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-onenurse-s-story

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

http://www.ultimatekeepers.com/news/news.htm

Fig 6-1 Child plays while nurse interviews parent.

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Make communication developmentally appropriate Get on childs 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., dont 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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Childrens work Childs 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 nurses 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 childs 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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Childs 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 Girls Boys Girls

Growth Chart Birth to 36 months Growth Chart Birth to 36 months Growth Charts 2 to 20 years 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 agegroup

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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 Childrens Hospital, Texas.

Image courtesy Paul Vincent Kuntz, Texas Childrens Hospital, Texas.

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

Unn Figure 6-1B Axillary. Image courtesy Paul Vincent Kuntz, Texas Childrens 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

Hair

Color Texture Turgor Lesions

Nails Hygiene

Cleanliness Infestations Color, texture

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

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Head and Neck

Shape Symmetry Palpate skull

Head control (>4 mos) ROM

Posterior fontanel closes by 2nd month Anterior fontanel closes by 12-18 mos

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Lids Conjuctiva Glands Cornea Pupils PERRLA Iris

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Strabismus
Corneal light reflex test (Hirschberg) Cover test

Pseudostrabismus

http://www.aafp.org/afp/2007/0201/p361.html

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Funduscopic exam
Red reflex

http://www.abcd-vision.org/Images/cataract-ebt500.jpg

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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
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

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 Achilles

Patellar

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Pain Assessment and Management in Children

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3 types of measures to assess childs 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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http://www.childcancerpain.org/content.cfm?content=assess13

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http://www.wikidoc.org/images/thumb/ e/eb/Pain_scale.jpg/600px69 Pain_scale.jpg

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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