Pediatric Assessment

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Pediatric Assessment

• Heather Hull, ARNP, PNP
• WSU Faculty

2
Three Areas of Focus

• History
• Development
• Physical Assessment

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Lecture Notes

• Focal Points For Assessment
• Developmental Stages
• Pediatric History
• Pediatric Measurements
• Physical Assessment

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Pediatric Focal Points

• Communication Approach
• Medical History
• Immunizations
• Development
• Nutrition
• Growth Measurements Vital Signs
• Physical Assessment
• Health Promotion

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Communication

• Developmental approach
• Family unit
• Parents as primary source for young
• Include child as appropriate
• Participation in treatment
• Anxiety increases teaching need

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Environmental Setting

• Comfortable safe
• Appropriate decor for all ages
• Accessible toys for young
• Appealing literature for older children

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Approach to Physical Exam

• Developmental readiness
• Get acquainted time
• Determine best exam place
• Be systematic, yet flexible
• Examine intrusive or painful areas last
• What do you want to examine before crying occurs?

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Neonate or Newborn

• Birth to 28 days
• Pre-term Gestational age lt37 weeks
• Term Gestational age 37-42 weeks
• Post-term Gestational age gt42 weeks

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Infant

• Birth-6 months Immobile, safety comfort,
  sensory stimulation, quite things first
• 6-12 months Separation/stranger anxiety, warm
  up, play techniques, parents lap

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Young Child (1-5 Years)

• Toddler (1-3 years) Parents lap, security,
  play, least intrusive things first, avoid no
  responses, offer acceptable choices, let touch
  equipment
• Pre-School (3-5/6 years) Keep parent close, exam
  table, protect modesty, consider magical
  thinking, use familiar, safe words, let touch
  equipment

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School Age (6-10/12 Years)

• Head to toe exam, respect modesty address
  questions directly to child, concrete
  explanations, elicit participation, answer
  questions honestly, offer acceptable choices

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Adolescent (13-18/21 Years)Pre-Adolescent (10-12
Years)

• Confidentiality
• Privacy (offer to examine alone)
• Protection of Modesty
• GAPS Guidelines for Adolescent Preventive
  Services
• Issues body image, eating disorders,
  behavioral/school issues, depression

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Biographic Data

• Name - Nickname
• Age Sex
• Parent Information
• Guardianship
• Insurance

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Informant

• Relationship to child
• Reliability

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Chief Complaint

• Brief statement with duration of major symptom
• Consider other problems

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Current Health Status

• Initial well child exam
• Interval well child exam
• ILL child exam or PI
• PI Present Illness

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General Past Medical

• State of health
• Appetite
• Weight gains - losses
• Fatigue
• Stresses

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Pregnancy Birth History

• Prenatal (Pregnancy)
• Natal (Birth)
• Neonatal (Newborn)

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Past Illnesses

• Age, date, sequelae
• Communicable
• Medical surgical
• Hospitalizations
• Trauma, poison

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Allergies

• Include type of reaction

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Immunizations

• Specific

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Medications

• OTC
• Current
• Past

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Transfusions
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Development

• Physical
• Developmental History

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Development

• Smile, raise head, roll
• Sit, stand, walk
• Talk, dress
• Bowel-bladder control
• Comparisons

• Progress in school
• Quality of work
• Grade failed
• Growth abnormalities

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Habits

• Infant
• Toddler
• Pre-School
• School Age
• Adolescent

• Current issues specific to age
• Sleep
• Elimination
• Exercise
• Behavior-discipline
• Substance use
• Sexuality

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Nutrition

• Infant Breast - Formula
• Solid foods
• Vitamins, iron, fluoride

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Nutrition

• Young child - irregular
• School age - picky eaters
• Adolescent - fast foods

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Family History

• Explained
• Genogram (to grandparents)

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Family Assessment

• Internal unit
• External factors interactions
• Ecomap

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Review of Systems

• Pediatric specific
• Growth
• Behavior changes
• Congenital manifestations
• Special senses

