week 11: paediatric assessment Flashcards
collecting data in general
Observations: Very large part; relates to how they’re feeling. For kids, playing is the largest sign of being okay; it’s bad if they aren’t playing
Interview Parent: Believe the parent if they say something’s wrong - keep an eye on the child; parents know their kids best and we rely on that info
Interview Child: If developmentally appropriate
Physical Assessment: Objective data
pediatric age classifications
Paeds goes from 0 (birth) - 18 years
12+ = physiologically similar to adults, 7 and under is where most variations are
Neonate: 0-1mo
Infant: 1-12mo
Toddler: 1-3yrs
Preschooler: 3-6yrs
School Age: 6-12yrs
Adolescent: 12-18yrs
principles of communication w children
Include the child; use their name or what they prefer to be called
Make communication developmentally appropriate: if they’re 5 but function at a 2 year old level, nurse them at a 2 year old level
Get on their eye level - Seen as equal rather than authoritarian; more comfortable
Assessments might be improvised; in parents arms, on the floor playing
Approach child quietly, gently, and be truthful: Ex., BP cuff is a “tight hug”
A needle: Will only hurt for a really short time and you’ll get a sticker after
Give the child choices as appropriate; introduce play - like the temperature thing or listening to their own heart - so long as it doesn’t take away from the assessment
Involve the child and pay attention to them
“normal” growth and development
Kids the same age can be at very different stages
Growth charts show percentiles to show if you’re concerned or not; look at the whole curve
They could even be completely normal regardless
Also consider culture, parent stature/height
piaget’s theory of cognitive development
Piaget’s Theory of Cognitive Development: Important w.r.t physical head-to-toe capabilities
Sensorimotor Stage: 0-2 yrs; object permanence, A-not-B error
Preoperational Stage: 2-6/7 yrs; egocentrism, lack of conservation
Concrete Operational: 7-11/12yrs; understanding perspectives, conservation, categories
Formal Operational: 12+yrs; abstract thinking, scientific reasoning
erikson’s psychosocial stages of development
Infant mental health, long-term outcomes in general
Life is a series of crises that are overcome to progress, develop from infancy to maturity
when approaching the paediatric patient
Always start with observing
Tends to be improvised with little order; can never just dive into the assessment
Remain calm, confident - kids love to push buttons if you’re panicking
Toddlers: No is their favourite word; don’t give them the choice
Don’t separate the parent and child if you don’t have to; use parent as resource
Establish rapport with parents AND child; parents are there to help
Be honest
tips w infants
WAHHHH is their favourite word - QUIET assessments
Parent should be nearby or holding baby, or in the crib
DON’T wake a sleeping baby unless concerned; depends on the situation and assessments are easier while the kid is sleeping; resp, HR - don’t do invasive ones
The second the baby cries = altered assessment, inaccurate
Comfort measures like pacifier, time assessments around feedings
tips w toddlers
NO is their favourite word - PLAY is big
Get the parents there to help; keep on lap, distract them
Greet by their name and pay attention to the parent
Use play therapy! Whatever toys, trucks, etc. are there
Infants love the “me do, me do” thing; let them play with equipment, BP cuff, stethoscope
Pay attention to their non-verbal behaviours
Praise the kids and give them choices, “what a good kid!” - parents and kids love it
Demonstrate what you’re gonna do on the parent, yourself, or on a doll first
tips w preschoolers
WHY is their favourite word - HELP with assessment
Increase verbal communication but keep it simple
Get them to “help” with their own assessments; hold the measuring tape, stethoscope
Use games
tips w school-age kids
May experience “developmental regression” - they might be 7 but act like they’re 4 because they’re scared of the unknown, retreat back to parents
Give them choices if the parent is present, but keep it appropriate
Use small talk for older kids when appropriate; school, friends, hobbies
Explain procedures and equipment so there are no surprises
Be patient and honest, get parents to help
tips w adolescents
PRIVACY is their big thing
Provide reassurance about their changing bodies; pull the curtains, ask if it’s okay for the parents to be there, put the stethoscope under shirt instead of lifting it up
Opportunity to provide information, health teaching, positive attitudes
When communicating, they’re not kids but they’re also not adults - be appropriate
pediatric measurements
Height/Length: From top of head to dorsiflexed foot, as straight as you can
Weight: Naked baby, zeroed scale (babies might pee when exposed to cool air)
Do before a feed; food weight throws it off
Head Circumference: Until 3 years; from frontal bone to occipital prominence (back of head)
Chest Circumference: Until 1 year; right below nipple line for babies
USE A CLEAN MEASURING TAPE
pediatric temp
Use axillary; halfway under arm and gentle pressure or up into armpit
DO NOT do rectal, tympanic (improper)
