ATI PEDS physical assessment PDF

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Accepted Practice Pediatric perspective When conducting physical examinations of children from birth through adolescence, there are quite a few unique considerations to keep in mind. Approach these differences by first establishing a rapport with the child and the family. Take some time to get acquainted with them. Establish a warm, safe, cheerful, and private environment. Remember that parents and other adults provide a critical link to understanding a child’s health. They are the primary source of information about the child and often help the child accept and cooperate with the examination. Listen to them when collecting data. It is essential to remember that parents will be responsible for carrying out the plan of care; therefore, they must know and understand that plan. For families who speak another language, include adequate interpretive skills or an appropriate interpreter in your physical examination “tool kit.”

Engage the parent and the child. Talk with the parent about how the child copes with new or stressful situations. Find out if the child has any experience with healthcare situations. Ask what the parents have told the child to expect at a healthcare visit, then observe the child carefully for readiness to engage with you during the examination. Include the child in the conversation to whatever extent is appropriate. Allow the parent to participate at whatever level is comfortable for the parent and for the child. Organize your examination. Consider the sequence of the steps of your examination and the attention span of the child. Perform the least invasive procedures first and the steps that might feel strange or uncomfortable for the child last. If the child will not participate in the conversation, talk with the parent. Try complementing the child for information the parent shares or for things the child can do to help draw the child into the experience.

Involve the child. Sometimes, playing a game will help a child relax and work with you. Try speaking in the third person, for example (for young children), “Little boys sometimes think it tickles when I listen to their tummy.” Explain each part of the examination to the child (and to the parent). Use concrete terms to describe what you are doing. Say, “I’m going to look in the back of your throat,” not, “I need to see your tonsils.” Encourage the child to ask questions during the examination, but do not pressure him. Take every opportunity to “teach” the child and parent about the human body in language that is simple and suitable for the child’s developmental level. Do not give the child more than three pieces of information about what you are going to do at any one time.

Keep a steady pace. Do not make rushed movements during the examination, especially toward the child. Work at a pace that is comfortable for the child. If he is anxious about one part of the examination, move on and return to that part later. If examining more than one child at a time (siblings), start with the most cooperative child and include the other children in the conversation as you perform the examination. Be honest. Be clear and honest about your expectations. Do not offer choices if there are none. Say, “I need for you to lie very still while I look into your ears,” not, “If you are ready, I’d like to look in your ears.” And, if necessary, ask for the child’s cooperation. If the child does not cooperate, see if the parent can help. Be sure to praise the child before, during, and after each step, even if the child had difficulty cooperating.

Age by age…

Especially for infants. A primary form of communication with infants involves nonverbal activities such as holding, rocking, and patting. Also important is talking to the infant in a quiet, unhurried, nonthreatening tone of voice. Watching the parents interact with the infant can give you examples of established communication patterns that you can use during the examination. Older infants have strong stranger and separation anxiety, so you might be more successful doing the examination when a parent holds the child. If you do hold an older infant, do it securely to convey a sense of confidence. As much as possible, perform the examination in a manner that allows the infant to see the parent at all times. Have the infant hold a favorite object (toy, stuffed animal, doll, blanket, pacifier) during the examination. Use the distraction of a bright object or a rattle to gain cooperation, if needed. A quiet, higher-pitched voice and smiling and engagement with the infant help promote a quick, efficient, thorough, and nontraumatic examination.

When the child is a toddler. Children in this age group are concrete thinkers who interpret your statements literally. If you tell toddlers you can see all the way through their ears to the other side, they will believe you. A toddler expresses herself through a broad range of nonverbal actions; observe these and take cues from the parent-toddler interaction you observe early in the visit. Monitor the toddler for signs of fear or anxiety and address it immediately in a quiet, soft, relaxed manner while also involving the parent. With this age group, misunderstanding generates an abnormal response of fear or anxiety. To prevent this, use short, concrete instructions and repeat them several times as you prepare to do the examination. Or, make up engaging scenarios, such as checking to see if a little boy has the muscles to be a superhero. Toddlers love dolls and puppets, so incorporate these props into the examination, demonstrating each step on the doll and letting the toddler practice on the doll. It is very helpful to let a toddler touch and play with the equipment before performing the examination. If the child remains uncooperative despite your best efforts, perform the examination as quickly as possible.

