Physical-Assessment PDF

Preview

Summary

Physical-Assessment...

Description

PEDIATRIC ASSESSMENT: FOCUS ON PHYSICAL ASSESSMENT CLASS 8

Pediatric Assessment: The Major Focus Major differences between children and adults Specific approaches and techniques to physical exam Normal findings, variations and common pathological conditions Interpretation of exam results

Major Concepts in Pediatric Physical Assessment Children are not little adults Understanding differences from adults is important Differences relate to both growth and development patterns Differences exist in motor skills and coordination, and in physiologic, psychosocial, behavioral, temperamental, language, and cognition areas

Skills Utilized in Working with Children Knowledge of growth and development Communication skills with children and their parents Understanding of family dynamics and parent-child relationships Knowledge of health promotion and anticipatory guidance

Major Concepts for Assessment and Health Promotion Development Medical history Nutritional status Growth and vital sign measurements Physical assessment Guidelines for well child supervision Anticipatory guidance Immunizations

1

Exam Settings Outpatient (office, clinic emergency room) Well child check Illness visit Inpatient Moderate to severe illness Anxiety and stress School setting or health office Children usually healthy Illness visits primarily common acute problems and some chronic illness issues Health screenings

Environmental Setting Safety is primary Pleasant, comfortable settings are helpful Accessible toys fo r young children are distracters and may reduce anxiety Age appropriate literature or items for teens and older children provide diversion in waiting areas

Standard Measurements Weight Height Head Circumference Chest Circumference Vital Signs Temperature Pulse, Heart Rate Respiration Blood Pressure Gestational Age Assessment and Intrauterine Growth Charts

Sensory Issues Smell: usually not tested; observe for unusual odors from child Taste: usually not tested; infants often prefer sweet tasting foods Touch: well developed in infant; if stimulated can invalidate other sensory tests Vision: right eye (OD), left eye (OS), both eyes (OU) Hearing: correlates with language development; localization requires both ears

Specific Evaluations Development Vision Hearing Language

2

Key Points to Assessment Procedure Head to foot exam is most orderly Vary sequence according to child’s response Examine young children in parent’s lap Do intrusive examinations last

Approach to Physical Exam Consider age and developmental level; observe for “readiness” clues Take time to get “acquainted” Use play techniques for infants and young children Determine best exam place ( table, parent’s lap, examiner’s lap) Use systematic approach; but be flexible to accommodate child’s behavior Examine least intrusive areas first (i.e., hands, arms) Examine sensitive, painful or intrusive areas last (i.e. ears, nose, mouth) Determine what exam you want to complete before possible crying (i.e. heart, abdomen)

Age Groups Neonate/Newborn Pre-term Term Post-term Infant Young, Immobile Older, Mobile Young Child Toddler Pre Schooler School Age or Older Child Adolescent Pre-Adolescent

Birth to 28 days Gestational age 42 weeks Birth to 1 year Birth to 6 months 6 to 12 months 1-5 years 1-3 years 3-6 years 6-12 years 13 to 18/21 years 10-12 years

Approach to Infants Birth to 6 months: If baby is comfortable and stress free, exam can be conducted on table. Sensory methods, such as voice, noise makers, toys to see or touch, or skin touch attract babies. They like a smiling human face. Do quiet things first, then head to toe. 6 to 12 months: Consider exam in parent’s lap due to separation or stranger anxiety (up to 4 years). “Warm up” more slowly with play techniques. Object permanence and ability to anticipate develops, so provide comfort measures after unpleasant procedures. Increased mobility leads to additional safety measures and limit-setting concepts, which continue with each age group.

3

Approach to Toddlers Exam in parent’s lap, due to need for parent security. Play games. Do least intrusive things first. Save ears, nose, throat for last. Avoid “no” responses or choices they can not make. Offer simple acceptable choices. Let them touch equipment.Approach to Pre-Schoolers Keep parent close. Some will cooperate with exam on table. Protect modesty. Use dolls, animals or parents to “examine” first. Magical thinking may cause fearfulness or thinking equipment is alive. Let them play with equipment. Use familiar, safe, non-frightening words and approaches.

