1. PEDIATRIC ASSESSMENT

2. 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

3. Introduction Key elements. Times: Every month in the 1st year.
Every 3 month of the 2nd and 3rd year.
Each 6 month of 4th and 5th year.
Yearly after the 6th year.

4. Physical Exam
Avoid touching painful areas until confidence has been gained.
Begin exam without instruments.
Allow child to determine order of exam if practical.
Use the same format as adult physical exam.

5. Infant Exam Examine on parent lap. Leave diaper on.
Comfort measures such as pacifier or bottle.
Talk softly.
Start with heart and lung sounds.
Ear and throat exam last.

6. Toddler Exam Examine on parent lap if uncooperative. Use play therapy.
Distract with stories.
Let toddler play with equipment / BP.
Call by name.
Praise frequently.
Quickly do exam.

7. History Bio-graphic Demographic Past Medical History Allergies
Personal Hx., Life styles, Health Hx. (past and current), and Family Hx.
Bio-graphic Demographic
Name, Date of Birth, Age
Parents & siblings info
Cultural practices
Religious practices
Parents’ occupations
Adolescent – work info
Past Medical History
Allergies
Past illness
Trauma / hospitalizations
Surgeries
Birth history
Developmental
Family Medical/Genetics
Current Health Status
Immunization Status
Chronic illnesses or conditions
What concerns do you have today?

8. Equipment What’s in Your setting?
Stethoscope & Sphygmomanometer
Pen Light
Otoscope / Opthalmoscope
Scale

9. 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

10. Physical Exam Technique
Inspection- eye only.
Palpation- tip of finger.
Percussion- use. . .
Dullness (solid organ), resonance (over solid organ or filled air), tympanic (hollow organ).
Auscultation- stethoscope.

11. History: Review of Systems
Skin
HEENT
Neck
Chest & Lungs / Respiratory
Heart & Cardiovascular GI GU
Musculoskeletal & Extremities
Neuro
Endocrine

12. Sleep & Activity
Appetite
Bowel & Bladder

13. Physical Assessment The approach is: But FLEXIBILIY is essential
Orderly
Systematic
Head-to-toe
But FLEXIBILIY is essential
And be kind and gentle
but firm, direct and honest

14. Physical Assessment General Appearance & Behavior Facial expression
Posture / movement
Hygiene
Behavior
Developmental Status

15. 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 ____ ?

16. Pediatric Vital Signs – Normal Ranges
Infant Toddler School-Age Adolescent
Heart Rate
Respiratory Rate
Systolic blood pressure
Diastolic blood pressure

17. Physical Assessment General Skin, hair, nails Head, neck, lymph nodes
Eyes, ears, nose, throat
Chest, Tanner Scale
Heart
Abdomen
Genitalia
Rectal
Musculoskeletal: feet, legs, back, gait

18. Palpation Use of your fingers and palms to determine: Temperature
Hydration
Texture
Shape
Movement
Areas of Tenderness
Warm hands and short nails
Palpate areas of tenderness / pain last
Talk with the child during palpation to help him relax
Be observant of reactions to palpation
Move firmly without hesitation

19. H E E N T
Head
Eyes
Ears
Nose
Neck
Throat

20. 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

21. Head
Shape:
“NormoCephalic – ATraumatic”
Lesions
? Edema

22. Head: Key Points Head Circumference (HC
Fontannels/sutures: Anterior closes at 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

25. Neuro Assessment LOC / Glasgow coma scale Pupil size Vital Signs Pain
Seizure Activity
Focal Deficits

26. Eyes Red Reflex Corneal Light Reflex Strabismus:
Alignment of eye important due to correlation with brain development
May need to corrected surgically
Preschoolers should have vision screening
Refer to ophthalmologist is there are concerns o

27. Eyes: Key Points Vision: Red reflex & blink in neonate
Examine external structure of the:
1- Conjunctiva
2- Sclera- clear
3- Cornea- cover the iris and pupil
4- pupils- compare for size, shape, test for reaction.
5- Iris- color, size and clarity M.
Irritations & infections

28. Ears: Key Points Ask about hearing concerns Inspect the ears
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
External shape and size.
Pinna: line, low set ear (retardation).
Internal structure.

29. Ear Exam Pinna is pulled down and back to straighten ear canal in
children under 3 years.

30. Nose & Throat / Mouth Exudate Pharynx Tonsils
Signs & Symptoms of Allerg
Assess for symmetry, deformity, skin lesion.
Palpate for septal deviation.
Smooth and moist, with pinkish color.
ic Rhinitis
Palate
Gums
Swallow
Oral Hygiene
Condition of teeth
Missing teeth
Orthodontic Appliances

31. 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

32. 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

33. Chest Anatomy. Inspection: symmetry, movement of chest wall.
Breathing pattern- abdominal breathing.
Palpation:
1- light palpation: in light circular motion to detect lesion and masses
2- deep palpation: palpate for internal organ like liver and spleen.

