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New School Nurse Orientation Physical Assessment
Angela Scott, MNSc,RN, APRN, BC Pediatric Clinical Nurse Specialist Arkansas Children’s Hospital September 21, 2016
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Disclosures Presenter has no conflicts to disclose
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Objectives Identify components and techniques of physical examination.
Differentiate the components of patient assessment for which the RN is legally responsible, as defined by Arkansas State Board of Nursing (ASBN). Demonstrate critical thinking skills through the critique & evaluation of nursing actions & patient outcomes in case-scenario discussion.
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Role of the Pediatric Nurse
Therapeutic relationship Family advocacy/Caring Disease Prevention/Health Promotion Health Teaching Support/Counseling Restorative Role Coordination/Collaboration Ethical Decision Making: American Nurses Association Code of Ethics
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Restorative Role Most basic of all nursing roles
Restoration of health through caregiving activities Significant aspect: Continual assessment & evaluation of physical status. Must be aware of normal findings to identify & document deviations intelligently Although responsible for implementing physician orders, are also held individually accountable for own actions and judgments regardless of written orders.
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Ethical Code for Nurses: Professional Self-Regulation
Developed by the American Nurses Association Focus is on the Nurse’s accountability and responsibility to the client Emphasizes the nursing role as an independent professional role that upholds its own legal liability.
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Critical Thinking….Defined
Critical thinking is purposeful, goal-directed thinking that assists individuals to make judgments based on evidence rather than guesswork. Alfaro-Lefevre, R. (1995)
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Critical Thinking Systematic thought process essential to a profession. Assists the professional in meeting the needs of the client. Based on the scientific method of inquiry, in which the nursing process also has roots. Critical thinking and nursing process considered crucial to professional nursing—they comprise a holistic approach to problem solving.
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Situational Awareness
Fundamental concept to maintain operational safety in high reliability organizations What is high reliability organization?
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Situational Awareness
Perception: of elements in the environment in a volume of time and space Comprehension: of their meaning Projection: of their status in the near future
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Take Away-- Nurses have a critical role in providing vigilance in health care and what we do or fail to do is directly related to patient outcomes.
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Thinking moments
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School Nursing Process—6 Steps
Assessment: Note the child’s complaint, take vital signs and a history of the complaint, and examine as needed Diagnosis: Formulate a diagnosis, based on the assessment data collected Outcome Identification: Identify exactly what you expect to happen with the student Planning: Develop a plan of care or action for the child Implementation: Implement the intervention identified; return the child to class or exclude from school Evaluation: Evaluate the outcome of the plan; follow up by checking on the student at the appropriate time (Loschiavo, J. 2012; Fast Facts for the School Nurse)
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Physical Examination: Approach & Overview
Skillful clinician Thorough without wasting time Systematic without being rigid Study and repetitive practice enables smooth flow of examination Able to accomplish in 5-10 minutes what first took much longer. Continuing progress should be a lifetime goal
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How Complete Should an Examination Be?
Comprehensive vs. Focused How do I decide? When to use Do you know the Normals?
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Examination Components
General survey Mental status Vital Signs Skin Head Eyes Ears Nose, Sinuses Mouth, Pharynx Neck Back, Posterior thorax & lungs Anterior thorax & lungs Cardiovascular system Breasts, Axillae Abdomen Genitourinary system Musculoskeletal system Neurologic exam: Cranial nerves, motor, sensory, reflexes
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General Survey Level of Consciousness Signs of Distress
Facial expression Apparent state of health Skin color & obvious lesions Height, weight, build Posture, gait, motor activity Odors of body or breath Vital signs
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Skin Color Moisture Temperature Texture Mobility & Turgor Nails Hair
Bruises Lesions Rashes Scars Stomas Wounds
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Head & Neck Hair Scalp Skull Face Skin The Head
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The Eyes Position & alignment Eyebrows Eyelids Lacrimal gland, sac
Conjunctiva & sclera Cornea & lens Pupils: size, shape, symmetry
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The Ears Auricle Ear canal Swelling Inflammation Tenderness Drainage
Piercings
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Nose & Sinuses Anterior & inferior surfaces of nose
Asymmetry, deformity Nasal Obstruction Drainage Sinuses Frontal Maxillary Nose & Sinuses
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Mouth & Pharynx Lips Oral Mucosa Gums, teeth Tongue Pharynx
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Piercings Wherever, whatever
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The Neck Symmetry Lymph nodes Trachea Carotid arteries Jugular veins
Masses Scars Lymph nodes Trachea Midline Tracheostomy Carotid arteries Jugular veins The Neck
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Thorax & Lungs Measurement Lines Lobes Trachea & Major Bronchi
Axillary (post, mid, anterior) Clavicular Sternal Scapular Vertebral Lobes Right: RUL, RML, RLL Left: LUL, LLL Trachea & Major Bronchi Breathing effort
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Lungs Breathing Color Auscultate Rate, rhythm Depth, effort
Retractions Color Pink Cyanosis Auscultate Symmetrical comparison Adventitious sounds: crackles, wheezing, rhonchi
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Cardiovascular System
Pulses Apical Carotid Brachial Radial Femoral Popliteal Post-tibial Dorsalis pedis Blood pressure Color Capillary refill Heart sounds Normal S1 (systolic), S2 (diastolic) Murmurs?
