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PENGKAJIAN KEPERAWATAN

PADA ANAK
(PEDIATRIC ASSESSMENT)

Ns. Murniati, M.Kep


Pengantar Keperawatan II
Prodi Keperawatan S1
STIKES Harapan Bangsa Purwokerto
TUJUAN
Memahami pentingnya pengkajian dan
triase
Mengidentifikasi komponen penting dari
pengkajian anak terfokus (focused
paediatric assessment)
o PAT (Pediatric Assessment Triangle)
o Initial & secondary assessment
o Physical assessment & history talking
Essential Pediatric Nursing Skills
Pengetahuan pertumbuhan dan Perkembangan
Mengembangkan Hubungan yang Terapeutik
Komunikasi dengan anak dan keluarga
Memahami dinamika keluarga dan interaksi orang tua-anak:
identifikasi KEY FAMILY MEMBERS
Pengetahuan tentang Promosi Kesehatan dan Pencegahan
Penyakit
Edukasi Pasien dan Panduan Antisipatoris (anticipatory guidance)
Praktik Perawatan yang Terapeutik dan Atraumatik
Advokasi pasien dan keluarga
Caring, Supportive & Culturally Sensitive Interactions
Koordinasi dan Kolaborasi
KEMAMPUAN BERPIKIR KRITIS
The single most important part of
the health assessment is
Komponen dari
Focused Pediatric Assessment

Initial assessment
(ABC) Appearance
Includes
PAT: Pediatric LOC & Behavior
Assessment
Triangle PAT
Ongoing Triage
Minor vs.
Serious vs.
Breathing Changes Skin Circulation
Life-Threatening
Problem- Focused
Examination
PAT: Pediatric Assessment Triangle
1. APPEARANCE

Tone
Interactiveness
Consolability
Look/gaze
Speech/cry
2. Work of Breathing
Suara napas abnormal (stridor,
wheezing)
Posisi abnormal
Retraksi
Nasal flaring
Head bobbing
3. Circulation to the Skin
Perfusi organ vital tidak
adekuat menyebabkan
mekanisme kompensasi
dalam fungsi non-esensial:
Pallor
Mottling
Cyanosis
Initial Assessment (s)
Primary Secondary
A = Airway F = Full Set of Vitals
B = Breathing G = Give Comfort
C = Circulation Measures including
D = Disability Pain Assessment & Tx.
E = Exposure H = Head to-Toe
assessment & history
(PE & History
Talking)
Vital Signs
Temperature: rectaljika sangat diperlukan
saja
Pulse: menggunakan apical untuk anak
dibawah 1 tahun, nadi radial pulse sesuai untuk
anak toddler & older children
Respirations: infant use abdominal muscles
Blood pressure: admission base line
And the Fifth Vital Sign is ____ ?
Pediatric Vital Signs Normal
Ranges
Infant Toddler School-Age Adolescent
Heart Rate
80-150 70-110 60-110 60-100

Respiratory Rate
24-38 22-30 14-22 12-22

Systolic blood pressure


65-100 90-105 90-120 110-125

Diastolic blood pressure


45 - 65 55-70 60-75 65-85
Pain Assessment
OLD CART
Onset: Ask client to describe when the pain began
Location: Where does it hurt?
Duration: how long the pain has been going on for
Characteristics: Client's description about the pain. 0-10
pain scale
Aggravating Factors: What makes the pain worse, or
causes the pain
Relieving Factors: what has client done to relieve the
pain
Treatment: What can I do to relieve the pain
Pain Assessment
History Talking
Bio-graphic Demographic Past Medical History
Name, Date of Birth, Age Allergies
Past illness
Parents & siblings info
Trauma / hospitalizations
Cultural practices Surgeries
Religious practices Birth history
Parents occupations Developmental
Adolescent work info Family Medical/Genetics