34. Neck: Key Points √ position, lymph nodes, masses, fistulas, clefts
Range of Motion (ROM)
Check clavicle in newborn
Head control in infant
Trachea & thyroid in midline
Carotid arteries (bruits)
Meningeal irritation

35. Chest Assessment Auscultation How does the child look? Color
Work of Breathing: Effort used to breathe
Auscultation
All 4 quadrants
Front and back
Take the time to listen
Be sure about “lungs CTAB”
(clear to auscultation bilaterally)

36. Lungs & Respiratory: Key Points
Clubbing
Snoring (expiratory): upper airway obstruction, allergy,
Dullness to percussion: fluid or mass
Increased or Decreased Respirations
Stridor
Wheezing

38. Chest Assessment Auscultation Wheezing Retractions Red Flags: grunting
Subcostal
Intercostal
Sub-sternal
Supra-clavicular
Red Flags:
grunting
nasal flaring
stridor

39. All that Wheezes isn’t always Asthma…
Think:
Infection
Foreign body aspiration
Anaphylaxis
Insect bites/stings, medications, food allergies

40. And all Asthma doesn’t always Wheeze!
Cough
Fatigue
Reduced exercise tolerance

41. Cough - Characteristics
Dry, non-productive
Mucousy – productive
Croupy
Acute – less than 2-3 weeks
Chronic – more than 2-3 weeks
Associating Symptoms

42. Auscultating Heart Sounds
Circulatory
Auscultating Heart Sounds
The Auscultation Assistant – Hear Heart Murmurs, Heart Sounds, and Breath Sounds.
Pillitter
Perfusion – capillary refill
“Warm to touch”

43. Gastro-Intestinal
Abdominal Assessment
Pillitteri

44. Abdomen
Use supine position with pillow under the head and knee flexed.
Divide abd. to 4 Quadrant, and examine from button to top.
Examination of the abdomen involve the inspection, auscultation, palpation and percussion.

45. 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

46. 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

47. Stomachaches and Abdominal Pain
Excessive gas
Chronic constipation
Lactose intolerance
Viral gastroenteritis
Irritable bowel syndrome
Heartburn or indigestion
GERD
Food allergy
Parasite infections (Giardia)
What are we most concerned about?

48. Stomachaches and Abdominal Pain
Appendicitis
Bowel obstruction -- Cholecystitis with or without gallstones
Food poisoning (salmonella, shigella)
Inflammatory Bowel Disease –
Crohn's disease
Ulcerative colitis
Hernia
Intussusception
Kidney stones
Pancreatitis
Sickle cell crisis
Ulcers
Urinary tract infections

49. Signs and Symptoms Appearance –color, facial, ROM, gait, position
Pain – get your pain scales out
Nausea
Vomiting
Diarrhea
Bloating
Inability to pass gas or stool

50. 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

51. Musculo-Skeletal
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:

52. Scoliosis Lateral curvature of spine Key Points: Barefoot
Feet Together
Bend Over –
Check Hips
Medline.com

53. Skin, Nails & Hair Rashes Lesions Lacerations Lumps Bumps Bruises
Bites
Infections

54. Common Skin Lesions Macule Papule Vesicle, bulla Pustule Cyst Patch
Plaque
Wheal
Striae
Scale
Crust
Keloid
Fissure
Ulcer
Petechiae
Purpura
Ecchymosis
Capillary bleeding: Petichiae and purpura
usually indicate serious conditions

55. Skin Infections Bacterial infections Abscess formation
Severity varies with skin integrity, immune and cellular defenses
Examples:
impetigo
cellulitis

56. The School-Age Child Privacy and modesty.
Explain procedures and equipment.
Interact with child during exam.

57. Adolescent Privacy issues – first consideration
HEADS: home life, education, alcohol, drugs, sexual activity / suicide
GAPS Guidelines for Adolescent Preventive Services
Bright Futures

58. Psychosocial Assessment
HEADS
Home life
Emotions / Depression or Education
Activities
Drugs / Alcohol / Substance Abuse
Sexuality activity or Suicide
SHADESS
School
Home
Activities
Drugs / Substance Abuse
Emotions / Depression
Sexuality
Safety

59. 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?

60. 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

61. Emergencies & Trauma
Allergic Reactions
Asthma
Head
Abdomen
Limb
Other

62. Behavioral / Mental Health Concerns
Developmental Delays
Depression
Aggressive Behaviors
Suicide Risks
Other Mental Health Issues

63. Chronic Conditions & Special Needs
Asthma
Diabetes
Neuro – seizures
Sickle Cell Anemia
Cerebral Palsy
ADHD

64. 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 8th ed.
AAP Preparticipation Physical Evaluation.
Resource Manual for the Nurse in the School Setting
American Medical Association Guidelines for Adolescent Preventive Services (GAPS)
American School Health Association
The Auscultation
BMI Calculator: /
2007 Asthma Guidelines:

65. ANY QUESTIONS

66. We Know It’s a Jungle Out There!

67. You Make the Difference!

68. 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.
Leah L. Curtin, RN, MS, MA, DSC, FAAN