1. The Comprehensive Pediatric Health Assessment
What do I need to know?
Jessica Keester, MSN, C-PNP, RN

2. Objectives Review the pediatric-focused assessment:
To understand the components of a comprehensive assessment
Discuss system-specific focused assessments; that vary most significantly in pediatric
To be able to demonstrate complete documentation of patient assessment
Handouts- tools to use in practice

3. Components of a Comprehensive Assessment
Patient History: (Subjective information)
Obtained from..
The client/ parent interview
Chart, Medical Records
Includes:
Family History
Past Medical History; medications; allergies
History related to current need for care or treatment
Chief Complaint
- Current issue being cared for
Do I need to ask this every shift?!
Where o I find it if I am new to the case?!

4. Components of a Comprehensive Assessment
Physical Exam (mostly objective information)
Objective Information:
Vital Signs, ht, wt (if applicable)
Head to Toe assessment
Should include focused exams by system: Inspection, Auscultation, Percussion, palpation
Focused Assessments
What systems? How often?
Subjective information:
Symptoms r/t system assessing
(Ie. pain, tenderness)

5. Subjective vs. Objective
Heart Rate?
Skin Breakdown?
Objective
Both!
Medications?
Medical History?
Subjective
Pain?
Subjective
Nausea?
Subjective
Subjective

6. Where do I start?

7. Client history
…AS important as the physical exam

8. Client History: Obtaining The Initial History
Preparation:
Review information do we have before the client interview:
Any Previous medical records
available on the patient
Order set/ plan of care
Medication List
Treatment schedule
Interview:
The complete health history is an opportunity to establish a relationship with the patient/family, gain insight into the family environment and dynamic, as well obtain health information
(Richardson, 2013)

9. Client History: Obtaining The Initial History
When you are the first person in your organization to assume care for this patient
Subjective information:
Family history
For example: Incidence of chronic conditions/ disability/ psychosocial diagnoses, serious illness, early death
-Maternal history of high risk pregnancy, drug/ alcohol use, prenatal history(s)
-Social History
Past Medical History of Patient
Diagnoses (chronic and acute)
Medical/ Surgical (ED visits, hospitalizations, etc)
Allergies; Medication List
Dynamic family situation
What their goal is for your services
(Richardson, 2013)

10. Client History: The Interval History
Re-admission/ Re-cert
When your organization is RE-assuming care of this patient/ OR 60 day update on plan of care
Subjective:
Any information above that is not previously documented in chart, or unable to obtain.
*Who did the previous assessment? Is it as detailed as you would make it?
* “To get started I’m just going to review some information with you that we already have in your chart”
Any Changes since last Comp Assessment was done
ED Visits, Hospitalizations
Office Visits: Changes to Plan of care or Medications
Significant Growth, changes in Developmental Status
Changes to Plan of Care
(Richardson, 2013)

11. “Other” Subjective information
Some examples from Devero:
Home Assessment (layout, sanitary, electrical)
Language
Psychosocial
Spiritual/ cultural
Neurological status
Emergency/ safety measures; Supplies
Advanced Directives
Supplies
 Ultimately the goal is to work these answers into a narrative; guide the conversation without reading question by question. Answer as much as you can by observation

12. Tips for the interview
The first impression can set a precedence for the duration of care; approach accordingly
*What impression is given if you have not read their chart/ medical record yet?
Be fully present with the client/ family during this time: Active Listening
Greet the patient/ family by name
Sit
Maintain eye contact with historian
Do NOT babysit the EMR
Allow time for the historian to recall, or decide how to word things
*Silence is ok!
Take the history in chronological order
prenatal  Infant toddler pre-school/ school age  adolescent
Clarify when needed!
It’s better to do this immediately than to go back later
“Is there anything else I have not addressed that you would like to discuss?”
Use your instincts!
(Henderson, Tierney, and Smetana, 2012.)

