Communication and Physical Assessment of the Child

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Discussion

◦How will you vary your communication techniques in Pediatric nursing?

http://www.workingnurse.com/articles/foster-care-for-at-risk-babies-one-nurse-s-story

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Appropriate introduction Privacy and confidentiality Telephone triage/counseling

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Encourage talking Direct the focus Listening and cultural awareness Silence, empathy, and anticipatory

guidance Avoid communication block

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Fig 6-1 Child plays while nurse interviews parent.

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Make communication developmentally appropriate

Get on child’s eye level

Approach child gently and quietly

Always be truthful Give child choices as

appropriate

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Fig 6-1 A young child may take the expression “a little stick in the arm” literally.

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Avoid analogies and metaphors Give instructions clearly Give instructions in positive manner Avoid long sentences, medical jargon;

“scary words” Give older child opportunity to talk without

parents present

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Infants:◦ Nonverbal◦ Crying as communication◦ Comfort ◦ Stranger anxiety

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Early childhood:◦ Focus on child in your communication◦ Explain what, how, and why◦ Use words he or she will recognize◦ Be consistent (e.g., don’t smile when doing

painful procedures)

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Adolescent:◦ Be honest with them◦ Be aware of privacy needs◦ Think about developmental regression◦ Importance of peers

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Children’s “work” Child’s “developmental workshop” As therapeutic intervention As stress reliever for child and family As pain reliever, distracter Creative communication

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Chief complaint (CC) History of present illness (HPI) History

◦ Birth◦ Dietary◦ PMH, PSH◦ Allergies◦ Current Meds◦ Immunizations◦ Growth and development◦ Habits

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Sexual history Family history Family structure Psychosocial history Review of systems (ROS)

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The nurse is admitting a 15 year old female with abdominal pain to the peds unit. Her mother is at the bedside◦ What communication techniques should be used?◦ What important questions should the nurse ask?

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The nurse is caring for a 2year old patient admitted last night with pneumonia. Upon entering the room the child begins to cry.◦ What should be the nurse’s approach?

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Discussion◦ How will you vary your assessment techniques

in a child?

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Head-to-toe sequence for assessing adult clients

Sequence altered to accommodate child’s developmental needs

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Minimize stress and anxiety Foster trust Allow for maximum preparation of child Preserve security of parent-child

relationship Maximize accuracy of assessment findings

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Child’s perception of painful procedures Parent presence Age-appropriate techniques

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Fig 6-4 Using paper-doll technique to prepare child for physical examination.

Fig 6-5 Preparing children for physical examination.

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Growth measurements:◦ Recumbent length for infants up to age 36

months + weight and head circumference◦ Standing height + weight after age 37 months ◦ Plot on growth chart

By gender and prematurity if appropriate <5th or >95th percentile considered outside

expected parameters for height, weight, head circumference

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Fig 6-8 Measurement of head, chest, and abdominal circumference and crown-to-heel (recumbent length).

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Boys Growth Chart Birth to 36 months Girls Growth Chart Birth to 36 months Boys Growth Charts 2 to 20 years Girls Growth Charts 2 to 20 years

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Ethnic differences Expected growth rates at various ages Significance of head circumference

measurements

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Fig 6-7 These children of identical age (8 years) are markedly different in size. Child on left, of Asian descent, is at 5th percentile for height and weight. Child on right is above 95th percentile for height and weight. However, both children demonstrate normal growth patterns.

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Importance of physiologic measurements in overall pediatric assessment

Comparison with normal values for each age-group

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Count respirations first Count apical heart rate second Measure blood pressure (BP) (if applicable)

third Measure temperature last

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Sites◦ Oral◦ Axillary◦ Ear◦ Rectal

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Image courtesy Paul Vincent Kuntz, Texas Children’s Hospital, Texas.

Unn Figure 6-1B Axillary. Image courtesy Paul Vincent Kuntz, Texas Children’s Hospital, Texas.