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Skin

• Birthmarks
• Rashes viral exanthums
• Hydration

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HEENT

• Vision strabismus
• Hearing language
• Allergies - infections

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Chest

• Breast changes
• Respiratory, frequency of infections

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Cardiovascular

• Dyspnea, fatigue
• FTT, poor feeding
• Squatting

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Gastrointestinal

• Diarrhea - constipation
• Dehydration
• Bowel training - encopresis

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Genitourinary

• Bladder training - enuresis
• UTI
• Menstrual abnormalities
• Abnormalities of penis, testes
• STDs, sexual activity

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Musculosketelal

• Congenital
• Degenerative - weakness/wasting
• Exercise

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Neurological

• Development
• Risk factors
• Seizure disorders - childhood onsets
• Behavioral (could be in Psychiatric)

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Endocrine

• Growth disturbances
• Congenital thyroid
• DM - rapid onset

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Hemotologic

• Anemias
• Bleeding disorders

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Evaluations

• Development
• Vision
• Hearing
• Language

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Developmental Evaluation

• Age - Neurologic Assessment
• Denver II Birth-6 years
• Personal - Social
• Fine motor - adaptive
• Language
• Gross motor

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Vision

• Birth - Pupils react, fixation, red reflex
• 6 weeks - follows to midline
• 4 months - follows 180
• 6 months - binocular fixation
• gt of intermittent strabismus

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Vision

• 1-4 years - critical period
• Amblyopia
• 3-4 years - 20/40 (refer 20/50)
• 6 years 20/20 - 20/30 (refer 20/40)
• Refer 2 line difference
• 9-12 years - lt referrals
• Adolescent

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Hearing

• Birth - global, reflexive, startle
• 4 months - turns to sound, eyes wide
• 6 months - localizes laterally
• 8-12 months - determines up or down
• 12 months - thinks about sound
• 16 months - localizes all planes

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Hearing

• Bilateral hearing for localization
• Hearing impaired visually alert
• Correlates with language development

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Language

• Birth - 4 months - vocalizations
• 4-6 months - imitation, turns to sound
• 6-9 months - mama, dada nonspecific
• 8-14 months - mama, dada, specific
• 12-18 months - 2 words
• 2 years - 2 word phrases

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Measurements

• Weight
• Height
• Head Circumference
• Chest Circumference
• Vital Signs

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Vital Signs

• Temperature
• Heart rate
• Respirations
• Blood pressure Cuff 1/2 - 2/3 of lower arm/leg

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Growth Assessment

• Measurements Growth Charts
• Intrauterine Charts Maturity Ratings
• Growth Charts Boys - Girls
• Birth-36 months
• 2-18 years
• Head Circumference Boys - Girls
• Birth-2 years

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Physical Assessment

• General appearance
• Degree of illness or distress
• Behavior

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Assessment Methods

• Inspection
• Palpation
• Percussion
• Auscultation
• Smell
• Responses

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Skin, Hair, Nails

• Color
• Texture turgor
• Birth marks
• Pigmentations
• Lesions exanthams
• Infestations
• Trauma

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Head

• Circumference - HC - FOC
• Fontanels sutures
• Symmetry

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Eyes

• Strabismus nystagmus
• EOMs Cover - Uncover Test
• Lazy Eye - Amblyopia
• Vision acuity color
• Irritations infections

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Ears

• Placement
• Otitis externa - tragus pain - drainage
• Otitis media - TMs - ear pulling - fever
• Hearing - localization - language
• Tests
• Weber
• Rhinne

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Nose

• Symmetry
• Nares
• Turbinates
• Allergy vs. infection

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Mouth Throat

• Stensens duct
• Lips, teeth, gums, buccal mucosa
• Palate, tongue pharynx
• Koplic spots

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Neck

• Suppleness ROM
• Torticollis
• Webbed
• Meningeal irritation

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Lymph Nodes

• Usual involvement
• Middle childhood hypertrophy

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Chest

• Thorax
• Structure
• Symmetry
• Lungs
• Rate Effort
• Lung Sounds
• Distress
• Heart