13. The interview helps establish a relationship with the client before moving into the invasive physical exam

14. Physical Assessment
…It’s a big deal too.

15. Components of the Physical Assessment:
Vitals:
Pulse/ hr
Respirations
Blood pressure (?)
Pulse ox (?)
**PAIN
Exam by system
General (……?)
Skin (throughout whole exam)
“HEENT” (+Mouth)
Neurological (reflexes?, developmental status..)
Respiratory
Gastrointestinal
MSK (motor skills, some neuro)
Genitalia (often PD for therapists..Nurses should NOT defer this if possible…)
 Subjective Data
**Be aware for MIX of subjective and OBJECTIVE data: For example: endocrine section- you as a therapist or nurse can not “assess” hypothyroid. That is a Medical Diagnosis. Devero groups together relative subjective findings of ROS and exam .

16. Physical “Exam” vs. “Assessment”…..
“Assessment” data is information you can gather. Subtle differences between fields. You can “assess” data that is given to you as a subjective assessment; or you can assess data that you collect based on your training and scope of practice
“Exam” data includes only the information you can collect independently; based on training and scope of practice.
Ie….. MEDICAL Practice/ Diagnosis
NURSING Practice/ Diagnosis
THERAPY Practice/ Diagnosis
“MID- LEVEL” Practice/ Diagnosis

17. Moving on.

18. What makes a pediatric patient different than an adult?
Gathering information
Explanation of procedure
Cooperation during the exam
Concept of invasive vs. non-invasive
Relationship with the family is as important as the client themselves.
….. Medications, compensating, anatomy changes with phase of development, etc. …..

19. Developmentally Appropriate
Care

20. Infant: Birth – 12 months
Development: Dependent to parent, will look to parents for security, reacts to parents anxiety levels Interview: Full interview taken with parent. “white coat” anxiety less of a factor, Least invasive first is most important (you never when they will get irritated with being touched!) Position: Before 4-6 months: can be on table, make sure parent is in view After 6 months: Best in parent arms, or laying on parent lap encourage parents to be an active part of the exam *great time to assess parent attachment to infant Sequence: If quiet, auscultate heart, lungs, abdomen. Heart and respiratory rates. Perform traumatic procedures last (eyes, ears, mouth [while infant is crying]). Elicit reflexes as body part examined.
(Richardson, 2013; Duderstadt, 2006)

21. What is “invasive” to infants/ kids??
Provider Tip:
What is “invasive” to infants/ kids??
Thermometers
Mouth, nose, ears…think orrifaces
Under their clothes
COLD

22. Toddlers: (12mo-3yo)
Development:
Still utilizes parent as safety; but begins to explore in sight of parent
Interview:
Full interview taken with parent. Should have some anxiety to new faces/ caregivers. Begin communication with child based on their growing vocabulary
Position:
Best to begin in parent arms, or on parent’s lap. A good approach is to assess on parent first than the child
Sequence:
Attempt to warm child up to you first, involving toys/ play, let them touch equipment before use. Attempt to auscultate heart, lung, abdomen first, get RR heart rate they may cooperate very well at first related to curiosity..this will not last long! Invasive assessments LAST!
(Richardson, 2013; Duderstadt, 2006)

23. Preschool: 3 yo-5yo Development:
Increased exploring; intentional limit pushing
Interview:
Full interview taken with parent. Should have some anxiety to new faces/ caregivers. Begin communication with child based on their growing vocabulary; If they are timid try averting eye contact
Position:
Child may want to begin on parent’s lap or holding parents hand, A successful approach is to assess on parent first than the child
Sequence:
Use play and toys to become acquainted and non- threatening; Inspect body through counting fingers; using minimal contact initially. Introduce equipment through play, let them feel and touch equipment. Auscultate as soon as possible–busy age group!
(Richardson, 2013; Duderstadt, 2006)

