Physical assessment the of child

Prepared by Raveen Isamel Abdullah

B.CS.in Nursing Hawler medical university

College of nursing 2016-2017

OUTLINES

• Introduction

• History taking and physical examination

• Steps of history taking

• Analyzing symptoms

• Nutritional assessment

Introduction

• Physical assessment is taking an educated, systematic look at all aspects of an individual’s health status utilizing knowledge, skills and tools of health history and physical exam.

1. To collect data- information about the client’s health, including physiological, psychological, sociocultural and spiritual aspects.

2. To establish actual and potential problems.

3. To establish the nurse-client relationship.

History taking

The format used for history taking may be:(1) Direct, in which the nurse asks for information via direct

interview with the informant.(2) Indirect, in which the informant supplies the information

by completing some type of questionnaire.

• The direct method is superior to the indirect approach or a combination of both. However, because time is limited, the direct approach is not always practical.

• If the nurse cannot use the direct approach, he or she should review the parents 'written responses and question them regarding any unusual answers.

Informant

One of the important elements of identifying information is the informant, the person(s) who furnishes the information.

Record(1) who the person is (child, parent, or other), (2) an impression of reliability and willingness to

communicate.(3) any special circumstances such as the use of an

interpreter or conflicting answers by more than one person.

Identifying information

1. Name2. Address3. Telephone4. Birth date and place5. Race or ethnic group6. Sex7. Religion8. Date of interview9. Informant

Chief Complaint

• To establish the major specific reason for the child’s and parents’ seeking professional health attention

• Elicit the chief complaint by asking open-ended, neutral questions such as: “What seems to be the matter?”“How may I help you?” or “Why did you come here today?”

• Avoid labeling-type questions such as: “How are you sick?” or “What is the problem?” It is possible that the reason for the visit is not an illness or problem.

Present Illness

• To obtain all details related to the chief complaint.

Its four major components are:

(1) The details of onset.

(2) A complete interval history.

(3) The present status.

(4) The reason for seeking help now.

Analyzing a Symptom

• Because pain is often the most characteristic symptom denoting the onset of a physical problem, it is used as an example for analysis of a symptom.

• Assessment includes (1) type, (2) location, (3) severity,(4) duration, and (5) influencing factors

Analyzing the Symptom: Pain

TypeBe as specific as possible. With young children, asking the parents

how they know the child is in pain may help describe its type, location, and severity.

For example/ • a parent may state, “My child must have a severe earache because

she pulls at her ears, rolls her head on the floor, and screams. Nothing seems to help.”

• Help older children describe the “hurt” by asking them if it is sharp, throbbing, dull, or stabbing.

• Record whatever words they use in quotes.

Analyzing the Symptom: Pain

Location

• Be specific. “Stomach pains” is too general a description.

• Children can better localize the pain if they are asked to “point with one finger to where it hurts”

• or to “point to where Mommy or Daddy would put a Band-Aid.”

• Determine if the pain radiates by asking, “Does the pain stay there or move? Show me

with your finger where the pain goes.”

Analyzing the Symptom: Pain

Severity• Severity is best determined by finding out how it

affects the child’s usual behavior.

• Pain that prevents a child from playing, interacting with others, sleeping, and eating is most often severe.

• Assess pain intensity using a rating scale, such as a numeric or FACES scale.

Analyzing the Symptom: Pain

Duration

• Include the duration, onset, and frequency.

• Describe these in terms of activity and behavior, such as “pain reported to last all night; child refused to sleep and cried intermittently.”

Analyzing the Symptom: Pain

Influencing Factors• Include anything that causes a change in the type, location, severity,

or duration of the pain:

(1) Precipitating events (those that cause or increase the pain)(2) Relieving events(those that lessen the pain, such as medications)

(3) Temporal events (times when the pain is relieved or increased)(4) Positional events(standing, sitting, lying down)(5) Associated events

(meals, stress, coughing).

History

• The history contains information relating to all previous aspects of the child’s health status and concentrates on several areas that are ordinarily passed over in the history of an adult.

Past History

To elicit a profile of the child’s previous illnesses, injuries, or operations.

1. Birth history (pregnancy, labor and delivery, prenatal history)

2. Previous illnesses, injuries, or operations3. Allergies4. Current medications5. Immunizations6. Growth and development7. Habits

Birth History

The birth history includes all data concerning

(1) The mother’s health during pregnancy.

(2) The labor and delivery.

(3) The infant’s condition immediately after birth.

• Because prenatal influences have significant effects on a child’s physical and emotional development, a thorough investigation of the birth history is essential.

Birth History Cont

• Because emotional factors also affect the outcome of pregnancy and the subsequent parent–child relationship, investigate:

(1) Crises during pregnancy.

(2) Prenatal attitudes toward the fetus.

Previous illnesses ,injuries, and operations

• When inquiring about past illnesses, begin with a general question such as “What other illnesses has your child had?”