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Breasts & Axillae Female Male Lymphatics
Tanner Sex Maturity Ratings (SMR) 1-5 Male 2 out of 3 adolescent boys develop gynecomastia Lymphatics From most of the breast drain to the axillary nodes Also drain to supraclavicular and infraclavicular nodes
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Abdomen Many structures 4 quadrants: RUQ, RLQ, LUQ, LLQ
Liver Gallbladder Spleen Stomach Aorta Colon Kidneys Bladder 4 quadrants: RUQ, RLQ, LUQ, LLQ 9 sections: Epigastric, Umbilical, Hypogastric/suprapubic
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The Abdomen Skin Umbilicus Contour Peristalsis Pulsations Bowel sounds
Palpation Visualize each organ in the region you are examining The Abdomen
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Genitourinary System: Male
Tanner Sex Maturity Ratings (SMR) 1-5 Penis Skin Prepuce (if present) Glans Urethra Scrotum Swelling Testicular torsion Hernias Femoral Inguinal Scrotal Incarcerated Strangulated
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Genitourinary System: Female
Tanner Sex Maturity Ratings (SMR) 1-5 External genitalia Mons pubis Labia majora Labia minora Prepuce Clitoris Vagina Urethra Paraurethral (Skene’s) glands Bartholin’s glands Hernias Inguinal Femoral
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Musculoskeletal System
Range of motion Limitation Unusual increase Inflammation Swelling Tenderness Heat Redness Crepitus Deformities Condition of surrounding tissues Muscular strength Symmetry Flexion, Extension Supination, Pronation Rotation Adduction, abduction Inversion, eversion Spinal curvature
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Nervous System Motor system Central NS Peripheral NS Sensory system
Body position, movements; muscle bulk, tone, strength Coordination Gait Sensory system Pain, temperature, touch Reflexes (0 to 4+) Biceps, triceps, supinator Abdominal Knee, ankle, plantar; clonus Central NS Brain Spinal cord Peripheral NS Cranial nerves Peripheral nerves Spinal reflexes Symmetry
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Further Neurological Examination
Meningeal signs Neck mobility Brudzinski’s sign Flexion of neck produces hip & knee flexion= + Brudzinski Kernig’s sign Flex leg at hip & knee, extend knee. Pain & increased resistance to knee extension= + Kernig Level of Consciousness A: alert V: responds to voice P: responds to pain U: unresponsive
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break
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Putting it all Together
Anatomic & physiologic differences Normal & abnormal patterns of growth & development Developmental levels Infancy—the 1st year Early childhood—years 1 through 4 Late childhood—years 5 through 12 Adolescence—years 13-21
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Milestones: 1 year Pulls to stand, cruises, takes few steps alone
Plays social games Precise pincer grasp Points with index finger Bangs two blocks together Vocabulary 1-3 words, plus “mama, dada” Drinks from cup Looks for dropped, hidden objects Waves “bye-bye” Feeds self
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Milestones: 2 years Goes up and down stairs one at a time Kicks ball
Stack 5-6 blocks Vocabulary at least 20 words Makes or imitates horizontal & circular strokes with crayon Can follow 2-step commands Imitates adults
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Milestones: 3 years Jumps in place, kicks ball, balances on one foot
Rides tricycle Knows own name, age, & sex Copies circle and cross Has self-care skills Shows early imaginative behavior
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Milestones: 4 years Can sing a song Draws a person w/three parts
Aware of gender of self and others Distinguishes fantasy from reality Gives first and last name Talks about daily activities & experiences Builds tower of 10 blocks Hops, jumps on 1 foot Rides tricycle or bicycle with training wheels Throws overhand ball
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Milestones: 5 years Dresses self without help
Knows own address and telephone number Can count on fingers Copies triangle or square Draws a person with a head, body, arms, legs Recognizes most letters of alphabet; prints some Plays make-believe and dress-up May be able to skip
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Milestones: 6 years Eager to act independently
Tests the limits of his body Increasing social maturity and intellectual skills Encourage child to begin to assume responsibility for toys, other belongings; selected chores; good health habits
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Milestones: 8 years In charge of self-care tasks
Able to focus on multiple aspects of a problem; uses logic Interested in how things work and has many questions Identifies with children of same gender Has best friend Health relationship now focused on child
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Milestones: 10 years Friends assume greater importance; child is more independent from family Peer pressure begins and influences risk-taking behavior Supporting & enhancing child’s self-esteem and self-confidence is critical School progress, achievements, problems Puberty approaching