24. School age: (5yo-12yo)
Development:
Seeking autonomy; exploring (self-exploration/ stimulation common) Still prefers parent closeness
Interview:
Include child in interview/ subjective information. Children this age generally like to answer questions about themselves; Provider lead style of interview
Position:
Sitting alone
Sequence:
In this time period it is appropriate to begin proceeding through head to toe assessment; examine genitalia last assessment, should notice discomfort or resistance with genital assessment.
(Richardson, 2013; Duderstadt, 2006)

25. Adolescent (12yo-18yo)
Development: Autonomy is very important to this age * specific struggle for patient who are medically dependent Interview: Let the adolescent patient speak for themselves; Patient-lead style of interview. Clarify questions you still have at the end, allow parents to add at the end. Position: Sitting/ Alone, may want parent to leave room during physical assessment *without developmental delay- allowing an autonomous assessment is best practice Sequence: Proceed in Head to toe assessment * genital area last- this is the only particularly invasive assessment to adolescents

26. Provider Tip:
EMOTIONAL DEVELOPMENTAL status is more relevant than age!
Follow recommendations for the age corresponding with development
Physical Development DOES NOT equal mental/ emotional development

27. PHYSICAL EXAM

28. General Guidelines on Physical Exam: Other Helpful hints
Have space well lit
Always approach child from front
Always ask permission; give choices
Don’t Lie- if it’s going to hurt, find a way to downplay it without lying “little pinch”
Have toys/ TV/ distraction
Involve Parents as much as possible
Avoid long explanations, child appropriate “Let me feel those strong muscles”
Approach exam prepared and organized
Limit others in room besides family members
Maintain privacy; dignity

29. Vital Signs Your Assessment How do these trend with age?
Heart rate- lowers with age
BP- raises with age
RR- Lowers with age
Sp02- Does not change- “norm” is always %
How do vital signs reflect compensation in Pediatrics?
Trend ___first, then trend ____  once this change occurs prognosis is OMINOUS

30. General Impression

31. Your Assessment “General” What your assessing.. Options:
 Facies  Posture  Body movement  Hygiene  Nutrition  Behavior  Development  State of awareness
Options:
Awake
Alert
tired
Listless
interactive
Lethargic**
pale
Ill-appearing/ well-appearing
Thin
Flushed
Content

32. HEENT Head Eyes Ears: Nose: Throat: Mouth:
Shape, Symmetry, Molding, circumfererence?
Strength (head lag), ROM, scalp, hair
Fontanelles
Eyes
Placement
Lids- observe placement, movement
Conjunctiva
Palpebral/ Bulbar
Discharge?
Ears:
Placement/ development
Note presence of any abnormal openings, tags of skin, or sinuses.
 Inspect hygiene (odor, discharge, color).
What body system develops the same time as ears?
Nose:
Position, alignment
Turbinates- color/ swelling of mucosa?
Nares*
Throat:
Tonsils-Grade 1-4, exudate, color
Mouth:
Teeth**, gums, buccal mucosa
Pharynx
Soft/ hard palate

33. Respiratory Your Assessment Trach? Add: Inspection: Auscultation:
Your Assessment
Inspection:
Shape, size, symmetry,
Evaluate respiratory movements for rate, rhythm, depth, quality, and character movement
Work of breathing
Auscultation:
(Diaphragm of stethoscope- for HIGH pitched sounds)
Needs to be quiet!
Where do you get most information?
What is normal?
What are abnormals?
Percussion:
What does it tell us? What is the “normal”?
Appreciate dullness of the left anterior chest due to heart and right lower chest due to liver.
Note the hyper-resonance of the left lower anterior chest due to air filled stomach.
Trach? Add:
Inspection:
Tracheostomy Site- ties in place, skin condition, secretions
Connected to source of O2/ vent settings?
Auscultation:
Diaphragm of stethoscope
Needs to be really quiet!
Coarse breath sounds likely to be patient norm
Vent: Differentiate self-initiated breaths/ vs. vent “breaths”
**This is when knowing pt baseline is critical!