Oral around 5 years if they can hold it under their tongue
pediatric pulse
Apical before 2 years of age; one full minute because kids are arrhythmic
Landmark: <4 years = 4ICS, between LMCL and Anterior Axillary Line
After 4 years, use 5ICS LMCL - or radial pulse if you can feel it
Paediatric stethoscope makes it more precise
pediatric resp rate
Usually while sleeping for babies; one full minute, kids breathe weird
They only use the diaphragm, not as efficient, may have apneic periods
Note the depth; if there’s indrawing anywhere (Suprasternal, Clavicular, Intercostal, Subcostal, Substernal), Tracheal Tugs
pediatric blood pressure
In hospital, machines are standard (but we’ll do it manually)
Don’t pump too high; just look at high of the chart
Use the right sized cuff and ONE STEP ONLY kids will hate you
Not fully necessary; 1BP/shift for comparison; can do arm or leg for infants
pediatric pain
Subjectively or Objectively
Pay attention to non-verbal behaviours, changes in vital signs from base
Wong-Baker Faces scale, 0-10, NIPS observations, other pain scales
pediatric head/face considerations
Symmetry
FONTANELLES: Anterior and posterior; feeling by running fingers across middle of head
Could be soft/flat (ideal, can feel a pulse), sunken (dehydration), bulging (high ICP)
Anterior closes after 12-18 (9mo-2yrs) months; abnormal if still open
Posterior closes after 2-3 (1-2) months
Feel for sutures as well
pediatric eyes
Observe colour, pupillary reflexes (reactivity, size), symmetry, eye movements
Red-reflex, strabismus (cross-eyed), have they had vision screening (5yo+)
pediatric ears
Inspect/Palpate external ears - infections are common because of horizontal eustachian tubes
Pull pinna down and back to straighten ear canal for <3 years; adults is pull up and back
pediatric cardiovascular
BP, HR, Resp (done), Skin (done), Cap refill (done)
PMI - Point of Maximal Impulse (Apical); 4ICS, lateral to MCL from 0-7yrs
6+ = Older kids, 5ICS LMCL
Heart Sounds: Auscultate heart valves for S1/S2, murmurs, friction rub
Chest Shape: Round in children, Oval in infants, Flat in Adolescents - abnormal is barrel, asymmetrical
Peripheral Pulses if you can palpate them; unlikely to feel pedis, radial, brachial in <2
pediatric respiratory
RR done
Auscultate anterior and posterior lung fields
Lung sounds sound different because chest wall is so thin
Lungs go down to 7th rib only
Other:
Cough with description (productive, dry, etc.), Secretions, O2 Sats
Suctioning: Possible; needs to be reasonable because linings are small and irritable
pediatric GI/Abdomen
Abdomen shape; soft, round, flat, based on age, umbilicus status
Bowel sounds - listen for 5 minutes to determine no sounds
Extra stuff:
Flatus (farts)
Stools for colour, consistency, amount, frequency, blood, mucous
Breastfed = Yellow mustardy stools, rare to be constipated; different with formula
Diet toleration type (NG, G tube, NPO, etc.), Appetite
Emesis (vomit): Colour, consistency, amount, frequency, blood, bile
Colostomy/Ileostomy: Amount, stoma, colour, consistency
Buttocks and Spine
Spina bifida (spinal cord protrudes as a bulge)
Patent anus - is it an open hole where things can pass through?
pediatric GU
Intake/Urine output (accurate, weigh # wet diapers, 12/24 hour balances)
Must measure all ins/outs, be on the lookout for UTI
Urine: Colour, odour, clarity, sediment, blood
Pain with urination (could be UTI; if baby cries while peeing)
Catheterization: Hard; small urethra, straight drainage
pediatric external genitalia
Not looked at unless there’s a reason - can be upsetting for teens
Signs of precocious puberty (hair, breasts, etc. too early)
Rashes, descended testicles, vaginal discharge, patent anus
pediatric MSK
Inspect arms, legs, joints for symmetry
Coordinated movements
Range of motion/Muscle strength for older kids
Tractions/Casts: Stuff for injuries that you don’t have to worry about
Tone (Floppy, Hypotonic, Hypertonic)
Babies like to stay in fetal position: Should be able to take them out easily and they slowly go back; hypertonic = hard to remove them, go straight back, hypo = floppy
pediatric neurological
Level of Consciousness: Are they alert? Aware of their surroundings? Orientation if appropriate; if younger - responding to cues, purposeful movements, eye contact
Interest in environment for babies
Communication: Speech if older
Cries: Should be strong and lusty; high-pitched = bad, high ICP, weak = low tone
Behaviours/Development as age appropriate
Ambulation: Ability to walk independently; average is 15 months***
Balance, Coordination, and Gait where appropriate (Romberg)
Modified GCS if appropriate
Strength of Suck: Could be normal, hypotonic, hypertonic - should be able to remove finger
Muscle tone
Rooting reflex
3-4mo
Stroke side of cheek; baby turns head
sucking reflex
10-12mo
Baby sucks on anything put into mouth
palmar grasp
3-4mo
Put fingers in hands and baby grabs it
plantar grasp
8-10mo
Touch ball of foot and toes curl
tonic neck
3-4mo
Turn head and arm goes out, other hand goes up (“Fencer”)
moro/startle reflexes
3mo
“Dropping” baby will make them reach out, throw out hands
stepping reflexes
2mo
Hold them up and they will “walk”
babinski reflexes
2yrs
Stroke bottom of foot and big toe raises, toes fan out
