Assessing the Child and Adolescent Health Assessment PDF

Assessing the Child and Adolescent Health Assessment Property of Susan L. Arnold, RN, MSN, ACUE  Many events in a child’s life affect growth and development. Development is directional; head to toe and midline to periphery Normal ph...

Assessing the Child and Adolescent Health Assessment Property of Susan L. Arnold, RN, MSN, ACUE  Many events in a child’s life affect growth and development. Development is directional; head to toe and midline to periphery Normal physical growth advances in a Developmen sequential, predictable path governed by the maturing brain. tal Normal development does not always Principles advance in all domains in an orderly, predictable fashion. Respect for cultural differences is essential for developing trusting relationships. Cultural differences can create communication barriers. A child’s growth and development is specific to that child; the physical assessment should be tailored to the developmental level of the child. Child-Centered Care  Family-centered approach is essential  Strong correlation between the health of the parents and the child.  Develop a rapport with the child and parent, sets the tone for the current visit and future visits and develops a sense of trust before beginning assessment.  White lab coats can be threatening to a child and intimidating to the parent.  Calm and relaxed demeanor is the best approach.  Talk to children at eye level; actively engage them through play.  Talk with the child in an age or developmentally appropriate manner.   Obtained from a variety of sources in an age- appropriate way through  Observation - Important Data  Child Collectio  Parent-child n interaction  Diagnostics  Health history  Physical exam  Urinalysis Hematocrit Blood lead levels Diagnosti Lipid Screening cs Infectious diseases Tuberculosis Sexually transmitted infections (STIs) Human immunodeficiency virus Tympanometry (HIV)  Child-centered approach Reason for the visit; well-child, school/sports physical, preoperative visit, sick visit, or emergency. Health History Attributes of a symptom COLDSPA mnemonic Observe child and parent/caregiver interaction  General health Birth history Past medical history Family health history Health History Psychosocial health history Sleep history Nutrition Elimination   Which statement about pica is true?  Pica is an eating disorder  Pica is common among healthy children Question  Pica is considered abnormal in all cultures  Pica is a benign eating practice that children eventually outgrow   Correct answer: A  Pica the most common eating disorder in individuals with developmental disabilities. Answer  In some societies, pica is a culturally sanctioned practice and is not considered to be pathologic. Health History  Skin  Hair and nails  Eyes and vision  Ears  Nose and sinuses  Mouth, teeth, and throat  Respiratory Health History Female breast development Typically, a primary care physician or midlevel provider will talk with children without parents present for part of the visit starting around age 11. Male breast development Young boys should be assured that gynecomastia usually resolves itself within 6 months to 2 years.   Cardiovascular  Congenital Heart Disease Health  How treated? History  Abdominal  Recurrent abdominal pain is a common pediatric complaint.   Musculoskeletal  Limited ROM  Difficulty running, jumping, climbing  Pain, stiffness, or paralysis in arms, legs or back  Fractures or bone deformities  Neurological Health  Headaches - common in children History  Dizziness, vertigo, feeling faint, muscle strength and coordination  Changes in speech  Seizures  Concussions (TBIs), head injuries  Memory or learning disabilities   Endocrine  Assess for type 1 diabetes  Frequent urination, increased appetite, Health weight loss, thirst, fatigue, blurry vision, History delayed healing  Growth pattern changes, delayed sexual maturation, or precocious puberty may indicate pituitary issues Preliminary Steps Maintain Use Maintain privacy Use a Children feel developmental vulnerable when age-appropriate exposed. approach A child’s chronological age is not an indicator of the child’s developmental stage. Physical Examination  Begin with less threatening and least intrusive procedures  Explain what you will be doing and what to expect  Utilize age-appropriate diversions  Allow the child to touch the equipment  If uncooperative, involve the parents and complete as quickly as possible  Developmental Approaches:  Toddlers – sit on parent’s lap, enlist aid of parent, use play and praise cooperation.  