| PEDIATRIC ASSESSMENT

Equipment
● Airway support equipment, Ambu-bags HISTORY: REVIEW OF SYSTEMS
● Stethoscope & Sphygmomanometer ● Skin
● Pen Light ● HEENT
● Pulse Ox & Cardiac Monitor ● Neck
● Nebulizer ● Chest & Lungs /Respiratory
● Thermometer ● Heart & Cardiovascular
● Otoscope / Ophthalmoscope ● GI
● О2 ● GU and GYN
● Musculoskeletal & Extremities
HISTORY ● Neuro
Bio-graphic Demographic ● Endocrine
● Name, Date of Birth, Age
● Parents & sibling's info ASSESSMENT FOR PAIN
● Cultural practices THIS OLD CART
● Religious practices O - Onset
● Parents' occupations L - Location
● Adolescent - work info D - Duration
C - Characteristics
Past Medical History A - Alleviating and Aggrating factors
● Allergies R - Radiating or relieving factors
● Past illness T - Timing
● Trauma/hospitalizations S - Severity
● Surgeries
● Birth history Patti's Nitty Gritty Trio
● Developmental ● Sleep and Activity
● Family Medical/Genetics ● Appetite
● ● Bowel and Bladder
Current Health Status - In a time crunch, these 3 questions should
● Immunization Status give you enough insight into the child's
● Chronic illnesses or conditions general functioning -
● What concerns do you have today? - Can get more detailed if any (+) responses

The single most important part of the health Components of a

assessment is: Our PATIENT Focused Pediatric Assessment
Always ABCs!
REVIEW OF SYSTEMS ● AIRWAY
● Ask questions about each system ● BREATHING
● Measurements: weight, height, head ● CIRCULATION
circumference, growth chart, BMI
● Nutrition: breastfed, formula, favorite PAT:
foods, beverages, eating habits ● Pediatric
● Growth and Development: Milestones for ● Assessment
each age group ● Triangle

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H = Head-to-Toe assessment and History
Ongoing Triage I = Inspect posterior surfaces rashes, bruising
● Minor vs.
● Serious vs. Physical Assessment
● Life-Threatening The approach is:
● Orderly
Problem- Focused Examination ● Systematic
● Head-to-toe
PAT - FLEXIBILITY is essential
● General Appearance - be kind and gentle
● Work of Breathing - but firm, direct and honest
● Circulation to the Skin
General Appearance & Behavior
Appearance ● Facial expression
● Tone ● Posture/movement
● Interactiveness ● Hygiene
● Consolability ● Behavior
● Look/gaze ● Developmental Status
● Speech/cry
Pediatric Vital Signs - Normal Ranges
Work of Breathing
● Increased or Decreased Infant Toddle School Adole
● Respirations r Age scent
● Stridor
● Wheezing Heart 80-150 70-110 60-110 60-100
Rate
Circulation to the Skin
● Inadequate perfusion of vital organs Respi 24-38 22-30 14-22 12-22
● Leads to compensatory Rate
● mechanisms in nonessential functions
- Ex: vasoconstriction in the skin. Systolic 65-100 90-105 90-120 110-125
BP
Initial Assessments
Primary Diastolic 45-65 55-70 60-75 65-85
A = Airway BP
B = Breathing
C = Circulation
Vital Signs
D = Disability
● Temperature: rectal only when absolutely
necessary
Secondary
● Pulse: Apical on children under 1yr
E = Exposure
● Respirations: infant uses abdominal
F = Full Set of Vitals
muscles
G = Give Comfort Measures including Pain
● Blood Pressure: admission baseline
Assessment and Tx.
● Fifth Vital Sign is pain
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Physical Assessment PERCUSSION

