Physical examination in child nursing.pptx

physical assessment in pediatric patients.

1. PHYSICAL ASSESSMENT IN PEDIATRICS

2. Physical assessment Process of gathering information about health status of the clients (children) Includes the study of client to identify strength and weakness, needs and problems It collects of baseline data that's used to evaluate patient's progress and effectiveness of the nursing care. The child's physical assessment usually performed to determine how sick the child is and what kind of interventions he/she needs Assessment of a child is a challenging for health care providers, as they are different from an adult anatomically, physiologically and psychologically. The causes of seeking medical help also differ from that of adults. Period of childhood is associated with rapid changes in the growth & development

3. Purposes of child health assessment Establish a nurse, parent and child relationship. Gather data about the child's general health status. Integrating physiology, psychology, cognitive, socio-cultural, developmental a spiritual dimension of child's growth and development. Identify the child's strength. Establishing a basis for nursing process.

4. Components of child health assessment History Taking Physical examination

5. History taking Obtaining history is an important aspect of health assessment and to evaluate the health status of an individual. Techniques for history taking in children vary from one age group to another. History regarding the child's health condition can be collected from parents or significant others or from grown up child. This skill should be designed in a way to encourage the guardians describe their observation of their child's illness. The success of interview depends primarily in the nurse's ability to establish and maintain sound interpersonal relationship with parents and child Basically, nurse can obtain history by asking questions in friendly approach according to level of understanding and thorough observation of nonverbal clues.

6. Purposes of pediatric health history To obtain data that is helpful in making diagnosis, treatment and formulate individualized plan for care. To establish relationship between the child and family and also to assess the understanding of the family members about their child's health. To correct misconceptions and misinformation of the family regarding the child rearing practices based on their own cultural and socio-economic patterns.

7. Difference between pediatric and adult history Content differences in history : Paediatric history includes: Prenatal and birth history Developmental history Social history of family - environmental risks Immunization history Parent as source of information: Parent's interpretation of signs, symptoms for the under 4 years of age are the main source of information. But children above the age of 4 may be able to provide some of their own history Observation of parent-child interactions like distractions and quality of relationship to parents may interfere with history taking Parental behaviours / emotions such as guilt, fear stress may effects on history

8. Outline of pediatric health history 1. General Information (Socio-demographic Data): Name: Age: Sex: Address: Caste/Ethic group: Religion 2. Chief Complains (as mentioned by the respondent/Parents): It is a brief statement of the reasons why the child was brought to a health facility. Only those symptoms should be mentioned for which the child is brought for treatment. The complaints should be in chronological order of the appearances of symptoms e.g. cough/cold, fever, difficulty in breathy. Name of unit: Hospital registration number: Date and time of history collection: Name of informant: Relation with the child:

9. Outline of pediatric health history 3. History of Present Illness: It includes details of onset, complete interval history (from onset to present), present status, reason for seeking help now, aggravating and alleviating factors, associated symptoms and prior history of similar problems and treatment. 4. Past Medical History: Major medical illnesses Major surgical illnesses-list operations and dates Trauma-fractures, lacerations Previous hospital admissions with dates and diagnoses Current medications Known allergies (not just drugs) Immunization status

10. Outline of pediatric health history 5. Prenatal and Birth History: Details of prenatal, intra-natal, prenatal, neonatal, postnatal information: Maternal health during pregnancy such as bleeding, trauma, infections, hypertension etc. Gestational age at delivery. Labor and delivery: type of delivery, place of delivery, duration of labor, use of instruments such as forceps. Neonatal period: Baby's condition at birth, apgar score, weight, presence of jaundice at birth, need for prolong hospitalization etc. 6. Immunization History: Immunization history should include primary immunization and booster doses, complete or incomplete immunization and find out the causes of incomplete immunization.

11. Outline of pediatric health history 7. Developmental History: Ages at which milestones were achieved and current developmental abilities -smiling, rolling sitting alone, crawling, walking, running, 1st word, toilet training, riding tricycle, etc (review developmental charts) School-present grade, specific problems, interaction with peers Behavior - enuresis, temper tantrums, thumb sucking, pica, nightmares etc. 8. Nutritional and Dietary History: It includes total calorie and type of food the child is eating at present or past, duration of breast feeding, weaning, any event during weaning, feeding problem, dietary pattern. If the child is being bottle-fed, it is important to find out the method of preparation and dilution technique.