• Ask about injuries that required medical

intervention, operations, and any other reason for hospitalization, including the dates of each incident.

• Focus on injuries such as accidental falls, poisoning, choking, or burns.

Taking an Allergy History

Has your child ever taken any drugs or tablets that have disagreed with him or her or caused an allergic reaction? If yes,

• Can you remember the name(s) of these drugs?• Can you describe the reaction?• Was the drug taken by mouth (as a tablet or syrup), or

was it an injection?• How soon after starting the drug did the reaction

happen?• How long ago did this happen?• Did anyone tell you it was an allergic reaction, or did

you decide for yourself?

Current Medications

• Inquire about current drug regimens, including vitamins, antipyretics (especially aspirin), antibiotics, antihistamines, decongestants, and herbs and homeopathic medications.

• List all medications, including their names, doses, schedules, durations, and reasons for administration.

Immunizations

• A record of all immunizations is essential. Because many parents are unaware of the exact name and date of each immunization, the most reliable source of information is a hospital, clinic, or private practitioner’s record.

• All immunizations and “boosters” are listed, stating(1) the name of the specific disease, (2) the number of injections,(3) the dosage (sometimes lesser amounts are given if a reaction isanticipated), (4) the ages when administered, and (5) the occurrenceof any reaction after the immunization.

Growth and Development

The most important previous growth patterns to record are:• Approximate weight at 6 months, 1 year, 2 years, and 5 years of age• Approximate length at ages 1 and 4 years• Dentition, including age of onset, number of teeth, and symptomsduring teething

Developmental milestones include:• Age of holding up head steadily• Age of sitting alone without support• Age of walking without assistance• Age of saying first words with meaning• Present grade in school• Scholastic performance• If the child has a best friend• Interactions with other children, peers, and adults.

Habits

• Habits are an important area to explore. Parents frequently express concerns during this part of the history.

• Encourage their input by saying, “Please tell me any concerns you have about your child’s

habits, activities, or development.”

Sexual history

• The sexual history is an essential component of adolescents’ health assessment.

• The history uncovers areas of concern related to sexual activity alerts the nurse to circumstances that may indicate screening for sexually transmitted infections or testing for pregnancy or need for sexual counseling.

Family Medical History

• To identify genetic traits or diseases that have familial tendencies and to assess exposure to a communicable disease in a family member and family habits that may affect the child’s health, such as smoking and chemical use.

Family Structure

• Family assessment is the collection of data about the composition of the family and the relationships among its members.

Ask(1) family composition

(2) home and community environment

(3) occupation and education of family members

(4) cultural and religious traditions

Family compostition

NUTRITIONAL ASSESSMENT

• To elicit information on the adequacy of the child’s nutritional intake and needs

1. Dietary intake

2. Clinical examination

• Anthropometry, an essential parameter of nutritional status, is the measurement of height, weight, head circumference, proportions, skin fold thickness, and arm circumference in young children.

• Height and head circumference reflect past nutrition, and weight, skin fold thickness, and arm circumference reflect present nutritional status

Growth and Development

NUTRITIONAL ASSESSMENT

• Dietary Reference Intakes (DRIs) are a set of four nutrient basedreference values that provide quantitative estimates of nutrient intake for use in assessing and planning dietary intake (AmericanAcademy of Pediatrics, 2009).

The specific DRIs are:Estimated Average Requirement (EAR)—Nutrient intake estimatedto meet the requirement of half the healthy individuals (50%) fora specific age and gender groupRecommended Dietary Allowance (RDA)—Average daily dietaryintake sufficient to meet the nutrient requirement of nearlyall (97%–98%) healthy individuals for a specific age and gendergroupAdequate Intake (AI)—Recommended intake level based on estimatesof nutrient intake by healthy groups of individualsTolerable Upper Intake Level (UL)—Highest average daily nutrientintake level likely to pose no risk of adverse health effects; as intakeincreases above the UL, risk of adverse effects increases.

NUTRITIONAL ASSESSMENT

Review of Systems

• The review of systems is a specific review of each body system following an order similar to that of the physical examination.

• Begin the review of a specific system with a broad statement such as “How has your child’s general health been?” or “Has your child had any problems with his eyes?” If the parent states that the child has had problems with some body function.“Tell me more about that.”

General

• Overall state of health, fatigue, recent or unexplained weight gain or loss (period of time for either), contributing factors (change of diet, illness,altered appetite),

• Exercise tolerance, fevers (time of day), chills, night sweats(unrelated to climatic conditions), frequent infections, general ability to carry

out activities of daily living.

Integument

• Pruritus, pigment or other color changes, acne, eruptions, rashes(location), tendency for bruising, petechiae, excessive dryness, general texture.

• disorders or deformities of nails, hair growth or loss, hair color change (for adolescents, use of hair dyes or other potentially toxic substances,such as hair straighteners)

Head and eye

• Head—Headaches, dizziness, injury and size.