Current Health Status


Immunization Status
Chronic illnesses or conditions
What concerns do you have today?
Untuk spesific injury
Use SAMPLE mnemonic:
Signs and symptoms
Allergies
Medication
Past Medical Illness
Last food or liquid
Events leading to injury or illness
Review of Systems
Ask questions about each system
Measurements: BB, TB, Lingkar kepala,
growth chart, BMI
Nutrition: ASI, formula, makanan favorit,
minuman, kebiasaan makan
Growth and Development: Milestones for
each age group
Review of Systems
Skin GI
HEENT GU & GYN
Neck Musculoskeletal
Chest & Lungs / & Extremities
Respiratory Neuro
Heart & Endocrine
Cardiovascular
Pattis Nitty Gritty Trio
1. Sleep & Activity
2. Appetite
3. Bowel & Bladder

Tambahkan rincian lebih lanjut jika ada (+)


respon
Physical Assessment
The approach is:
Orderly
Systematic
Head-to-toe

Fleksibilitas lebih penting


Bersikap baik dan lembut
firm, direct and honest
Empat ketrampilan dasar:
1. Inspection
2. Palpation
3. Percussion
4. Auscultation

Sequence for abdominal:


1.inspection, 2.auscultation,
3.percussion, 4.palpation
Inspection

Use all your senses


The essential First Step of the
Physical Exam
Palpation
Gunakan jari dan telapak tangan untuk meraba:
Suhu
Hidrasi
Teksture
Bentuk
Pergerakan
Areas of Tenderness
Tangan hangat dan kuku pendek
Palpasi area yang tegang/nyeri untuk yang terakhir kali
Bicara dengan anak selama melakukan palpasi utk membuat rileks
Perhatikan reaksi anak tiap kali anda melakukan palpasi
Untuk anak yang geli: letakkan tangan anak
diatas tangan anda dan minta anak yang
melakukan tekanan ke bawah
Percussion
Gunakan ketukan untuk menghasilkan
suara
Bisa dilakukan secara langsung maupun
tidak langsung
Auscultation
Listening for body sounds
Bell: low-pitched
heart
Diaphragm: high-pitched
lung & bowel

LUNGS:
Listen to all lung fields
FRONT AND BACK!
auscultate for breath sounds and adventitious sounds
Physical Assessment
General Appearance & Behavior

Facial expression
Posture / movement
Hygiene
Behavior
Developmental Status
H E E N T
Head & Neck: Symmetry of skull and face,
Structure, movement, trachea, thyroid, vessels
and lymph nodes
Eyes : Vision, placement, external and internal
fundoscopic exam
Ears : Hearing, external, ear canal and otoscopic
exam of tympanic membrane
Nose : Structure, exudate, sinuses Structure,
exudate, sinuses
Mouth & Throat : Structures of mouth, teeth
and pharynx
Key point : area kepala
Head Circumference (HC)
Fontannel/sutura: Anterior menutup usia 10-18
bulan, posterior menutup usia 2 bulan
Simetrisitas & bentuk : muka & cranium/tengkorak
Bruits: Temporal bruits signifikan stlh usia 5 tahun
Rambut : pola, rontok, hygiene, pediculosis (anak
usia sekolah)
Sinus
Ekspresi wajah: sedih, signs of abuse, allergy,
fatigue
Abnormal facies: Diagnostic facies of common
syndromes or illnesses
Key point: mata
Penglihatan : reflek merah (red reflex) dan berkedip
pada bayi
Melihat cahaya usia 5-6 minggu
Melihat sampai dengan 180 derajat pada usia 4 bulan
Cek Strabismus untuk anak preschool
Snellen chart untuk anak yang lebih tua
Irritasi dan infeksi
Amblyopia (lazy eye): Corneal light reflex, binocular
vision, cover-uncover test
EOMs: cek dengan melihat 6 titik pandang
Fundoscopic exam of internal eye & retina
Key Points : Telinga
Tanyakan tentang masalah pendengaran
Periksa telinga
Nilai bentuk telinga : normal/tidak,
discharge ada? Normal atau tidak
Key points: hidung
Exam nose & mouth after ears
Observe shape & structural deviations
Nares: (check patency, mucous membranes,
discharge, turbinates, bleeding)
Septum: (check for deviation)
Infants are obligate nose breathers
Nasal flaring is associated with respiratory
distress
Allergy: allergic salute - line across nose.
Mouth & Pharynx: Key Points
Lips: color, symmetry, moisture, swelling, sores,
fissures
Buccal mucosa, gingivae, tongue & palate for
moisture, color, intactness, bleeding, lesions.
Tongue & frenulum - movement, size & texture
Teeth - caries, malocclusion and loose teeth.
Uvula: symmetrical movement or bifid uvula
Voice quality, Speech
Breath - halitosis
Neck: Key Points
Posisi leher, nodus limfe, masa, fistula, celah
Supel atau tidak & Range of Motion (ROM)
Check klavikula pada bayi baru lahir
Kontrol kepala pada bayi
Trachea & thyroid berada di tengah
Arteri karotis
Torticollis (kekakuan otot)
Webbing (kulit diantara leher dan bahunya
menyatu)
Iritasi Meningeal
Neuro Assessment
LOC / Glasgow coma scale
Confusion, Delirium, Stupor, Coma
Pupil size
CNS grossly intact: II XII
Pain
Seizure Activity
Focal Deficits
Glasgow Coma Scale
The lowest possible GCS is 3 (deep coma or death) while the highest is 15
(fully awake person).