12. Outline of pediatric health history 9. Personal History: It includes hygiene, sleep and rest, eliminations habit, exercise and rest, play hobbies, special talents, relationship with others (sibling and parent), behavioral problems including child's understanding the problem etc. 10. Family History: Educational status of parents, parental occupation, parents' habits, type of family and presence of genetic or hereditary disease in the family members, history of any other suffering from any contagious or noncontagious illness such as hypertension, diabetes mellitus mental retardation seizures, allergies, asthma, congenital disorders etc. 11. Socio-economic/Environmental History: It includes total family income and its source, cooking place, fuel used for cooking, availability of sufficient food to family, parental occupation, having water supply, waste disposal, communication facilities, recreational facilities etc.

13. Outline of pediatric health history 12. Sexual History: It is an essential component of an adolescent health assessment. It includes eliciting information concerning the child's sexual concerns and activities and any pertinent data regarding adults sexual activity that influences the child. 13. Review of Systems: At the completion of history taking, "review of systems" should be done to exclude any missing during history taking. Following information will be collected through systems review along with details history: General: activity, appetite, sleep, weight change, edema, Appearance: fever, behavior pattern, mood, hygiene, level of consciousness, self care, Skin rash, eruptions, nodules, change in skin color, sweating, itching, infection, hair growth, texture change, Eczema, asthma, drug allergy, food allergy, sinus problems, hay fever etc.

14. Outline of pediatric health history: Ask from head to toe Head: Headache, head trauma, swelling infected areas, dizziness, any masses, fontanels, unusual shape etc. Eye: Vision, corrective lenses, strabismus, discharge, photophobia, orbital swelling, itching. infection cataract etc. • Ear: Hearing, infections, drainage, pain, tinnitus. Nose: Running nose, drainage, epistaxis, nasal patency and smell and sinusitis. Mouth and Teeth: Ulcers, patches, toothache, dental carries, malocclusions, hygiene, chewing, infection.

15. Ask from head to toe Throat: Sore throat, tonsillitis, difficulty in swallowing. Speech: Change in voice, hoarseness, stammering. Respiratory: Breathing difficulty, shortness of breath, chest pain, cough and cold, wheezing strider and blood in cough, cyanosis and palpitation. Cardiovascular: Cyanosis, fainting, exercise intolerance, palpitation squatting position, chest pain, cardiac defects, anaemia etc.

16. Ask from head to toe Haematological : Pallor, anemia, bruises, bleeding. Gastrointestinal: Appetite, nausea, vomiting, abdominal pain and size, bowel habit, nature of stools, passage of parasite, jaundice. Genitourinary: Haematuria , enuresis, discharge, dysuria, previous urinary tract infection, menstruation in adolescents and abdominal pain. Gynaecology : Menarche, menstrual history, dysmernorrhea for female adolescent

17. Ask from head to toe Musculo-skeletal: Deformity, fracture, joint pain or swelling, limit of movement, gait change, scoliosis. Neurological: Weakness or clumsiness, coordination, balance, gait, tremor, convulsions, personality change, headache, seizure, fainting, loss of memory and level of consciousness. Endocrine and metabolic: Intolerance to weather changes, excessive thirst and urination, sweating, salty taste to skin, growth pattern, polyuria, polyphagia etc. Lymphatic: History of frequent infections, enlarged lymph nodes in any region of body, swelling and tenderness.

18. General Approach for history taking Gather as much data as possible by observation first Position of child: parent's lap vs. exam table Stay at the child's level as much as possible. Order of exam: least distressing to most distressing-examine painful area last Rapport with child: develop rapport by explaining the procedure to the child's level and use distraction while talking Be honest: If something is going to hurt, tell them that in a calm fashion Understand developmental stages and its impact on child's response for example, stranger anxiety is a normal stage of development, which tends to make examining a previously cooperative child more difficult.

19. Approach according to age group Infant: perform examination on the parents lap, encourage parents involvement Toddler: allow the toddler to sit on the parents lap and use play materials to distract attention Preschooler: perform examination on the bed or table, explain procedure in simple way, and divert attention using play and storytelling. Offer choices when possible and applicable School age children: explain procedure in simple language, and tell the importance of examination Adolescent: maintain privacy and confidentiality, ask for presence of parents involvement, respect their value and give health teaching.

20. Physical assessment: General princple Examination should be done according to the needs of the child in an orderly manner. Gentle handing of the child with minimum exposure is very important and always least distracting to high distracting (perform painful procedure at last). Examination should be done informally with a friendly approach, appreciating the cooperation and assistance. Attempt to develop rapport with the child should be made from the moment of first meet. Explanation about the procedure should be useful in older children for gaining co-operation.