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Milestones: 11-14 years Dramatic physical changes
Beginning abstract thought Peer group profoundly important Exploration: alcohol, smoking, drugs; sexual Academic challenges Need appropriate limits set Potential for self-harm Eating disorders Steroid use Poor physical fitness Injuries
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Milestones: 15-17 years Pubertal development nearing completion
Increasingly comfortable with sexual identity Transitioning from concrete to formal operational thinking Better able to understand complexities in causality and perspectives of others Maturing moral development Safety issues: violence, driving, alcohol, drugs Feelings of sadness & depression are not “normal” moodiness during this period
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Milestones: 18-21 years Pubertal development complete
Achieving autonomy & creating adult sense of self Vocational & higher education pursuits Many high-risk behaviors peak at this time
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Early Childhood Challenge is to complete the examination without producing a physical struggle, a crying child, or distraught parent Demonstrate procedure on yourself, doll, toy animal Tell the child what to do instead of asking the child to do it Order your assessment from least distressing procedures first to most distressing last Tell child about likelihood of pain or unpleasant sensations immediately prior to the event
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Late Childhood Little difficulty in examining most school-age children
Child’s modesty is important; maintain privacy Order of examination can follow that used with adults
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Adolescence Key is comfortable environment in which they feel safe
Establish a trusting relationship Modesty and privacy paramount Order of exam can follow that used with adults
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An Assessment Pearl: OLDCART
O: onset L: location D: duration C: characteristics A: aggravating factors R: relieving factors T: treatment
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General Survey Temperature Pulse Respiratory rate Blood Pressure
Somatic Growth: height, weight
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Skin Texture Color: mottled, acrocyanosis Lanugo Turgor Common Issues:
Rashes—flat, raised, color? Lesions—draining, not draining? Bruises—random or patterned? Cutting, excessive tattooing—keep on your radar
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Head & Neck Early & late childhood: follow adult exam Common Issues:
Headache—allergy, migraine, tension, tumor Head injuries Concussion Traumatic Brain Injury (TBI)
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Eye Early & late childhood Common Issues: Vision disturbance Eye pain
Observe sclera, pupils, irises, extraocular movements Visual fields: while child’s head in midline, bring object into the child’s field of vision from behind the child, into upper & lower temporal fields on both sides. Eyes deviate in direction of the object. Red reflex present Common Issues: Vision disturbance Eye pain
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Ear Early & late childhood Common Issues:
Auricle upward, outward, and backward for view Common Issues: Ear pain Foreign objects
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Nose & Throat Common Issues: Early & late childhood Pain Infections
Shedding of primary teeth at age 6, beginning of permanent teeth Tonsils Lymph nodes Common Issues: Pain Infections
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Thorax, Breasts, Lungs Early & late childhood Common Issues:
Same as adult exam Common Issues: Chest pain
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Heart Early & late childhood
Conducted like that of adult, with few exceptions PMI is higher (4th ICS until age 7); located left of MCL to age 4, at MCL age 4-6, right of MCL at age 7 Sinus arrhythmia common PVCs quite common Murmurs Innocent Organic The athlete’s heart
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Abdomen, GI, GU Bowel movements & urination Early & late childhood
Tanner staging Precocious puberty if before age 8 Common Issues: Pain
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Musculoskeletal Early, & late childhood Common Issues:
Like that of adult Range of motion Alignment variations during growth Hip dysplasia Limp Scoliosis Common Issues: Pain Fractures
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Nervous system Early & late childhood Think…Wiring Common Issues:
Conducted much like adult exam Gait both walking and running Think…Wiring Common Issues: Overall mental health Anxieties Seizures
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The BIG Problems Anaphylaxis—suspected or actual Head trauma
Airway obstruction or respiratory failure Cardiac arrest Open fracture Burns—large area Infectious Diseases—Meningitis, Measles Multi-drug resistant organisms (MDROs)
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Thinking moments
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THANK YOU!!!
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