Pediatric Assessment 35 - prenhall.com

1 AssessmentCHAPTERI was scared when we brought Latoya to the hospital. She looked helpless,afraid, and sick. The nurses and doctors took over when we got to thehospital, and I felt better because they seemed to know what to do. Father of Latoya, 6 months oldLEARNING OBJECTIVES961 Describe the elements of a health history for aninfant or child of different ages. Identify communication strategies to improve thequality of historical data collected. Describe the strategies to gain cooperation of ayoung child for Assessment . Describe the differences in sequence of the physicalassessment for infants, children, and adolescents. Modify physical Assessment techniques accordingto the age and developmental stage of the child. Determine the sexual maturity rating of males andfemales based upon physical signs of secondarysexual characteristics present.

2 Recognize at least five important signs of a seriousalteration in health condition that require urgentnursing GlossaryAnimations:Otoscope ExaminationMouth and Throat Examination3D EyeMovement of JointsSkills 9-1 9-7: Growth MeasurementsSkill 9-10: Blood PressureSkills 9-11 9-14: Body Temperature MeasurementsSkills 9-18 and 9-19: Visual Acuity ScreeningNCLEX RN ReviewCompanion WebsiteNew Pediatric Blood Pressure TablesTechniques for Assessing Selected Primitive Reflexes,with Normal Findings and TheirExpected Age of OccurrenceThinking CriticallyNCLEX RN ReviewCase 2/16/06 1:44 PM Page 961 How do examination techniques vary by the age of the child? Howdoes the nurse encourage infants and toddlers to cooperate with theexamination? This chapter provides an overview of Pediatric as-sessment, including history taking and examination techniques geared to theunique needs of Pediatric patients.

3 Strategies for obtaining the child s his-tory are presented first. The remainder of the chapter then outlines a sys-tematic process for physical examination of the AND PHYSIOLOGIC CHARACTERISTICSOF INFANTS AND CHILDRENC hildren and infants are not only smaller than adults, but also significantlydifferent physiologically. Knowledge of Pediatric anatomic and physiologicdifferences will aid in recognizing normal variations found during the phys-ical examination. It also assists with understanding the different physiologicresponses children have to illness and injury. The illustration in As ChildrenGrow provides an overview of important anatomic and physiologic differ-ences between children and THE CHILD S HISTORYCOMMUNICATION STRATEGIESThe health history interview is a very personal conversation with a parent, care-taker, or adolescent during which private concerns and feelings are shared.

4 Tryto ensure that this exchange of information with the parent or the child is clearlyunderstood by both parties and that it is an effective communication. Effectivecommunication is difficult to accomplish because parents and children oftendo not correctly interpret what the nurse says, just as the nurse may not under-stand completely what the parent or child says. People s interpretation of infor-mation is based on their life experiences, culture, and to Build a Rapport with the FamilyWhen beginning the history, make sure the parents understand the purposeof the interview and that the information will be used appropriately. To de-velop rapport, demonstrate interest in and concern for the child and familyduring the interview. This rapport forms the foundation for the collabora-tive relationship between the nurse and parent that will provide the bestnursing care for the child.

5 The following strategies help to establish rapportwith the child s family during the nursing history: Make a self-introduction (name, title or position, and role in caring forthe child). To demonstrate respect,ask all family members present whatname they prefer you to use when talking with them. Explain the purpose of the interview and why the nursing history isdifferent from the information collected by other health example, The nurses will use this information to plan nursing carebest suited for your child. Provide privacy and remove as many distractions as possible during theinterview. If the patient s room does not offer privacy, attempt to find avacant patient room or lounge. Assure the parents and the child that theinformation provided during the Assessment is protected under theHealth Insurance Portability and Accountability Act (HIPAA), a federallaw that requires written consent to be provided before healthinformation can be shared with healthcare providers outside the impulse, 995 Auscultation, 970 Bronchophony, 994 Coloboma, 977 Crepitus, 992 Egophony, 994 Hypertelorism, 976 Inspection, 970 Nasal flaring, 989 Palpation, 970 Percussion, 970 Retractions, 991 Tactile fremitus, 992 Whispered pectoriloquy, 994 KEY 2/16/06 1:44 PM Page 962 Pediatric Assessment963 Direct the focus of the interview with open-endedquestions.