General Use of tapping to produce sounds that are
● Skin, hair, and nails characterized according to
● Head, neck, and lymph nodes ● Intensity
● Eyes, ears, nose, throat ● Pitch
● Chest, Tanner Scale ● Duration
● Heart ● Quality
● Abdomen ● Direct vs. Indirect
● Genitalia, Tanner Scale
● Rectal AUSCULTATION
● Musculoskeletal: feet, legs, back, gait Listening to body sounds
● Bell: low-pitched
Sequence for abdominal: (IAPEPA) - heart
1. Inspection, 2. Auscultation, ● Diaphragm: high-pitched
3. Percussion, 4. Palpation - lung and bowel
● LUNGS
FOUR BASIC SKILLS - Listen to all lung fields
- FRONT AND BACK!
INSPECTION
● Use all your senses IPPA
● The essential ● Practice, Practice, Practice by knowing
● First Step of the Physical Exam what the norm is, you'll be able to pick up
on the abnormal, even if you can't diagnose
PALPATION it.
● The important thing is to be able to say
Use of fingers and palms to determine:
● Temperature - "This is not right"
● Hydration - and refer appropriately!
● Texture
● Shape HEENT
● Movement HEAD, EYES, EARS, NOSE, NECK, THROAT
● Areas of Tenderness
● Warm hands and short nails ● Head: Symmetry of skull and face
● Palpate areas of tenderness/pain last ● Neck: Structure, movement, trachea,
● Talk with the child during palpation to thyroid, vessels, and lymph nodes
help him relax ● Eyes: Vision, placement, external and
● Be observant of reactions to palpation internal fundoscopic exam
● Move firmly without hesitation ● Ears: Hearing, external, ear canal, and
● For the ticklish child: place her hands over otoscopic exam of the tympanic membrane
your hands and have the child do the ● Nose: Structure, exudate, sinuses
pressing down. ● Mouth: Structures of mouth, teeth and
pharynx

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HEAD
Shape: ● Finger to examiner's finger 4-6 yrs
- “NormoCephalic ATraumatic" ● Ability to stand with eyes closed (Romberg)
● Lesions 3-4 yrs
● Edema ● Rapid alternations of hands (prone, supine)
school age
EAD HEAD: KEY POINTS ● Tandum walk 4-6 yrs
● Head Circumference (HC) ● Walk on toes, heels school age
● Fontanelles/sutures: Anterior closes at ● Stand on one foot for 3-6 yrs
10-18 months, posterior by 2 months ● Motor Function: Gross motor and Fine
● Symmetry and shape: Face and skull motor movements
● Bruits: Temporal bruits may be significant ● Sensory function
after 5 years ● Reflexes
● Hair: Patterns, loss, hygiene, pediculosis in
school aged child Cranial Nerves
● Sinuses: Palpate for tenderness in older ● C1 - Smell
children ● C2 - Visual acuity, visual fields, fundus
● Facial expression: Sadness, signs of abuse, ● C3, 4, 6 - EOM, 6 fields of gaze
allergy, fatigue ● C5 - Sensory to face: Motor-clench teeth,
● Abnormal facies: "Diagnostic facies" of ● C5 and C7 - Corneal reflex
common syndromes or illnesses ● C7 - Raise eyebrows, frown, close eyes
tight, show teeth, smile, puff cheeks,
NEURO ASSESSMENT taste-anterior 2/3 tongue
● LOC / Glasgow coma scale ● C8 - Hearing & equilibrium
● Confusion, Delirium, Stupor, Coma ● C9 - say "ah," equal movement of soft
● Pupil size palate & uvula
● CNS grossly intact: II - XII ● C10 - Gag, Taste, posterior 1/3 tongue
● Vital Signs ● C11 - Shoulder shrug & head turn with
● Pain resistance
● Seizure Activity ● C12 - Tongue movement
● Focal Deficits
REFLEXES
NEUROLOGICAL KEY POINTS ● Deep tendon:
● Cranial Nerves ● Biceps C5, C6
● Cerebral Function: ● Triceps C6, C7, C8
● Mental status, appearance, behavior, ● Brachioradialis C5, C6
cooperation ● Patellar L2, L3, L4
● LOC, language, emotional status, social ● Achilles S1, S2
response, attention span ● Superficial:
● Cerebellar Function ● Cremasteric T12, L1, L2
● Balance, gait & leg coordination, ataxia, ● Abdominal T7, T8, T9, T10, T11
posture, tremors ● Infant Automatisms:
● Finger to the nose (fingers to thumb) 3-4 ● Primitive Reflexes
yrs

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Glasgow Coma Scale Similarities and differences from standard

- The lowest possible GCS is 3 (deep coma or
death) while the highest is 15 (fully awake).
medical evaluation?
● Incorporates all facets of a conventional
medical history:
● The approach is more specific to older
persons.
● Including non-medical domains
● Emphasis on functional capacity and
quality of life
● Incorporating a multi-disciplinary team

Tailored practice to meet busy clinical demands!

● Less comprehensive and more
problem-directed.
● Incorporation of various tools and survey
instruments in the assessments.
● Patient-driven assessment instruments are
time efficient.