Preschoolers – Use storytelling; use doll and puppet play  School-Age – Explain procedures and equipment; teach about bodies  Adolescent – Ensure privacy and confidentiality, offer option to have parent present or absent, health teaching General Survey  Purpose: To assess physical appearance, state of nutrition, personality, interaction with the parent(s), siblings, nurse, and healthcare provider  Assess:  Hygiene and condition of clothing  Overall development of motor skills, coordination, and speech for age/development  Behavior – activity, interactions with others, attention span, ability to follow directions, eye contact, overall personality.  General Survey Normal Findings Abnormal Findings  Good hygiene  Poor hygiene, body odor  Seasonally clothed  Inappropriately clothed  Straight posture (based on  Poor posture growth & development)  Speechclear and attention  Decreased motor skills span appropriate for age and coordination  Alert & cooperative  Minimal or no eye contact  Good eye contact  Aggressive, negative or  Motorskills and uncooperative coordination appropriate for age.  Positive social interactions Measurements  Plot findings on standard gender specific growth charts and evaluate:  Weight – age-appropriate scale  Length or height  Evaluate findings and appropriately document:  Temperature  Oral – approximately 4-5 years  Rectal – may need provider order  Tympanic – 6 months or older  Axillary  Temporal  Heart rate  Respiratory rate  Blood pressure  Pain   Purpose: To Assessing assess normal somatic growth Weight specific to weight.  Child or adolescent should be wearing only lightweight underclothing or a hospital gown.  Toddler should be weighed nude; otherwise, the weight should be documented including a notation of the additional clothing or shoes the child is wearing.   A child must be able to stand independently to obtain an accurate weight on a standing scale; if unable to stand, weigh sitting or lying on the appropriate scale.  Generally, children older Assessin than 36 months can be weighed on a standing g Weight  scale. Once calibrated, have the child/adolescent stand on the scale with feet a comfortable distance apart, arms and hands at their side, and head up and facing forward.  Document the weight in pounds and kilograms.  Assessing Weight Normal Findings Abnormal Findings  Normalweight for age  Growth failure reflected as according to growth weight lower than the 5th chart. percentile for the child’s age on standard growth charts or a weight curve that falls more than two percentile lines on the National Center for Health Statistics   Purpose: To assess for somatic growth specific to length or height. Assessin  Equipment: Age-appropriate: g Length stadiometer, length board, or measuring tape or  Two measurers are required for Height an accurate measurement.  One measurer holds the infant’s head and the second aligns the infant’s trunk and legs. Assessing Length or Height  To measure a child using a length board, gently position the child on his or her back in the center of the board so the shoulders and buttocks are flat against the board.  Length boards are used for measuring children younger than 24 months of age or for children 24 – 36 months who cannot stand unassisted. Using Length Board or Recumbent Length  Gently hold the head in midline, firmly press on both knees to fully extend both legs while bringing the footboard firmly against the heels, toes pointing upward.  Measuring recumbent length; mark at top of head and bottom of heel.  Both legs should be fully extended for an accurate measurement.  Note the length in centimeters and inches Assessing Height  Ask the patient to remove shoes and place feet together before measuring height.  Measure the patient’s height with he or she standing upright as straight as possible under a stadiometer.  Carefully lower the horizontal bar until it touches to top of the patient’s head.  Assessing Height Normal Findings Abnormal Findings  Shortstature, subnormal Normal height for height for age age Familial short stature or temporary delay in skeletal growth can lead to a normal variant.  Head Circumferenc e  Should be measured with every physical exam if under 2 years of age.  Plot on age and gender appropriate growth chart; should fall between similar ranges as the height and weight.  Purpose: To assess the core body temperature Equipment: Electronic thermometer, Assessing temporal artery thermometer, Temperature tympanic thermometer Choosing the correct technique for assessing temperature depends on the age of the child and institutional policy.  