21. Physical assessment: General princple Remember the three warms; warm smile, warm hands and warm stethoscope. Avoid making abrupt movements because that may startle a child. Restraints should be used only whenever necessary. Remember that the safest place for a young child is on parents lap. Privacy and warmth need to be maintained as much as possible. Positioning of the child to be maintained accordingly such as for examination of abdomen, child is positioned in supine, Encourage parent's presence if the child is young. Recording should be done immediately with accurate information.

22. Equipment needed for physical examination Electronic Weighing Scale Measuring tape and height measuring scale if available Equipments to measure vital signs: blood pressure cuff appropriate size for age, stethoscope ( paediatric ) thermometer Others equipments : Snellen eye chart, otoscope and speculum (2.5-4.0mm) ,ophthalmoscope, reflex hammer, skin fold calipers, marking pen, peanut, or chocolate, small bell, bright colored object, Disposable gloves if available, cotton swab and paper bag Growth charts and child's record chart.

23. Sequence of physical examination 1. Vital signs: Vital signs measurements are key elements in evaluating the physical status of vital organs. It includes: Temperature: Axillary temperature is more common and safe method for all stages unless specific indication for other method to measure temperature in children. Pulse (Heart rate): Palpate anti-cubital or radial pulse for older child and auscultation in apex for heart beats in very young baby or palpate femoral pulse for young baby (infant). Count pulse for full minutes. Respiration: Count respiration for full minute by observing the movements of the abdominal wall while infant / young baby is in mother's lap. Blood Pressure: Measure blood pressure with cuffs completely encircling the extremity (upper/lower) and the width covering one half or ⅔ of the length of the upper arms/legs.

24. . 2. Anthropometrics Measurements Anthropometrics measurement includes child's weight, length/height, head circumference, chest circumference, mid-upper arm circumference, skin-fold thickness etc. All findings should be maintained by plotting growth chart. Measure Chest circumference: it is usually measured the levels of nipple preferably in mid inspiration. In child <=5 years measure in lying down position and >5 years measure in standing position

25. Sequence of physical examination 2. Anthropometrics Measurements Measure weight of infants/children using Digital Infant Scale or Beam Balance Scale Measure length upto 2 years of age in the supine position by using infantometer or a measuring tape and standing height thereafter height thereafter using stadiometer or height scale Crown-heel (Recumbent length) Crown-rump (Sitting length)

26. 2. Anthropometrics Measurements Measure head circumference of all children less than 2 years of age or with the history relating to neurological disease. Head circumference ( occipito -frontal circumference: OFC) is measured across frontal (above the eyebrow) - occipital prominence which is the greatest diameter. Sequence of physical examination

27. Sequence of physical examination 3. General Appearance: Observe general appearance of child's that include body position, posture, evidence of pain, crying, alertness, irritability, distress, hygine , mental status, mental status, behavoriol pattern, general development, speech, fear, anxiety, cyanosis, malformation and dehydration 4. Skin: examine Skin for color, pigmentation, lesions, jaundice, cyanosis, scar, superficial vascular condition, moisture, edema, condition of mucous membrane, presence od birth marks, hemangioma tenderness, masses, texture, turger , elasticity, rash, patches, subcutaneous nodules etc. 5. Lymph nodes: Observe and palpate the lymph nodes for enlargement, tenderness, pain.

28. Sequence of physical examination 6. Hair: Observe color and distribution of hair on head, back and other parts of the body, alopecia 7. Nail: Cyanosis, pallor, capillary filling time, capillary pulsations, kollonychias and leskonychia in growing nails. 8. Neurological examination Assess level of consciousness, muscle tone, balance and coordination, sensory and motor function Observe and examine cerebral function (memory, cognition and language), cranial motor function, Nerve function, deep tendon reflex, muscle tone, gait balance, coordination, sensory etc.

29. Sequence of physical examination 9. Head and Neck Face: Observe for general appearance, shape, size symmetrical movements, coarse, puffy, and positioning and shape of eyes, mouth, ear and nose, parotid glands, nasal bridge, tenderness over sinuses. Eye. Observe for discharge, eyelids, eyelashes, conjunctives, sclera, pupil, comes, visual field test, distance between the eyes, distributions of eyebrows, epicanthal fold, exophthalmos, condition of pupils, cataract, corneal opacities, squint, nystagmus, hemorrhage, blockage of naso crimal ducts etc. Ear: Shape, size, position, low set ear, deformities, discharge, tenderness over mastoid bone and hearing abilities, wax, furuncle etc. For examination pull pinna down and back in less than 3yrs old baby and pull up and back above 3and more than 3 yrs old baby, Perform hearing test.