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Respiratory Rates

• NB 35-50
• 1st year 30
• 1-5 years 25
• 5-10 years 20
• 10-15 years 18

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Respiratory Distress

• Tachypnea
• Retractions
• Grunting
• Nasal flaring
• Restlessness
• Cyanosis

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Croup Signs

• Inspiratory Stridor
• Barking, brassy cough
• Hoarseness

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Severe Croup Signs

• Drooling
• Dysphagia
• Dysphonia
• Inability to cough

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Respiratory Sounds

• Upper airway congestion
• Lower airway involvement
• Mid level or extrathoracic (Croup)

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Adventitious Sounds

• Crackles (rales)
• Rhonchi (Senororous wheeze)
• Wheeze
• Pleural friction rub
• Stridor

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Cardiovascular

• Heart rate BP
• NB 120
• Hypoxia
• Peripheral pulses symmetry
• Murmurs

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Pulse Averages

• 1st year 110
• 1-5 years 95
• 5-10 years 85
• 10-15 years 75

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Blood Pressure

• NB 80/46
• 1st year 95/60
• 1-5 years 100/65
• 5-10 years 105/60
• 10-15 years 115/65
• Pulse pressure 20-50

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Physiologic Murmurs

• Do not increase over time
• Systolic
• 2nd - 3rd ICS, LSB
• Low grade, soft - not harsh
• Do not radiate
• Change with position
• Physiologic splitting of S2

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Abdomen

• Liver, spleen, kidneys
• Masses
• Tenderness
• Bowel sounds
• Hernias

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Genitourinary

• Sexual development
• Tanner stage
• Sexual activity
• STDs
• Hernias

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Tanner

• 1 - 5 stages
• 1 Prepubertal
• 5 Adult development
• 2 - 4 developing stages

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Tanner (Female)

• 2 - Breast bud sparse pubic hair
• 3 - Further breast areola
• 3 - Courser pubic hair - triangle
• 4 - Secondary breast mound
• 4 - Pubic hair denser, pubic area

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Tanner (Male)

• 2 - Enlargement scrotum testes
• 2 - Scrotal reddening texture
• 2 - Sparse pubic hair
• 3 - Penile enlargement hair
• 3 - Testes scrotum enlargement
• 4 - Increased penile diameter - hair

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Female

• External inspection
• Legs in frog position
• Periurethral area, introitus, anus
• Labial adhesions
• Discharge
• Foreign bodies
• Abuse/trauma

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Male

• Circumcision
• Testes descended
• Urethral meatus
• Scrotal deviations
• Inguinal hernia

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Musculoskeletal

• Asymmetry
• Gait
• Limping
• Weakness

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Extremities

• Digits
• Foot placement (in-out)
• Bowleg (genu varum)
• Knock knee (genu valgum)

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Congenital Hip Dislocation

• Asymmetrical hip abduction
• Asymmetrical thigh gluteal folds
• Ortolanis click
• Barlows test
• Allis sign
• Trendelenburg stand/gait

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Other Hip Conditions

• Legg-Calves Perthes
• Slipped Capital Femoral Epiphysis

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Back

• Spina bifida
• Pilonidal dimple - sinus tract
• Scoliosis

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Scoliosis

• Pre-adolescent growth
• Lateral thoracic curvature
• Contra lateral hip hump
• Prominent scapula
• Asymmetry - shoulder, arms, hips

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Neurological

• Mental (Cerebral)
• Gross motor (Cerebellar)
• Fine motor (coordination)
• Sensory
• Reflexes
• Cranial nerves (developmental approach)

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Infants

• Look for symmetry of movement
• Neonatal (primitive) reflexe
• Disappear by 4 - 6 months
• Babinski reflex until child walks well

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Infant Reflexes

• Crawling
• Blink (dazzle)
• Moro - Startle
• Rooting sucking
• Tonic neck

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Infant Reflexes

• Step or dance
• Incurvation (Galant)
• Extrusion
• Palmar grasp