34. Respiratory… Tracheostomy… Suction? Inspection: Auscultation:
Tracheostomy Site- ties in place, skin condition, secretions
Connected to source of O2/ vent settings?
Auscultation:
Diaphragm of stethoscope
Needs to be really quiet!
Coarse breath sounds likely to be patient norm
Vent: Differentiate self-initiated breaths/ vs. vent “breaths”
**This is when knowing pt baseline is critical!
Suction?
-Pre-assessment
-Amount , consistency, color of secretions
-Post-assessment! (…Did it work?!)

35. *think feedings for infants
Cardiac
Paleness
Pulses
SOB
“bluing”
Tires easily
*think feedings for infants
Inspection
Heaves, lifts
Palpation
Thrills
Auscultation
Where do you listen?
What position should the child be in?
Valves
Aortic area—Second right intercostal space close to sternum Pulmonic area—Second left intercostal space close to sternum Erb point—Second and third left intercostal spaces close to sternum Tricuspid area—Fifth right and left intercostal spaces close to sternum Mitral or apical area—Fifth intercostal space, left midclavicular line (third to fourth intercostal space and lateral to left midclavicular line [MCL] in infants)

36. Murmurs Your Assessment Cardiac
-Most benign murmurs are early - mid systolic.
-Diastolic murmurs almost always indicate pathology.
-A systolic murmur is present between S1 and S2
-A diastolic murmur is present between S2 and S1
-A continuous murmur is present in systole and diastole
Mitral area
Mitral valve prolapse, regurgitation, and stenosis; Still’s murmur, aortic stenosis
Tricuspid area
Tricuspid regurgitation, ventricular septal defect (VSD), Still’s murmur, hypertrophic cardiomyopathy.
Pulmonary area
Pulmonary regurgitation and stenosis, ASD, TAPVR, PDA, and pulmonary flow murmurs.
Aortic area
Aortic stenosis, benign aortic systolic murmur
Using the bell and diaphragm, you should first perform a sweep at these locations for heart sounds and then a second sweep for murmurs.
S1/S2
3rd Heart tone (physiologic)
Innocent Murmur

37. Abdomen/ G.I Your Assessment Inspection
What tells us most about the G.I tract and it’s functioning?
Inspection
Size, contour, shape, umbilicus
-> GT? Location? Patent?
-> Ostomy site?
Auscultation
What is normal?
Palpation
Location of internal organs important to interpret findings
Percussion
Which anatomy produces which sounds?
*Subjective information, Pain

38. Documentation

39. How does this compare to the head to toe assessment you learned in school?
What indicates more information is needed?
Any chronically effected system
Changes to previous assessment/ baseline
ANY documented “abnormal”- regardless of history

40. I think of physical assessment as 3 components …
Head to Toe
To be completed at the beginning of shift (1st hour)
Comprehensive- every system
On-Going Assessment/ “Progress note”
System specific re-assessment based on systems that are affected (see previous slide)
About every 2hours- based on patient condition
Intervention based Assessment
Re-evaluation based on interventions, medications
Pre-assessment, intervention assessment, Post-assessment (see suctioning example 

41. On-Going Assessment/ “Progress note”
Shift head to toe assessment
On-Going Assessment/ “Progress note”
Procedural

42. Case Studies

44. References:
Allen, P., Vessey, J., & Schapiro, N. (2010). Child with a chronic condition (5th Ed.). St.Louis, MO: Mosby Elsevier.
Burns, C., Dunn, A., Brady, M., Starr, N., & Blosser, C. (2013). Pediatric Primary Care (5th). Philadelphia, PA: Mosby Elsevier
Craven, R., Hirnle, C., & Jenson, S. (2013). Fundamentals of nursing; Human health and function (7th. Ed.). Philadelphia, PA: Wolters Kluwer Health/ Lippincot WIlliams & Wilkins.