Rectal temperatures taken with digital thermometers are recommended by the American Academy of Pediatrics (American Academy of Pediatrics, 2012) for children 3 years of age or younger. May require a provider’s Assessing order. Temperatur A digital oral thermometer can be e used when children reach the age of 4-5 years and are able to keep their mouths closed with the probe correctly placed under the tongue.  Tympanic thermometer may be used in infants 6 months or older but it must be placed in the ear canal correctly to obtain an Assessing accurate reading. Temperatur Axillary temperatures are e not considered reliable but can be helpful in screening for fever in a less invasive manner.  Temperature Ranges  Normal:  Rectal: 98.7 F to 100.3 F (37.1 C to 37.9 C)  Oral: 97.5 F to 99.5 F (36 C to 37.5 C)  Tympanic: 98.2 F to 100 F (36.8 C to 37.8 C)  Temporal: 98.7 F to 100.4 F (37.1 C to 38 C)  Abnormal:  Rectal: < 98.7 F to > 100.4 F (< 37.1 C to > 38 C)  Oral: < 97.5 F to > 99.5 F ( < 36 C to > 37.5 C)  Tympanic: < 98.2 F to > 100.4 F ( 38 C) (infants) < 98.2 F to > 100 F (< 36.8 C to 37.8 C) (child)  Temporal: < 98.7 F to > 100.4 F (37.1 C to > 38 C) Assessing Heart Rate  Purpose: To assess the heart rate.  Equipment:  Watch or clock with second hand  Stethoscope, age-appropriate.  Assessing the heart rate of a child is similar to adults.  Appropriate-size stethoscopes allow the health care provider to focus on sounds Normal Heart Rate bpm = beats per minute  Infant: 80 to 120 bpm  Toddler: 80 to 110 bpm  School-Age: 70 to 100 bpm  Adolescent: 55 to 90 bpm Abnormal Findings  A heart rate that is abnormally fast or abnormally slow may indicate cardiac disease  Tachycardia – heart rate > 160 – 180 bpm in child over 5 years of age (can be normal during stress)  Bradycardia – heart rate less than 60 bpm   Purpose: To assess the pulmonary ventilation  Equipment:  Stethoscope  Watch or clock with Assessing a second hand  Assessing the Respirato respiratory rate of a ry Rate child older than one year is similar to that for an adult.  Document rate, depth, rhythm, sounds, and effort  Assessing Respiratory Rate bpm = breaths per minute Normal Findings Abnormal Findings  Infant: 30 to 53  Respiratory rate > 60  Toddler: 22 to 37  Retractions  Preschooler: 20 to 28  Nasal flaring  School-Age: 18-25  Grunting  Adolescent: 12-20  Pale,mottled or blue skin color  Change in consciousness Assessing Blood Pressure  Purpose: To assess circulatory blood volume as the heart contracts and relaxes.  Equipment: Noninvasive blood pressure (BP) device, size-appropriate BP cuff  Most important to obtain accurate BP is using a cuff that is appropriate for the size of child’s upper arm or leg Normal BPs in Children  Age Group Systolic (mm Hg) Diastolic (mmHg  Infant: 65 – 100 45 - 65  Toddler: 90 – 105 55 - 70  School-Age: 100 – 120 60 - 75  Adolescent: 110 – 135 65 - 85   The nurse obtains a ten-year-old’s vital signs: T (tympanic) 99.5°F; HR 58; RR 20; BP 105/62. Which finding is Question abnormal? A. Temperature B. Heart rate C. Respiratory rate D. Blood pressure   Correct answer: B – Heart Rate  Normal tympanic temperature: 98.2°F to 100°F or 36.8°C to 37.8°C Answer  Normal heart rate: 75 – 118  Normal respiratory rate: 18 - 25  Normal blood pressure: 102-120/ 61- 80  Purpose: To assess actual or potential tissue damage Children experience pain differently than adults. Even Assessing verbal children find it difficult to Pain locate, describe, and quantify pain. Children in pain are not easily distracted and are often disinterested in activities that would ordinarily gain their attention.   Best method for pain assessment in children includes using a validated, reliable, age- Assessing appropriate tool that accounts for the Pain cognitive ability, language, and cultural background of the child. FLACC Scale Wong-Baker FACES Scale Oucher! Scale  The OUCHER! is a poster displaying two scales: a number scale for older children and a picture scale for younger children.  The child selects the picture that best describes her or his pain.  The picture is easily converted to a number value from 1-10 with 1 being no pain and 10 being the worst possible Inspecting/Palpating Skin  Purpose: To identify changes in skin, including rashes, lesions, masses, and abnormal mole  Assessing the skin of a child is similar to the adults.  