1 2 3 4 5 6
Does not Opens eyes Opens Opens eyes N/A N/A
EYES
open eyes in response eyes in spontaneously
to painful response
stimuli to voice

Makes no Incomprehen Utters Confused, Oriented, N/A


VERBAL
sounds sible sounds inappropri disorientated converses
ate words normally

MOTOR Makes no Extension to Abnormal Flexion / Localizes Obeys


movements painful stimuli flexion to Withdrawal to painful commands
painful painful stimuli stimuli
stimuli
Cranial Nerves

C1 - Smell
C2 - Visual acuity, visual fields, fundus
C3, 4, 6 - EOM, 6 fields of gaze
C5 - Sensory to face: Motor--clench teeth,
C5 & C7 - Corneal reflex
C7 - Raise eyebrows, frown, close eyes tight, show teeth,
smile, puff cheeks, taste--anterior 2/3 tongue
C8 - Hearing & equilibrium
C9 say "ah," equal movement of soft palate & uvula
C10 - Gag, Taste, posterior 1/3 tongue
C11 - Shoulder shrug & head turn with resistance
C12 - Tongue movement
REFLEKS
Deep tendon:
Biceps C5, C6
Triceps C6, C7, C8
Brachioradialis C5, C6
Patellar L2, L3, L4
Achilles S1, S2

Infant Automatisms:
Primitive Reflexes
Chest Assessment
BAGAIMANA ANAK TERLIHAT?
WARNA
Work of Breathing: Usaha
untuk bernapas
Auscultation
Lakukan pada 4 kuadran
Depan dan belakang
Beri waktu untuk mendengarkan
Be sure about lungs CTAB
(clear to auscultation bilaterally)
Snoring (expiratory): upper airway obstruction,
allergy
Fremitus:
Increased in pneumonia, atelectasis, mass
Decreased in asthma, pneumothorax or FB
Dullness to percussion: fluid or mass
Lungs & Respiratory:
Variation
Wheezing
Retractions
Subcostal
Intercostal
Sub-sternal
Supra-clavicular
Red Flags:
grunting
nasal flaring
stridor
Circulatory
Auscultating Heart Sounds
The Auscultation Assistant Hear Heart Murmurs, Heart Sounds,
and Breath Sounds. http://www.wilkes.med.ucla.edu/inex.htm

Pillitter

Perfusion capillary refill


Warm to touch
Gastro-Intestinal
Abdominal Assessment

Pillitteri
Abdomen: Key Points
Contour
Bowel Sounds & Peristalsis
Skin: color, veins
Umbilicus
Assess for Tenderness, Ridigity, Tympany,
Dullness
Hernias: umbilical, inguinal, femoral
Masses - size, shape, dullness, position, mobility
Liver, Spleen, Kidneys, Bladder
6F
Bowel Sounds
Normal: every 10 to 30 seconds.
Listen in each quadrant long enough to
hear at least one bowel sound.
Absent
Hypoactive
Normoactive
Hyperactive
Signs and Symptoms