Approach to School-Age Child Do a head to toe exam. Respect modesty. Address questions more directly to child. Explain in concrete terms. Medical diagrams or teaching dolls are helpful. Elicit their active participation in history, exam and care plan. Answer questions honestly.

Approach to Adolescents Confidentiality, privacy, protection of modesty are important. Explain confidentiality parameters. Offer to examine alone, without parent present. Address questions to patient. Keep in mind, depression is more common in adolescents, especially girls. More common concerns among girls include body-image distortion, loss of appetite & weight, & lack of satisfaction. More common concerns among boys include irritability, social withdrawal & drop in school performance. A health promotion system such as GAPS, Guidelines for Adolescent Preventive Services can be useful

An Additional Growth and Development Handout is Available to Download This is a 5-page summary, including one chart and additional summaries of pertinent growth and development theories

General Assessment: Key Points Note general appearance State of wellness Degree of illness or distress Behavior

General Assessment: Body:

Symmetry, nutrition, build, hygiene, breath, odor, posture, movement, coordination, facial expression

Behavior:

Development, attitude, affect, responsiveness/awareness, cooperation, speech, LOC (person, place, time), thought process, attention span, concentration, memory

Distress:

Posture, (flexion/extension), pain, facial grimace, respiration

4

Skin, Hair and Nails: Skin – Key Points Color: Texture & Turgor: Edema: Birth Marks Pigmentations: Infectious lesions: Capillary bleeding: Infestations: Pruritis: Trauma: Hand:

Jaundice, pallor, cyanosis, erythema, ecchymosis Degree of hydration or dehydration Periorbital (crying, allergies, renal disease, juvenile hypothyroidism) Dependent (renal or cardiac disease) Hyperpigmentation (endocrine, growth dis turbance); hypopigmentation Viral, bacterial, fungal (erythema, macule, papule, vesicule, pustule) Petichiae and purpura usually indicate serious conditions Pediculosis, scabies, insect bites Dry skin, allergy, eczema, contact dermatitis, hepatic, renal, lesions Scars, ecchymosis, signs of abuse Dermatoglyphic variations associated with syndromes

Common Skin Variations in Newborns and Infants Thin, transparent skin, especially premature Color Variations Vascular Markings Pigmentations Lanugo (downy hair) more prominent in premature Original hair may shed at 4-8 weeks, and be replaced

Skin Color Variations Jaundice: Acrocyanosis Cutis marmorata Erythema toxicum Harlequin color change Milia Miliaria (4 types) Neonatal acne, prickly head Pallor Plethora

Pathologic in first 24 hrs. physiologic after 24 hrs. Cyanotic, cool extremities; warm, pink trunk Bluish mottling due to chilling or stress Papules, vesicles on erythematous base @24-48 hrs. Lower side of body red, upper side pale – change reverses it White papular epidermal cysts with sebaceous retention Obstruction of sweat ducts from head and humidity Miliaria – crystallina, rubra, pustulosa, profunda Anemia or anoxia Erythematous flush, due to polycythemia

Skin Vascular Markings Capillary hemangiomas (telangiectasia or telangiectataic nevus or nevus simplex --- “stork bites,” “angel kisses”) --- usually fade Nevus flammeus (“port wine stains”), nevus vasculosis ---not likely to fade Can be associated with Sturge-Weber Syndrome Strawberry hemangioma: bright red, lobulated tumor

5

Cavernous hemangioma: bluish red, more vascular than strawberry Skin Pigmentations Mongolian spots in d arker pigmented infants Pigmented nevi, Café au Lait ( girls Hip or knee pain May have history of trauma + Trendelenburg Slipped Capital Femoral Epiphysis Adolescents: boys > girls Obese Hip or knee pain Joint infection

