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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
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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
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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
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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
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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
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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
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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!