Inspect: color, odor, lesions, rashes  Palpate: texture, temperature, moisture, turgor, edema  Assessing the Skin Normal Findings Abnormal Findings  Good hygiene  Bruises  Skin warm, moist  Vascular lesions  Uniform color  Changes in skin texture  No abnormal lesions  Rash  Neviuniform brown color,  Bluishhue or yellowing of regular borders, less than the skin 0.6 cm Inspecting/Palpating Hair and Scalp  Purpose: To assess for changes or abnormalities in the hair and scalp  Equipment: Gloves  Assessing the hair and scalp of a child is similar to adults.  Observe distribution, characteristics, infestations, or presence of unusual body hair.  Inspecting/Palpating Hair and Scalp Normal Findings Abnormal Findings  Hairclean, curly or  Dirty, matted hair straight texture  Dry, dull, brittle  Uniform thickness  Hair loss and distribution  Alopecia (balding)  Colorbrown, black,  Alopecia areata (spot blonde, red, white, or gray. baldness)  Scalp  Tineacapitis clean and intact, no lesions (ringworm)  Lice Inspecting/Palpating Fingernails & Toenails  Purpose: To assess for healthy nails or presence of vitamin deficiency, malnutrition, disease, or infection  Assessing the fingernails and toenails of a child is similar to adults. Inspecting/Palpating Fingernails & Toenails Normal Findings Abnormal Findings  Nailssmooth, short,  Changes in color, shape, uniform thickness texture, or thickness.  Nail base angle 160  Capillary refill > than 2 degrees seconds  Firmly adhere to the nail  Tenderness with palpation bed.  Redness or signs of  Nail bed pink infection or inflammation  Capillary refill < 3  Blue nailbeds – cyanosis seconds  Clubbing  Non-tender to palpation  Ragged short nails – nail biting Inspecting Head, Face, Mouth, and Neck  Purpose: To assess for any alterations in growth and development or abnormalities  Assessing the head, face, mouth, and neck of a child is similar to adults but requires some pediatric considerations. Inspecting Head and Face  Measure head circumference for children up to 3 years old  Assess:  Shape, Symmetry, ROM  Fontanels: anterior usually closes by 18 months, posterior by 2 months  Plagiocephaly (cranial asymmetry)  Opisthotonos, pain on flexion or hyperextension of head (meningeal irritation) Inspecting and Palpating the Nose  Purpose: To assess for tenderness, inflammation, deviation, or passageway occlusion.  Inspect: symmetry, septal alignment, color, or swelling, drainage, or foreign object obstruction  Palpate: for tenderness or swelling  Assess: nasal passageway patency Assessing Mouth  Anxious children can find examination of the mouth frightening and will clench their teeth and purse their lips to prevent a glimpse into their mouths.  Assistance from the parent in restraining the child may be needed and, in this case, consider performing this examination last.  Turn examining the child’s mouth into a game. Ask, “Let’s see what is in your mouth” or “Can you stick out your whole tongue?” or “Let me see your teeth.” or “ Can I see if there are any butterflies in there”  Tongue Airway occlusion caused by tongue d/t tongue being larger in oropharynx Palate Narrow, flat, or high arched Mouth palate; cleft palate Teeth and Neck Color, number, integrity, malocclusion or malposition Neck Torticollis (stiff neck), opisthotonos (pain on flexion or hyperextension) Assessing Ears  Purpose: To assess for ear deformities and tenderness  Assessing the ears and hearing in a child is similar to adults. Inspecting the Eyes  Purpose: To assess any abnormalities of the eye  Equipment: Penlight  Assessing the eyes of a child is similar to adults.  Prepare the child for the examination by showing the child the penlight and demonstrating the light source, how it shines in the eye, and the need for darkening the room.  For young children, use distraction to encourage them to keep their eyes open. Testing Visual Acuity  Purpose: To measure a child’s vision to see details at near and far distances  Equipment: Snellen chart, Tumbling E, HOTV, Kindergarten Eye Chart  Begin between ages 3 and 4 years.  Use the tumbling E or HOTV test for children unable to read.  Children should wear glasses during testing.  For young children turn the assessment into a game. Have the child watch your nose or tell you if you are smiling or Special not while you cover one of the child’s eyes. Considerati The cover test is usually easier to perform if the examiner uses ons his or her hand to cover the child’s eye rather than a card- type occlude. Visual fields can be examined with the young child sitting in the parent’s lap.  Testing Visual Acuity Normal Findings Abnormal Findings  Visual acuity:  The higher the 1 year-20/200, denominator the poorer distant visual acuity. 2 years-20/70,  Nearsightedness (myopia)  5 years-20/30,  Farsightedness (hyperopia)  6 years and up- 20/20.  