30. Sequence of physical examination 9. Head and Neck Skull: Shape, condition of scalp, hair, swelling, alopecia, impetigo, nits, fontanels (up to 2 yrs of age), suture, movement of head, head holding Nose: Examine nose for shape, size, discharge, nostrils flaring, bleeding, deviated septum, depressed nasal bridge, nasal polyp, foreign body, nasal mucosa, Para-nasal sinuses, tenderness patency etc. Mouth and throat: Examine the color of lips, lesions at the corners of mouth, deft, teeth, caries, shape, gum bleeding, hypertrophy of gum, mucosal congestion, petechi , kopliks spots, tongue and pharyrus ; presence of any infections, tonsillitis, gag reflex, condition of uvula. Neck: Shape, size, movement, presence of nuchal rigidity swallowing, tenderness prominent veins supra-sternal in-drawing, location of trachea, tenderness, thyroid etc.

31. Sequence of physical examination 10. Chest: Lungs Inspection: Shape, size, symmetry, and movement, circumference, Harrison's, groove, sternal angle, expansion, sub costal or intercostals in-drawing position of nipple, breast development, fullness of intercostals spaces, spinal deformities, superficial swelling, skin condition, type and rate of respiration chest wall configuration-pigeon chest). Palpation and Percussion: Upper border of liver dullness, intercostals spaces, cardiac dullness, detect any tenderness swelling thrill. Though palpation and percussion is not possible in small baby and not that much significant. In case of older children it is done as in adult. Auscultation: To find out the wheeze, rhonchi and crackles.

32. Sequence of physical examination 10. Chest: Heart Inspection: Inspect the color of extremities, presence of central cyanosis, prominent veins, apical impulse, pre-cordial pulsation clubbing and edema Palpation: Palpate peripheral pulse and qualities in upper and lower extremities Auscultation: Auscultate the heart to find out the heart atapical pulse, murmur, rhythm etc. Heart is auscultated in 4 area which are aortic, tricuspid, pulmonic and mitral area. Auscultate apical pulse with stethoscope for a full 60 seconds /1 minute Areas of auscultation for apical pulse /heartbeat :3-4*intercostals space for infants, 4*intercostals space for <7 years age and 5"intercostals space for > 7 years old children

33. Sequence of physical examination 11. Abdomen: During abdomen examination follow the sequence of inspection, auscultation, palpation and percussion to obtain correct bowel sound. Inspection: Size, shape, distended prominent veins, peristalsis, umbilicus, swelling, scar, cleanliness, any congenital anomalies such as hernia, color of skin etc. Auscultation: Peristaltic sounds (note: auscultation before palpation and percussion). Palpation: Tenderness, rigidity, doughy feeling, skin turgor, flow of blood in prominent veins, fluid thrill, superficial or visceral swelling, mass, lesions, rebound tenderness, inguinal lymph node, liver, spleen and kidney. Liver, spleen and kidney may be palpable in newborn. Percussion: Upper margin of liver dullness, spleen dullness, shifting dullness, full bladder, tympanic etc.

34. Sequence of physical examination 12. Genitalia: Sex determination, sexual maturity, inguinal lesions Male: examine for urethral opening and its abnormalities, (hypospadias, epispadias), phimosis, hydrocele, hernia, undescended testis, size of penis etc. Female: Labia major, minora, vaginal and urethral opening, discharge, cleanliness, infections, swelling of bartholin’s gland in adolescence Anus and rectum: examine for patency, presence of fissures or fistula, rectal prolapsed etc (rectal and pelvic examination is not performed routinely)

35. Sequence of physical examination 13. Musculo-skeletal system Assess gait, posture, coordination, muscle size and strength, range of motion Back: assess spine for its curvature, sacral dimple, gapping or other congenital deformities, kyphosis and S lordosis etc Limbs: examine for any deformities, asymmetry, hemi-hypertrophy, bow legs, knock-knees, edema, any swelling or limitation of movements of joints, paralysis, clubbing of fingers, number of fingers and toes(syndactyly, polydactyly), creases on the palms and soles, changes in the nails, deformity of the feet, any infection, tenderness, swelling, cleanliness etc. Hips: examine to detect Ortolani’s and Barlow’s signs in musculoskeletal system disorders

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