Appearance color, facial, ROM, gait, position


Pain get your pain scales out
Nausea
Vomiting
Diarrhea
Bloating/ kembung
Inability to pass gas or stool
Musculo-Skeletal
Neck, shoulder, elbow, wrist, hip,
knee, ankle, foot, digits
Alignment, contour, strength,
weakness & symmetry
Limb, joint mobility: stiffness,
contractures
Gait observe child walking
without shoes
Spinal alignment - Scoliosis
Muscle Strength & Tone
Hips
Reflexes
Assessment
The Five Ps:
Pain
Paresthesia
Passive stretch
Pressure
Pulse-less-ness
Skin, Nails & Hair
Rashes
Lesions
Lacerations
Lumps/Bumps
(benjolan)
Bruises (memar)
Bites
Infections
GROWTH & DEVELOPMENT
Less than 2 months old

Consoled when held, gently rocked


Brief awake periods
Little or no eye contact
No social smile
Does not recognise parents vs.
strangers
Limited behavioral repertoire
2-6 Months Old
Social smile
Recognizes caregivers
Tracks light faces
Strong cry, increasing vocalization
Rolls over sits with support
When possible, do much of the exam in
caretaker s lap/arms lap/arms.
6-12 Months Old

Socially interactive, babbles


Sits without support, increased mobility
Everything goes in mouth
Stranger/separation anxiety
Sit or squat to get at eye level, when
examining, use toe-to-head approach.
1-3 Years Old

Terrible twos
Increased mobility
Curious about every thing, no fear
Egocentric, very strong opinions
Not swayed by logic
Language comprehension is greater
than expression.
The School-Age Child

Analytical, understands
cause and effect
Cooperative, age of
reason
Privacy and modesty
Explain procedures and
equipment.
Interact with child during
exam.
Adolescent

Privacy issues first


consideration
HEADS: home life,
education, alcohol,
drugs, sexual
activity / suicide
Psychosocial Assessment

HEADS SHADESS
Home life School
Emotions / Home
Depression and Activities
Education
Drugs / Substance
Activities
Abuse
Drugs / Alcohol /
Substance Emotions /
Abuse Depression
Sexuality Sexuality
activity and Safety
Suicide
The Bottom Line

Begin with PAT followed by ABCDEs.


Form a general impression to guide
management priorities.
Treat respiratory distress failure and shock
when recognized.
Focused history and detailed PE
Perform ongoing assessment throughout
stay.
Resources and References
Chandler, J. Pediatric Nursing: Nursing Care of Children and Young Adults:
Pediatric Physical Assessment
Colyar, M. Well Child Assessment for Primary Care Providers. Philadelphia, PA: F.A.
Davis Company.
Duderstadt, K. Pediatric Physical Examination. St. Louis, MO: Mosby, Inc.
Engel, J. Pediatric Assessment 5th. Ed. St. Louis, MO: Mosby, Inc.
Wongs Essentials of Pediatric Nursing 8th ed.
AAP Preparticipation Physical Evaluation. Available @ www.aap.org
American Medical Association Guidelines for Adolescent Preventive Services (GAPS)
http://www.ama-assn.org/ama/pub/category/2280.html
American School Health Association http://www.ashaweb.org
The Auscultation Assistant @ http://www.wilkes.med.ucla.edu/intro.html
BMI Calculator: http://www.cdc.gov/nccdphp/dnpa/bmi /
2007 Asthma Guidelines: http://www.nhlbi.nih.gov/guidelines/asthma/index.htm
Ball, J. W., & Bindler, R. C. (2003). Pediatric nursing: Caring for children (3rd ed.).
Upper Saddle River, NJ: Pearson Education. Chapter 4.
Jarvis, C. (2004). Physical examination and health assessment (4th ed.). St. Louis,
MO: Saunders. Unit 3