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Physical Assessment & Medication Documentation Spring 2008 Susan Beggs, RN MSN Common considerations • Communication strategies • Identifiers • Questioning of the child or parent • Strategies to gain cooperation • Removing distractions • Privacy • Awareness of growth and development milestones Types of health histories • Data from birth to current status (the complete history) • Well history • Problem-oriented history • Psychosocial data • Daily routines, issues that impact daily living Beginning the assessment Exam begins with the 1st mtg All measurements are taken: wt, ht, head circumference Should be plotted to obtain the percentile Review of symptoms Developmental approach to the exam Young child: foot to head Older child: head to toe Exam techniques Vary by the age of the child Build rapport with the family Develop cultural competence Involve the child in the interview if age appropriate Be honest with the child when answering questions Utilize “careful listening” Nursing Practice techniques for physical assessment Inspection Palpation Auscultation Percussion Normal findings in children Small, firm, nontender, and shotty lymph nodes may be palpable Tonsils of varying sizes; often larger in young children Pupils of equal size, round and reactive to light and accommodation Pulses in upper and lower extremities; bilaterally symmetric Terminology for head shape Normocephalic Microcephalic Macrocephalic Bossing Physical exam Skin: perfusion, turgor, color, lesions Hair: distribution, loss, lice, pubic areas Head/skull: symmetry, circumference, sutures in infants Eyes/ears: *red reflex, TM, muscles of the eye, lacrimal glands, conjunctiva Physical exam, cont. Lips, tongue, gums, palate, teeth Neck: movement, nodes, thyroid Chest: shape, movement, effort, function A B Funnel chest (Pectus excavatum) pigeon chest (pectus carinatum) Physical Assessment Heart sounds: murmurs, apical rate, arrhythmias, blood pressure, and rhythm Abdomen: shape, bowel sounds, underlying organs Genitals: Preparation for the exam crucial! Include the anus and rectum, assessment for pubertal development and sexual maturity Physical Assessment, cont. Musculo/skeletal system: one and joints, ROM, strength, posture, spinal alignment Inspection of the limbs Nervous system: cognition, balance, CN function, language, reflexes Physical exam of darkskinned children Erythema: dusky red or violet Cyanosis: black or dusky Jaundice: diffusely darker than the child’s normal color Psychosocial Assessment Home environment Employment and education Eating Activities Drugs (substance use) Sexuality Suicide/depression Safety Concluding the exam What questions should be asked at the end of every interview? Ask yourself… What if a 14 year old girl weighs 93 lbs. Would the nurse be concerned? What if she weighed 110 lbs 6 months earlier? What if a year earlier she had weighed 105 lbs? Ask yourself…. A 2 yr old child being seen for well check is resistant to the exam. What techniques would be helpful for the nurse to use with a toddler? Another challenge…. Kelly, aged 15 months, comes in for a well child check. How would the nurse assess height and weight? Suspicions of child abuse/neglect detected during assessment Dress Grooming and personal hygiene Posture and movements Body image Speech and communication Facial characteristics and expressions Psychologic state Critical thinking after the exam Compiling the data Describing the elements of the health history Modifying assessments based on ages Determining the sexual maturity Recognizing 5 important signs of a serious alteration that require urgent attention Critical thinking exercise Leah, 17 years old, is a single mother who brings her 6 month old child to the clinic. Leah has not kept her appointments the last two months. She reports, “I hate to take time off work when she is well but my supervisor said it was important for her to get a checkup; I guess I messed up” Part II: Medications for the pediatric patient Small, very accurate dosages All medications ordered must be calculated by the nurse All weights based on kilograms Calculations of the medications The nurse is responsible for the accurate ADMINISTRATION of the medication The most accurate ADMINISTRATION is performed by the nurse calculating the dosage before giving Let’s calculate John weighs 8.2 kilograms. The doctor orders Ampicillin 200 mg q 6hrs. Is this amount appropriate for 24 hrs? Sarah, age 12 and weighing 44 kilograms, has a temp of 102º. The doctor has ordered Tylenol 81 mg q 6 for fever above 101.8º. Is this an appropriate dose for Sarah? Syringe pump vs. Plum® How do you make a decision about the type of pump to use? All meds given IV are administered on a pump Making the decision….. Let’s Have a Great Rotation!