Preschooler pointers. Many of the communication skills used for toddlers work well for this age group. Because of ever-expanding verbal communication skills, it is somewhat easier to gain a preschooler’s cooperation for various parts of the examination. Children in this age group like to please and conform, and that makes examining this age group somewhat easier. Again, enlist parental assistance if the child becomes resistant or frightened by the examination. Most preschoolers know the names of quite a few body parts, and you can use this both to gain cooperation and to teach. Preschoolers are very modest, so give them the opportunity to undress themselves for the examination. Encourage them to ask questions during the examination. Make your responses short, specific, and in simple language the child can understand. This is an ideal opportunity to begin to introduce proper terminology as the child demonstrates knowledge of various body parts. Rewards (stickers, small toys) are also effective and can help set the stage positively for future healthcare visits. Working with school-age children. At this stage, children remain concrete thinkers but are becoming more sophisticated. Many have had prior experience with healthcare staff, and it is particularly important to know whether these experiences have been positive or negative before you begin the examination. Do not attempt to rush through your examination. School-age children are sensitive to embarrassment and may fear injury. Explain every step of the examination, especially if the child has not had any prior experience in this type of setting. Children in this stage often respond well to reassurance and praise (for allowing the examination, for cooperation with the examination). Talking in the third person to younger children in this group can be very effective in reducing their anxiety and gaining their cooperation. Explain in simple terms the various parts of the examination and why you are doing each step. This group responds very well to discussion about what you are doing as you do it.

Communicating with adolescents. In this stage, verbal skills are often more sophisticated than behavioral skills. It is important to understand what an adolescent’s prior experiences with healthcare have been as you approach the examination. Following the adolescent’s cues, address fears verbally and directly. Expect the adolescent to use monosyllabic responses plus a wide range of nonverbal expressions, such as anger, reticence, or other behavior that is considered inappropriate in other settings. Be patient and avoid prying, confrontation, continuous and repetitive questioning, and judgmental attitudes. Start the discussion, or refocus it if the examination is not proceeding well, with nonthreatening subjects such as school, friends, sports, or other extracurricular activities. Respect the adolescent’s privacy and emphasize confidentiality. Whenever appropriate, do at least part of the examination and history taking without the parent in the room. This gives the adolescent an opportunity to convey any sensitive issues. However, be aware of any specific state laws about children’s confidentiality and be clear with the adolescent about what you are required to share with parents and others before he discloses anything in confidence. Determine the adolescent’s comprehension level and attempt to confirm understanding throughout the visit. Share your findings as you proceed through the examination and ask him to reiterate what you have said in his own words to confirm accuracy of understanding.

Accepted Practice General patient survey and anthropometric measurements

Components include:  Observe body characteristics and check body mass index, or BMI.

Note facial expression and the presence or absence of distress. Observe hygiene, grooming, and dress. Check for any odors. Evaluate affect (bright, pleasant, anxious, apprehensive, depressed, angry, hostile).  Measure weight, height, head circumference, and body mass index.

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General patient survey

As you greet your patient, begin your general patient survey. The information you obtain from this survey can provide valuable information about the child’s well-being and about the relationship between the child and the parent. Start the survey by taking note of the child’s general appearance and behavior. She should appear well nourished and developed for her age. Note body posture and movement. Be sure to note the child’s facial expression as well. Are there any signs of pain or distress? Note the behavior and tone of voice the parent uses with the child. Is the interaction between the two warm and caring and appropriate for the situation? Does the parent reassure the child and encourage her to interact with you? Observe hygiene, grooming, and dress. Is the child dressed appropriately for the season and the situation? Pay attention to any noticeable odors as well. Finally, note the child’s mood, or affect. Is he smiling and pleasant? Does he appear anxious or apprehensive? Depressed? Is he angry or hostile?

Anthropometric measurements

Growth measurements are an important component of pediatric care. Children are unique and grow at variable rates, thus it is important to measure and plot their weight, height, and head circumference on the appropriate standardized growth charts. The Centers for Disease Control and Prevention has made these charts available for boys and girls, ages 0 to 36 months and 2 to 20 years of age, for height and length, weight, and weight to length and height. For children who are less than 24 months, growth should be plotted on the World Health Organization (WHO) charts. There are also special growth charts for children with specific genetic disorders such as Down syndrome. Each child’s growth is plotted on a curve, and the child should follow the curve consistently through adolescence. Measurements that fall within the 5th to 95th percentiles are considered within the normal range for growth. Standardized growth charts help clinicians assess for trends and compare growth to previous measurements and to that of the child’s peers.

Although standardized charts are valuable, body mass index (BMI) is now used more often in practice today. An indirect measure of body fat, BMI provides a better picture of the child’s growth status. Clinicians use BMI measurements to predict the potential for obesity and to determine whether or not a child is growing adequately. Calculated using a formula that compares height to weight, BMI is included on gender-specific growth charts for children between the ages of 2 and 20 years.

Weight

Infants. Weigh infants on a platform-type scale with clothes and diaper removed. To obtain an accurate weight, be sure to calibrate the scale prior to placing the infant on the scale. Cover the platform of the scale with a clean cloth or a disposable pad before calibrating the scale. For safety while the infant is being weighed, stand next to the scale at all times to make sure the infant cannot roll off, and keep the parent close to the infant to help reduce the infant’s anxiety. Weigh to the nearest ½ ounce and record the weight on the appropriate flow sheet. Toddlers/Preschoolers/School-age children. For children who are able to stand and cooperate with the procedure, use an upright scale. To obtain the most accurate weight possible, the child should only wear underwear. However, because scales are not often in a private area and children may be uncomfortable taking their clothes off to be weighed, this is not always appropriate. Under these circumstances, have them take off their shoes and jacket or coat and record the weight on the appropriate flow sheet.