• Eyes—Visual problems (behaviors indicative of blurred vision, such as bumping into objects, sitting close to television, holding a book close to face, writing with head near desk, squinting, rubbing the eyes, bending head in an awkward position), cross eyes (strabismus), eye infections, edema of the eyelids, excessive tearing, use of glasses or contact lenses, date of last optic examination.

Ears, Nose and Mouth

• Ears—Earaches, discharge, evidence of hearing loss (ask about behaviors, such as the need to repeat requests, loud speech, inattentive behavior), results of any previous auditory testing.

• Nose—Nosebleeds (epistaxis), constant or frequent runny or stuffy nose, nasal obstruction (difficulty breathing), alteration or loss of sense of smell

• Mouth—Mouth breathing, gum bleeding, toothaches, tooth brushing, use of fluoride, difficulty with teething (symptoms), last visit to dentist (especially if temporary dentition is complete), response to dentist.

Throat, Neck and chest

Throat—Sore throats, difficulty swallowing, choking (especially when chewing food; may be from poor chewing habits), hoarseness or other voice irregularities.

Neck—Pain, limitation of movement, stiffness, difficulty holding head straight (torticollis), thyroid enlargement, enlarged nodes or other masses.

Chest—Breast enlargement, discharge, masses, enlarged axillary nodes (for adolescent girls, ask about breast self-examination).

Respiratory

• Chronic cough, frequent colds (number per year), wheezing, shortness of breath at rest or on exertion, difficulty breathing, sputum production, infections (pneumonia, tuberculosis),

• Date of last chest x-ray examination, skin reaction from tuberculin testing.

Cardiovascular and Gastrointestinal

• Cardiovascular—Cyanosis or fatigue on exertion, history of heart murmur or rheumatic fever, anemia, date of last blood count, blood type, recent transfusion.

• Gastrointestinal (questions in regard to appetite, food tolerance, and elimination habits are asked elsewhere)—Nausea, vomiting (not associated with eating; may be indicative of brain tumor or increased intracranial pressure),jaundice or yellowing skin or sclera, belching, flatulence, recent change in bowel habits (blood in stools, change of color, diarrhea or constipation)

Genitourinary

• Genitourinary—Pain on urination, frequency, hesitancy, urgency, hematuria,nocturia, polyuria, unpleasant odor to urine, force of stream, discharge , change in size of scrotum.

• date of last urinalysis (for adolescents, sexually transmitted infection, type of treatment; for male adolescents, ask about testicular self-examination).

Gynecologic

• Menarche, date of last menstrual period, regularity or problems with menstruation, vaginal discharge, pruritus(ITCHING).

• Date and result of last Papanicolaou(Pap)test

• If sexually active, type of contraception.

• sexually transmitted infection and type of treatment.

• Musculoskeletal—Weakness, clumsiness, lack of coordination, unusual movements, back or joint stiffness, muscle pains or cramps, abnormal gait,deformity, fractures, serious sprains, activity level.

• Neurologic—Seizures, tremors, dizziness, loss of memory, general affect,fears, nightmares, speech problems, any unusual habits.

• Endocrine—Intolerance to weather changes, excessive thirst or urination,excessive sweating, salty taste to skin, signs of early puberty.

Physiologic Measurements

• Physiologic measurements, key elements in evaluating physical status of vital functions, include temperature, pulse, respiration, and BP.

• Compare each physiologic recording with normal values for that age group

Temparature

• Temperature is the measure of heat content within an individual's body.

• The core temperature most closely reflects the temperature of the blood flow through the carotid arteries to the hypothalamus.

• Sites: Oral,axillary ,ear based(Aural),rectal, Temporal Artery(An infrared sensor probe scans across forehead, capturing heat from arterial blood flow).

PulsePulse

A satisfactory pulse can be taken radially in children older than 2 years of age.

• However, in infants and young children, the apical impulse(heard through a stethoscope held to the chest at the apex of the heart)is more reliable.

• Count the pulse for 1 full minute in infants and young children because of possible irregularities in rhythm. However, when frequent apical rates are necessary,use shorter counting times (e.g., 15- or 30-second

intervals).

Respiration

Respiration

• Count the respiratory rate in children in the same manner as for adult patients.

• However, in infants, observe abdominal movements because respirations are primarily diaphragmatic.

• Because the movements are irregular, count them for 1 full minute for accuracy.

Blood Pressure

Blood Pressure

• Blood pressure measurement by noninvasive methods is part of a routine vital sign determination.

• Measure BP annually in children3 years of age through adolescence and in children with symptoms of hypertension, children in emergency departments and intensive care

units, and high-risk infants

References

• Marilyn J.Hockenberry,David Wilson ,2009,Essentials of Pediatric Nursing,(8)Edition.PP95-143.