractions • Subcostal • Intercostal • Sub-sternal • Supra-clavicular Red Flags: • grunting • nasal flaring • stridor
  • 62.
    All that Wheezes isn’talways Asthma… Think: • Infection • Foreign body aspiration • Anaphylaxis • Insect bites/stings, medications, food allergies
  • 63.
    And all Asthma doesn’talways Wheeze! • Cough • Fatigue • Reduced exercise tolerance
  • 64.
    Coughs • Allergies • Asthma •Infections – pneumonia, bronchitis, bronchiolitis • Sinusitis – Post-nasal drip • GERD • Cigarette smoking • Exposure to secondhand smoke, • Other pollutants
  • 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 • Call911 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
  • 69.
  • 70.
    Abdomen: Key Points •Contour • Bowel Sounds & Peristalsis • Skin: color, veins • Umbilicus • Assess for Tenderness, Ridigity, Tympany, Dullness • Hernias: umbilical, inguinal, femoral • Masses - size, shape, dullness, position, mobility • Liver, Spleen, Kidneys, Bladder
  • 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?
  • 73.
    Stomachaches and Abdominal Pain •Appendicitis • Hernia • Bowel obstruction -- • Intussusception Cholecystitis with or without gallstones • Kidney stones • Food poisoning • Pancreatitis (salmonella, shigella) • Sickle cell crisis • Inflammatory Bowel • Ulcers Disease – • Urinary tract • Crohn's disease infections • Ulcerative colitis
  • 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
  • 75.
    Diagnostic breakdown ofone year's admissions for abdominal pain in a district general hospital. Davenport, M. BMJ 1996;312:498-501 Copyright ©1996 BMJ Publishing Group Ltd.
  • 76.
    Bottom Line: Acuteor Not Soft, non-tender, non-distended no rebound, no HSM, no mass, BS NA x 4Q Can the child hop? Ball & Bindler
  • 77.
    Musculo-Skeletal • FROM, MAE- neck, shoulder, elbow, wrist, hip, knee, ankle, foot, digits • Alignment, contour, strength, weakness & symmetry • Limb, joint mobility: stiffness, contractures • Gait – observe child walking without shoes • Spinal alignment - Scoliosis • Muscle Strength & Tone • Hips – O & B • Reflexes • Pre-Participation Sports P.E. – • NJ’s new guidelines: http://www.state.nj.us/education/districts/ppeq.doc
  • 78.
    Scoliosis Lateral curvature of spine Key Points: •Barefoot Medline.com •Feet Together •Bend Over –”Diving Of a Diving Board” •Check Hips
  • 79.
    Assessment • The FiveP’s: • Pain • Paresthesia • Passive stretch • Pressure • Pulse-less-ness
  • 80.
    Skin, Nails &Hair • Rashes • Lesions • Lacerations • Lumps • Bumps • Bruises • Bites • Infections
  • 81.
    Common Skin Lesions • Macule • Scale • Papule • Crust • Vesicle, bulla • Keloid • Pustule • Fissure • Cyst • Ulcer • Patch • Petechiae • Plaque • Purpura • Wheal • Ecchymosis • Striae Capillary bleeding: Petichiae and purpura usually indicate serious conditions
  • 82.
    Skin Infections • Bacterialinfections • Abscess formation • Severity varies with skin integrity, immune and cellular defenses • Examples: • impetigo • cellulitis
  • 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 • Inflammatoryreaction 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
  • 86.
    Miscellaneous Skin Disorders • Urticaria • Psoriasis • Alopecia • Intertrigo • Stevens-Johnson syndrome • Neurofibromatosis
  • 87.
    Atopic Dermatitis • Atype 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 FocusedAssessments • The “I don’t feel good” – where do I begin? • Behavioral / Mental Health Concerns • Chronic Conditions & Special Needs • What Else?
  • 94.
    The “I don’tfeel good”
  • 95.
    Appearance PAT Includes LOC & Behavior PAT and Breathing Changes Skin Circulation This OLD CART
  • 96.
    Common School Health FocusedAssessments • Emergencies & Trauma – Allergic Reactions, Asthma, Head, Abdomen, Limb, Other • Skin – Rashes, Lacerations, Lumps, Bumps & Bruises • The Frequent Fliers – Headaches, Stomachaches, Chest Pain, Coughs & Fevers • Other HEENT
  • 97.
    Emergencies & Trauma •Allergic Reactions • Asthma • Head • Abdomen • Limb • Other
  • 98.
    The Frequent Fliers • Headaches • Stomachaches • Nosebleeds • Chest Pain • Coughs • & Fevers
  • 99.
    Frequent Fliers If onlyyou could cash in on those miles!
  • 100.
    Behavioral / MentalHealth Concerns • Developmental Delays • Depression • Aggressive Behaviors • Suicide Risks • Other Mental Health Issues
  • 101.
    Chronic Conditions & Special Needs • Asthma • Diabetes • Neuro – seizures • Sickle Cell Anemia • Cerebral Palsy • ADHD
  • 102.
    Additional “To –Do’s” • Documentation • –SOAP Notes • Quality Improvement – - chart reviews • Confidentiality – seriously!
  • 103.
  • 104.
    • Jan ChandlerRN, 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
  • 106.
    We Know It’s aJungle Out There!
  • 108.
    The Power ofNursing 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

  • #6 PRIZE!
  • #23 Inspection and auscultation are performed before palpation and percussion because touching the abdomen may change the characteristics of the bowel sounds.