Adolescents. Use an upright scale to obtain an adolescent’s height. Again, having the adolescent wear as little clothing as possible facilitates obtaining an accurate weight. Because some adolescent girls become preoccupied with their weight and body image, it is important to be aware of the signs and symptoms

of eating disorders, such as anorexia nervosa or bulimia nervosa. Provide education and resources to patients and their parents when you detect any possibility of these disorders.

Height/Length

Infants. To measure the height or length of a child up to the age of 24 months, use a horizontal measuring board. If you are using a birth-to-36-months length-for-age chart, use the board for children up to 36 months of age. If a board is not available, use a measuring tape, but keep in mind that it is less accurate. If you do use a measuring tape, place the infant on a papercovered surface, with the legs fully extended and the head midline. Mark the end points of the top of the head and the heels of the feet on the paper sheet. Pick up the infant and measure between the head and heel marks to obtain the length. For the most accurate measurement, place the infant in a supine position with the head at midline and the legs flat on the table. Because this is not a normal position for an infant, gently hold the infant in place until the measurement is taken.

Toddlers/Preschoolers/School-age children. Measure height using a stadiometer and be sure to use the appropriate grid (stature for height) chart. Encourage the child to stand straight and tall and to look straight ahead. Make sure the child’s head, shoulders, and heels touch the wall. The measuring device should sit gently on the top of the child’s head. The number just under the measuring device is the child’s height; measure to the nearest 1/8 inch.

Adolescents. Use a stadiometer to measure an adolescent’s height. As with toddlers and preschoolers, encourage the adolescent to stand straight and tall with his head, shoulders, and heels touching the wall. The number just below the measuring device is the height to record.

Head circumference

Infants. Head circumference should be measured at birth and at every checkup up to 36 months of age and the measurements plotted on the appropriate growth grid. Place the tape measure around the widest part of the infant’s head, which is slightly above the eyebrows and the pinna of the ears and around the occipital prominence at the back of the skull. Head circumference is noted to increase by 1.5 cm/month in first 6 months and then drops to 1.25 cm/month. Be sure to measure to tenths of a centimeter, because the percentile charts have grids with 0.5 cm.

Toddlers/Preschoolers/School-age children. Head circumference is generally measured up to 36 months of age, and beyond if the child’s head size is questionable or the child has physiologic problems such as hydrocephalus. When measuring head circumference, place the tape measure around the widest part of the child’s head, which is slightly above the eyebrows and the pinna of the ears and around the occipital prominence at the back of the skull. A toddler’s head circumference generally increases by about 1 inch during the second year and about 1.25 cm/year until age 5. Adolescents. Measuring head circumference is not a routine part of the physical examination for this age group.

Accepted Practice Vital signs

Components include:  Measure temperature.  Assess pulse.  Evaluate respiration.  Measure blood pressure.

Overview

After conducting a general survey, take the physiologic measurements essential for the data-collection portion of the physical assessment of your pediatric patient. Many clinicians begin by measuring height (or for infants, length), head circumference for children up to the age of 3 years, and a body mass index. (For more information about growth measurements, see the accepted practice section that covers this area of physical assessment.) In some healthcare settings, pain and oxygen saturation are also considered vital signs and may also be measured depending on the reason the child needs healthcare. (These parameters will also be covered in more depth in this and other skills modules.) How you measure a child’s vital signs varies to some extent with the age of the child. For example, when your patient is an infant, it is best to count respirations first. If you take the infant’s temperature first, you have to “disturb” him, and, if he cries in response to that procedure, you won’t obtain an accurate baseline respiratory rate. If your patient is a preschooler, it is important to be as noninvasive as possible. At this stage, children fear intrusive procedures, so an axillary or a tympanic temperature measurement is usually a better choice than a rectal measurement. It is essential to use critical thinking when evaluating vital sign numbers with normal ranges for age and correlating them with your general physical assessment of the health status of the patient. The normal ranges for heart or respiratory rate might not be appropriate for an acutely ill patient and vital signs within those ranges could actually reflect deterioration. For example, a 3-yearold child with asthma who has had a heart rate of 150 and a respiratory rate of 44 but on retake of vital signs has a normal heart rate of 100 and a respiratory rate of 20 may be “tiring out” and respiratory failure might be imminent. Vital sign numbers alone have little meaning; you must analyze them critically for individual patients. Findings such as a rapid heart rate may be related to pain, fever, or anxiety. An elevated skin temperature may be due to excessive bundling or overdressing of an infant. It is also important to compare your findings with measurements documented at previous assessments, as well as with the normal ranges of vital signs for the particular age group.

Temperature

Body temperature is more variable in infants and children than it is in adults. There is some controversy about the optimal method of measuring temperature in children. Core body temperature provides the most accurate and useful data, and the rectal route is most reflective of core temperature. It can be used for children of all ages (although it is no longer standard procedure for newborns), but it is not without risks. It is invasive, and therefore can be upsetting for many children, so you have to weigh the need for absolute accuracy agains...