Feet/legs: Variations may begin in feet, tibia or upper let & hip area Feet turning in: varus Feet turning out: valgus Legs: Bowleg (genu varum -- knees 2 inches apart) Knock-knee (genu valgum -- ankles 3 inches apart) Movement limitation: crepitus with joint movement meningeal signs, such as stiff neck, opisthotonous Muscular dystrophy Progressive muscular weakness (Gower’s sign) Cerebral palsy or other muscular disease Pes equinus (weight bearing on toes) Short heel cords

Neurological Evaluation: Key Points Cerebral Function: "Mental status" appearance, behavior, cooperation LOC, language, emotional status, social response, attention span

Cerebellar Function Balance, gait & leg coordination, ataxia, posture, tremors Finger to nose (fingers to thumb) 3-4 yrs Finger to examiner's finger 4-6 yrs Ability to stand with eyes closed (Romberg) 3-4 yrs Rapid alternations of hands (prone, supine) school age Tandum walk 4-6 yrs Walk on toes, heels school age Stand on one foot 3-6 yrs

Motor Function: Gross motor & fine motor movements Muscle size, symmetry, strength, tone, movement Involuntary movements, posture Developmental maturation

18

Sensory function Tested in cranial nerves Sharp-dull 2 point discrimination Stereognosis Graphesthesia Infants: responsive to touch, vision, hearing, smell Present only one sensory stimulation at a time, if testing Reflexes Deep tendon: Biceps C5, C6 Triceps C6, C7, C8 Brachioradialis C5, C6 Patellar L2, L3, L4 Achilles S1, S2 Superficial: Cremasteric T12, L1, L2 Abdominal T7, T8, T9, T10, T11 Infant Automatisms: Primitive Reflexes Cranial Nerves C1 Smell C2 Visual acuity, visual fields, fundus C3, 4, 6 EOM, 6 fields of gaze C5 Sensory to face: Motor--clench teeth, Corneal reflex---is C5 & C7 C7 Raise eyebrows, frown, close eyes tight, show teeth, smile, puff cheeks, Taste--anterior 2/3 tongue C8 Hearing & equilibrium C9 "ah" equal movement of soft palate & uvula C10 Gag, Taste, posterior 1/3 tongue C11 Shoulder shrug & head turn with resistance C12 Tongue movement Infant Reflexes: Most disappear between 4-6 months of age Blink (dazzle) st Blinks to bright light, 1 year of life, absence indicates blindness Root Turns direction cheek is stroked, disappears 3-4 months, may persist longer, absence indicates neruologic disorder Suck Sucks in response to stimuli, may persist during infancy, weak or absent reflex indicates developmental/neurological disorder Extrusion Tongue extends out when t ouched, disappears at 4 months, persistent extrusion may indicate Down’s Moro & Startle Arms & legs extend symmetrically & arms return to midline, when stimulated by position change or sudden noise, disappears by 4-6 months, absence or asymmetry of responses indicate injury, neurological disorder or hearing loss

19

Galant's (trunk incurvation) Back moves toward paraspinal side stimulated, present for 4-8 weeks, absence may indicate spinal cord lesions Dance or step Feet withdraw or step up, when foot touched to surface, present 4-8 weeks, persistence indicates neurological problem Palmar grasp Finger’s curve around object placed in palm or palmar aspect of fingers, disappears 3-4 months, persistence indicates neurologic disorder Tonic neck Fencing position: head turn-arm extend, leg extend to same side & all reverse with change to opposite side, appears strongest at 2 months & disappears by 6 months, persistence indicates neurological problem Neck righting When supine, shoulders, trunk pelvis turn to direction head is turned, absence or persistence beyond 6 months indicates neurological disorder Crawling Symmetrical crawling movements when prone, asymmetries indicate neurological disorder Babinski + for toe fanning, present until child walks well, or at 2 years of age

20

21...