BACTERIAL MENINGITIS
Structured Approach
● Clinical Manifestations in an Older Child
Multidimensional
● High fever
● Functional ability
● Headache
● Physical health (pharmacy)
● LOC Changes / GCS
● Cognition
● Nuchal rigidity / stiff neck
● Mental health
● + Kernigs = inability to extend legs
● Socio-environmental
● + Brudzinski sign = flexion of hips when
Multidisciplinary
the neck is flexed
● Physician
● Purple rash (check for blanching)
● Social worker
● “Looks Sick"
● Nutritionist
●
● Physical therapist
Geriatric Evaluation
● Occupational therapist
● Geriatric H and P
● Family
● Functional
● Cognitive/Affective
Functional Ability
● Medications
● Functional status refers to a person's
● Nutritional
ability to perform tasks that are required
● Bone Integrity/Falls
for living.
● Strength/Sarcopenia
● Continence
Two key divisions of functional ability:
● Eyes/Ears
● Activities of daily living (ADL)
● ETOH/Tobacco/Sex
● Instrumental activities of daily living
● EnviroSocial
(IADL).
● Capacity
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IADLS
● At 3yrs, IADL impairment is a predictor of
incident dementia
● I impairment, OR=1
● 2 impairments, OR=2.34
● 3 impairments, OR=4.54
● 4 impairments, lacked statistical power
Mobility
● The Get Up and Go Test is a practical
balance and gait assessment test for an
official assessment. The Timed Up and Go
Test is another test of basic functional
mobility for frail elderly persons.
● Balance can also be evaluated using the
Functional Reach Test. In this test, the
patient stands next to a wall with feet
stationary and one arm outstretched. They
then lean forward as far as they can
without stepping. Reaching a distance of
fewer than six inches is considered
abnormal. If further testing is advisable,
the Tinetti Balance and Gait Evaluation is
the standard.
Get up and Go test
● Staff should be trained to perform the "Get
Up and Go Test” at check-in and query
those with gait or balance problems for
falls.
● Rise from an armless chair without using
your hands.
● Stand still momentarily.
● Walk to a wall 10 feet away.
● Turnaround w/o touching the wall.
● Walk back to the chair.
● Turn around.
● Sit down.
● Individuals with difficulty or demonstrate
unsteadiness performing this test requires
further assessment
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Get up and Go
● ONLY VALID FOR PATIENTS NOT USING
AN ASSISTIVE DEVICE
● Get up and walk 10ft, and return to the
chair
< 10 -Freely mobile
< 20 Mostly independent
20-29 Variable mobility
30 Assisted mobility
Shoulder Function
● A simple test is to inquire about pain and
observe a range of motion. Ask the patient
to put their hands behind their head and
then in the back of their waist. If any pain
or limitation is present, a more complete
examination and potential referral are
recommended
Hand Function
● The ability to grasp and pinch is needed
for dressing, grooming, toileting, and
feeding. to pick up small objects (coins,
eating utensils, cups) from a flat surface.
Another measure is grasp strength. The
patient is asked to squeeze two of the
physician or
examiner’s fingers with each hand. Pinch
strength can be assessed by having the
patient firmly hold a piece of paper
between the thumb and index finger
Nutrition: 4 Components Specific to the Geriatric
Assessment
● Nutritional history performed with a
nutritional health checklist
● Record of a patient's usual food intake
based on 24-hour dietary recall
● Physical examination with particular
attention to signs associated with
inadequate nutrition or over-consumption
and
● Select laboratory tests, if applicable
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VISION
- The U.S. Preventive Services Task Force
(USPSTF): found insufficient evidence to
recommend for or against screening with
an ophthalmoscope in asymptomatic older
patients.
- Common causes of vision impairment:
presbyopia, glaucoma, diabetic
retinopathy, cataracts, and ARMD

Hearing Impairment
● Audioscope
● A handheld otoscope with a
built-in audiometer
● Whisper Test

URINARY CONTINENCE
● Complications: decubitus ulcers,
sepsis, renal failure, urinary tract
infections, and increased
mortality.
● Psychosocial implications: loss of
self-esteem, restriction of social
and sexual activities, and
depression.
● Key deciding factor: Nursing home
placement.

BALANCE AND FALL PREVENTION

● leading cause of hospitalization
and injury-related death in
persons 75 years and older.
● Tool to assess a patient's fall risk-
16 secs

The Tinetti Balance and Gait Evaluation:

● This test involves observing as a patient
gets up from a chair without using his or
her arms, walks 10 ft, turns around, walks
back, and returns to a seated position.
● Failure or difficulty to perform the test:
increased risk of falling and need further
evaluation.

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