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Presentation on theme: "Ricci, Chapter 32 PHYSICAL ASSESSMENT OF THE CHILD."— Presentation transcript:


2  Head-to-toe sequence not always appropriate.  Understand child’s perception of painful procedures.  Expect success.  Private room decorated according to age.  Have toys and games available if possible. GENERAL APPROACHES TOWARD EXAMINING THE CHILD

3  Use non-threatening approach.  Provide time for play and to become acquainted. Do as much as possible without touching.  Tell child what will happen within their understanding.  Cooperation enhanced with parent’s presence unless teen. Infants and toddlers may be examined in parent’s lap.  Begin with games and non-invasive procedures. Examine painful, invasive, and private areas last. PREPARATION OF THE CHILD

4  Making eye contact  Allowing touching  Talking to nurse  Accepting offered equipment  Sitting on exam table instead of parent’s lap SIGNS OF READINESS

5  Talk to parent for a while.  Talk to child by way of transition object.  Make complimentary remarks about child (consider cultural differences.)  Tell funny story or do a magic trick. IF CHILD IS NOT SHOWING READINESS….

6  Assess what the reason is .  Try to involve the parent and child.  Avoid prolonged explanations of the procedure.  Use firm, direct approach with a calm and gentle voice.  Gently restrain the child.  Proceed as quickly as possible. IF THAT DOESN’T WORK…….

7  Recumbent length for infants up to age 36 months + weight and head circumference  Standing height and weight after 36 months  Plot height, weight, and head circumference on growth chart by gender and adjust for prematurity if appropriate. May also need to do BMI.  Growth spurts are expected.  Less than 5 th or greater than 95 th percentile is considered outside expected parameters. HCP usually considers ethnic and genetic differences or nutrition issues as possible causes. ASSESSING GROWTH

8  Methods vary including oral, axillary, rectal, tympanic, and temporal. Do whatever is available and is preferred by parent and HCP. If rectal, safety is of utmost importance.  Normal temps are same as adults  Apical pulse x 1 min for kids under 10 yrs. Radial acceptable over 10 yrs.  Rapid pulse is easier to count if you close your eyes and tap your fingers.  Infants have abdominal respiratory movements. Take x 1 min due to normal irregularity.  Normal rates Table 32.3, p. 1098. TEMPERATURE, PULSE, RESPIRATIONS

9  Baseline during first 3 years unless child meets criteria on p. 1098. Do at each checkup after age 3.  May use Dinamap or auscultated.  Proper fit includes 40% of MAC; length 80-100%.  Norms in Appendix H. Average for 1 yr old is approx 80/40; lowest normal adult BP of 90/60 is achieved by an average of 8 yrs old.  If upper extremities are higher than lower extremities, or if pulse pressure is less than 10 or more than 50, may indicate cardiac defec.t  Prehypertension is risk in obese children. BLOOD PRESSURE

10  Respirations first while child is quiet.  Apical HR second. May do if child is sleeping.  Temp is third unless it is rectal. If rectal, do blood pressure third and temp last. PROPER VS SEQUENCE FOR INFANTS/TODDLERS

11  Facial expression  Behavior  Speech  Extremity movements, coordination  Hair, nails, and hygiene may give clue to care of child or presence of stress.  Assessing color variations 1104, 1105.  Note rashes or injuries GENERAL APPEARANCE AND SKIN

12  Note head shape and size. Head circ is important.  Palpate anterior and posterior fontanels. Posterior closes first at 2 months. Anterior closes between 9-18 months. Should be flat, not bulging or sunken.  Head control by 4 months  Neck should be supple, not stiff (nuccal rigidity).  Lymph nodes are larger in children but should be movable and non-tender. Tender, enlarged nodes usually indicate infection or inflammation close to their location. Hard, immovable, non- tender nodes usually indicate neoplasm. HEAD AND NECK

13  Check for eye slant, folds, symmetry, redness  Vision screening—make sure to have correct Snellen chart  Color vision established between 6 and 12 months  Check ear placement and shape  Internal ear exam is invasive  Check for deviated septum, nasal drainage  Inspect lip and palate  Check condition of teeth. Number of teeth = age of child in months minus 6  Mucous membranes  Tongue protrusion  Tonsils bigger than adults EENT

14  Size, shape of chest; symmetry of chest movements; assess for worker breathing.  Check breasts for Tanner staging, if age appropriate (1115)  Barrel or pigeon chest indicates respiratory condition  Lung sounds are vesicular; inspiratory sounds are easier to hear  Ask child to play blowing games to get them to deep breathe CHEST AND LUNGS

15  PMI at 4 th intercostal until about age 7 yrs, then 5 th  May listen while child is sleeping  S1 synchronous with carotid or brachial  Sinus arrhythmia is normal. Heart speeds up with inspiration; slows down with expiration.  Split S2 is normal  Refer all murmurs to HCP. Some may be innocent, but it is not within the nurse’s scope of practice to decide. HEART

16  Inspect, auscultate, and palpate  May auscultate while child is sleeping  Minimize tickling sensations by having child put hand on top of yours  Report visible peristaltic waves  Report umbilical and inguinal hernias  Inspect umbilical stump, if applicable  Give infant a bottle or pacifer during exam to enhance your ability to hear ABDOMEN

17  Assess Tanner stages (1118, 1120)  Check for testicular descent (cryptorchidism)  Is male urinary meatus at midline?  Circumcised? If not, do not force back foreskin  Look for abuse by bruising, fissures, redness, swelling, discharge  No internal female exam unless sexually active  Note symmetry of gluteal folds  Check for anal reflex GENITALIA

18  Check for spinal curvature  County fingers and toes to detect polydactyly or syndactyly  Bow-legs (genu varum). Feet together—knees 2 or more inches apart  Knock-knees (genu valcum); knees together—ankles 3 or more inches apart  Check for pigeon toe (toeing in)  Check for symmetrical folds in thighs BACK AND EXTREMITIES

19  Use fun games  Assess level of consciousness  Sensory testing  Check reflexes  Patellar, triceps, biceps, achilles  Primitive reflexes  Test cerebellar function (balance and coordination):  Balance on 1 foot  Finger-to-nose test  Heel to toe walk  Romberg  Finger to nose test  Rapid alternating movements NEUROLOGICAL

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