Children should identify colors by age 5. Assessing Respiratory System  Purpose: To assess for any abnormalities of the respiratory system  Equipment: Appropriate-sized stethoscope  Assessing the respiratory system in a child is similar to adults.  Thoracic diameter reaches adult ration by age 5-6  Children under 7 years are abdominal breathers  Thin chest walls in children radiate sound.  Use of accessory muscles and nasal flaring are signs of respiratory distress. Assessing Respiratory System Normal Findings Younger than 5-6 years: anteroposterior (AP) diameter is 1:1 Older than 6 years: AP-to-lateral ratio is approximately 1:2 and the costal angle less than 90 degrees Conical shape: smaller at the top and widens at the bottom Thin chest walls radiate sound Assessing Respiratory System Abnormal Findings Asymmetrical chest movement Cyanosis Irregular or rapid respirations Accessory muscle retractions, nasal flaring, grunting Crepitus Adventitious breath sounds  Assessing Cardiac System  Purpose: To assess for any abnormalities in cardiac system.  Equipment: Age- appropriate stethoscope  Assessing the cardiac system in a child is similar to an adult with a few pediatric considerations. Special Considerations  In infants and children < 7 years old, the mitral area is located at or near the fourth intercostal space.  In children > 7 years old, the mitral area is located at or near the fifth intercostal space, at the midclavicular line.  Auscultation - sinus arrhythmia and a split- second heart sound changing with respiration is not unusual. Assessing Abdomen  Purpose: To assess for any abnormalities of the abdomen  Equipment: Age- appropriate stethoscope  Assessing the abdomen in child is similar to the adult.  The abdomen is prominent/protubera nt in nature in standing and supine positions up to 4 years of age. After 4 years of age, the abdomen is only  Assessing Abdomen Normal Findings Abnormal Findings  Prominent, cylindrical  Increased peristaltic abdomens, pot-bellied in waves LUQ to RLQ young children because of physiological lordosis  Abdominal distention of the spine caused by fluid, fat,  Visibleperistalsis and feces, or flatulence. aortic pulsations in thin  Inguinal hernia children  Diastasis  Inflammation, redness, recti normal musculature variation in or drainage from young children umbilicus  Umbilicuspink, midline,  Umbilical hernia without redness, drainage, or herniation.  Purpose: To assess for any abnormalities of the bones and muscles. Equipment: Gloves Assessing Musculoskele tal System Sequence of Assessment Inspection Palpation Assessing Range of Motion (ROM) Assessing strength Special Considerations  Newborns present with a rounded or C-shaped spinal curve.  Scoliosis assessment in a child to identify an abnormal lateral curvature of the spine; may look like a “C” or “S”. Special Considerations  Playing a game with the younger child such as “Simon Says” may help to assess the ROM of both upper and lower extremities. If necessary, demonstrate the technique to the child.  Toddlers can usually walk alone by 12-13 months. Their balance is unsteady, and they use a wide base of support for walking.  Toddlers are usually bowlegged (genu varum), after beginning to walk until their back and leg muscles are well- developed. Special Considerations  A child should be walking, jumping, and climbing by three years of age  The preschooler’s gait is more balanced, and they use a smaller base of support to walk.  Children from ages 2-7 years may be normally knock- kneed (genu valgum). Neurologic Assessment  Headaches are common (53% of children and adolescents)  Difficulty walking or muscle strength or coordination  Dizziness or fainting  Change in speech  Concussion (TBI)  Headache  Sluggish, hazy, foggy  Clumsy  Mood, behavior, or personality changes  Double/blurry vision  Nausea/vomiting  Concentration/memory problems  Dizziness Endocrine  Type 1 Diabetes:  Polyuria – frequent urination  Polydipsia – feeling very thirsty  Polyphagia – feeling very hungry even though eating normally  Extreme fatigue  Blurry vision  Slow healing cuts or bruises  Weight loss despite eating normally  Pituitary gland issues:  Growth pattern changes  Delayed sexual maturation  Precocious puberty Teaching/Anticipatory Guidance  Teaching that focuses on the issues that are specific to the developmental stage of the child  Promotes health and prevents disease  It is important to gather information from the child and parent and throughout the health assessment to provide meaningful anticipatory guidance.