Image courtesy Paul Vincent Kuntz, Texas Children’s Hospital, Texas.

Unn Figure 6-1C Ear based (aural). Image courtesy Paul Vincent Kuntz, Texas Children’s Hospital, Texas.

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Measurement devices Cuff selection Cuff placement Interpretation of BP measurement

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Fig 6-12 Sites for measuring blood pressure. A, Upper arm. B, Lower arm or forearm. C, Thigh. D, Calf or ankle.

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General appearance Skin Hair, nails, hygiene Lymph nodes Head and neck EENT Chest Heart Lungs Abdomen Genitalia Back and extremities Neurologic assessment

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General Appearance◦ Facies◦ Posture◦ Position◦ Body movement◦ Behavior◦ Development

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Skin◦ Color◦ Texture◦ Turgor◦ Lesions

Hair◦ Cleanliness◦ Infestations◦ Color, texture

Nails Hygiene

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http://www.buzzle.com/img/articleImages/339343-21124-29.jpg

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Head and Neck◦ Shape ◦ Symmetry◦ Palpate skull

Posterior fontanel closes by 2nd month

Anterior fontanel closes by 12-18 mos

◦ Head control (>4 mos)

◦ ROM

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Lids Conjuctiva Glands Cornea Pupils PERRLA Iris

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Strabismus◦ Corneal light reflex test

(Hirschberg)◦ Cover test

Pseudostrabismus

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Funduscopic exam◦ Red reflex

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Snellen chart◦ Usually start at 6yo◦ Stand at 10 feet◦ Must identify 4/6 on

line to pass

Tumbling E/HOTV ◦ If unable to read

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http://emedicine.medscape.com/article/994656-media

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Inspect◦ Contour◦ Movement◦ Umbilicus◦ Hernia

Auscultate Palpation

◦ Superficial ◦ Deep

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http://www.allina.com/mdex/nd7575g.htm

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The nurse is caring for an 8-year-old patient with RLQ pain, vomiting and fever. The patient is waiting for a CT of the abdomen this morning to r/o appendicitis.◦ How will the nurse approach examination of this

child?

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http://www.merckmedicus.com/pp/us/hcp/thcp_dorlands_content_split.jsp?pg=/ppdocs/us/common/dorlands/drlnd/four_01/000044180.htm

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Tailor position•to avoid cremasteric reflex

Blocking inguinal canal

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Symmetry Temperature Color Pulses Pigeon toe Plantar reflex

◦ Babinski Deep tendon reflexes

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Plantar reflex+Babinski <1yo

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Knock knee Bowleg

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Balance◦ On one foot◦ Heel toe walk

Coordination◦ Rapid movements

Cerebellar function◦ Finger-to-nose test◦ Heel-to-shin test◦ Romberg test

Cranial nerves

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Triceps Biceps

Patellar

Achilles

Pain Assessment and Management in Children

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3 types of measures to assess child’s pain:◦ Behavioral

Children with limited communication skills Ex: FLACC

◦ Physiologic Physiologic parameters Ex: HR, RR, BP, vagal tone

◦ Self-report Cognitive ability to describe Ex: FACES, Numeric

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FLACC Pain Assessment Tool (2 mos-7yo)◦ Categories

Facial expression (0-2) Leg movement (0-2) Activity (0-2) Cry (0-2) Consolability (0-2)

0= no pain, 10=worst pain

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68http://www.childcancerpain.org/content.cfm?content=assess13

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Nonpharmacologic management◦ Distraction◦ Relaxation◦ Positive self-talk◦ Guided imagery◦ Containment◦ Nonnutritive sucking◦ Kangaroo care

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Nonopioids Opioids PCA Epidural Transdermal Analgesia

◦ EMLA Intradermal route

◦ Lidocaine

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Respiratory depression Constipation Pruritis N/V Sedation Dependence Withdrawal symptoms Tolerance

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