6 Use close-ended questions or directingstatements to clarify information. Open-endedquestions are useful to initiate the interview, develop arapport, and understand the parent s perceptions ofthe child s problem. For example: Tell me whatproblems led to Roberto s admission to the hospital. Close-ended questions are used to obtain detailedinformation. For example: How high was Tommy sfever this morning? Ask one question at a time so that the parent or childunderstands what piece of information is desired andso that it is clear which question the parent isanswering. Does any member of your family havediabetes, heart disease, or sickle cell anemia? is amultiple question. Ask about each disease separately toensure the most accurate surface area large for weight,making infants susceptible proportionately larger, makingchild susceptible to head metabolic rate, higher oxygenneeds, higher caloric puberty, percentage of cartilagein ribs is higher, making them moreflexible and about 10 years, there is a fasterrespiratory rate, fewer and smalleralveoli, and less lung volume.

7 Tidalvolume is proportional to weight(7 to 10 mL/kg).Up to about 4 or 5 years, diaphragmis primary breathing muscle. CO2 isnot effectively expired when child isdistressed, making child susceptibleto metabolic puberty, bones are soft andmore easily bent and lack tone, power, andcoordination during infancy. Musclesare 25% of weight in infants versus40% in fontanelle and open suturespalpable up to about 18 fontanelle closes between 2 and 3 large relative to smallnasal and oral airway , narrow trachea in children under 5 years makes themsusceptible to foreign offers poor protection for the liver and spleen, making themsusceptible to 12 to 18 months of age,kidneys do not concentrate urineeffectively and do not exert optimalcontrol over electrolyte secretionand later school age, proportionof body weight in water is larger,with more water in extracellularspaces.

8 Daily water exchange rateis much volume is weight dependent: 80 brain cells present at birth;myelinization and furtherdevelopment of nerve fibers occurduring first late school age and adolescence, cardiac output israte dependent not stroke volumedependent, making heart rate more are not just small adults. There are important anatomic and physiologic differences between children and adults that will change basedon a child s growth and Are Not Just Small AdultsChildren Are Not Just Small AdultsDEVELOPING CULTURALCOMPETENCEPHRASING YOUR QUESTIONSSome cultural groups, particularly Asians, try to anticipate the answersyou want to hear, or say yes even if they do not understand the ques-tion. This is done in an effort to please you or as an expression ofpoliteness. Remember to phrase your questions in a neutral 2/16/06 1:44 PM Page 963964 CHAPTER 35 Involve the child in the interview by asking age-appropriate questions.

9 Young children can be asked, What is your doll s name? or Where does it hurt? Demonstrating an interest in the child initiatesdevelopment of rapport with both child and older children and teens questions about theirillness or injury. Offer them an opportunity toprivately discuss their major concerns when theirparents are not present. Be honest with the child when answering questions orwhen giving information about what will need to learn that they can trust their nurse. Choose the language style best understood by the parentand child. Commonly used phrases can have differentmeanings to persons in various regions of the country orto different ethnic groups. To improve communication,request frequent feedback from the parents or child toensure that their interpretation of phrases is accurate.

10 Use an interpreter to improve communication whennot fluent in the family s primary language. To ensureconfidentiality of information for parents, avoid usinga family member for history ListeningComplete attention is necessary to hear and accuratelyinterpret information the parents and child give during thenursing history. Carefully listen to the information pro-vided by the parent, as well as how it is expressed, and ob-serve behavior during the interaction. Does the parent hesitate or avoid answering certainquestions? Pay attention to the parent s attitude or tone of voicewhen the child s problems are discussed. Determine ifit is consistent with the seriousness of the child sproblem. The tone of voice can reveal anxiety, anger, orlack of concern. Be alert to any underlying themes.