Physical Assessment of Children Depending of Age.

Physical Assessment Physical Assessment of Children of Children

Depending of AgeDepending of Age

Physical Assessment Physical Assessment of Children of Children

Depending of AgeDepending of Age

Physical Assessment of Infant

Assessment is NOT in the head-to-toe manner When quiet, auscultate heart, lungs, abdomen Assess heart & respiratory rates before

temperature Palpate and percuss same areas Perform traumatic procedures last Elicit reflexes as body part examined Elicit Moro reflex last Encourage caretaker to hold infant during exam

Distract with soft voice, offer pacifier, music or toy

Physical Assessment of Toddler

Inspect body areas through play – “count fingers and toes”

Allow toddler to handle equipment during assessment and distract with toys and bubbles

Use minimal physical contact initially Perform traumatic procedures last Introduce equipment slowly Auscultate, percuss, palpate when quiet Give choices whenever possible

Photo Source: Del Mar Image Library; Used with permission

Physical Assessment of Preschooler

If cooperative, proceed with head-to-toe If uncooperative, proceed as with toddler Request self undressing and allow to wear

underpants Allow child to handle equipment used in

assessment Don’t forget “magical thinking” Make up “story” about steps of the procedure Give choices when possible If proceed as game, will gain cooperation

Photo Source: Del Mar Image Library; Used with permission

Physical Assessment of School-Age Child

Proceed in head-to-toe May examine genitalia last in older children Respect need for privacy – remember modesty! Explain purpose of equipment and significance Teach about body function and care of body

Physical Assessment of the Adolescent

Ask adolescent if he/she would like parent/caretaker present during interview/assessment Provide privacy Head-to-toe assessment appropriate Incorporate questions/assessment related to genitals/sexuality in middle of exam Answer questions in a straightforward, non- condescending manner Include the adolescent in planning their care

Pain AssessmentPain AssessmentPain AssessmentPain Assessment

Pain • “Pain is whatever the experiencing

person says it is, existing whenever the person says it does.”

– McCaffery and Pasero, 1999

• This includes VERBAL and NONVERBAL expressions of pain

Pain Facts and Pain Facts and FallaciesFallacies

• FACT: Children are under treated for pain

• FACT: Analgesia is withheld for fear of the child becoming addicted

• FALLACY: Analgesia should be withheld because it may cause respiratory depression in children

• FALLACY: Infants do not feel pain

Principles of Pain Assessment Principles of Pain Assessment in Children: QUESTTin Children: QUESTT

• Question the child• Use a pain rating scale• Evaluate behavioral and physiologic

changes• Secure parent’s involvement• Take the cause of pain into account• Take action and evaluate results

Pain Rating Scales• Not all pain rating scales are

reliable or appropriate for children• Should be age appropriate• Consistent use of same scale by all

staff• Familiarize child with scale

Pain ScalesPain Scales• FACES pain rating scale• Numeric scale• FLACC scale

– Facial expression– Legs (normal relaxed, tense, kicking,

drawn up)– Activity (quiet, squirming, arched,

jerking, etc)– Cry (none, moaning, whimpering,

scream, sob)– Consolability (content, easy or difficult to

console)

Nonpharmacologic Interventions

• Based on age• Swaddling, pacifier, holding,

rocking• Distraction• Relaxation, guided imagery• Cutaneous stimulation

Anesthetics: Topical and Local

• Major advancement for atraumatic care

• EMLA• NUMBY stuff• Intradermal local anesthetics• Importance of timing

AnalgesicsAnalgesics• Opioids• NSAIDs• “Potentiators”• Lytic cocktail (DPT)—Demerol,

Phenergan, and Thorazine• Co-analgesics, amnesics,

sedatives, etc.• Role of placebos

Dosage of Analgesia• Based on body weight up to 50 kg• Concept of “titration”• Ceiling effect of non-opioids• First pass effect• PCA

Fears of Bodily Injury and Pain

• Common fears among children• May persist into adulthood and

result in avoidance of needed care

Pain Assessment: Infants

Assessment of pain includes the use of pain scales that usually evaluate indicators of pain such as cry, breathing patterns, facial expressions, position of extremities, and state of alertness

Examples: FLACC scale, NIPS scale

Young Infant’s Young Infant’s Response to PainResponse to Pain

• Generalized response of rigidity, thrashing

• Loud crying• Facial expressions of pain (grimace)• No understanding of relationship

between stimuli and subsequent pain

Older Infant’s Response Older Infant’s Response to Painto Pain

• Withdrawal from painful stimuli• Loud crying• Facial grimace• Physical resistance

Pain Assessment: Toddlers

Toddlers may have a word that is used for pain (“owie,” “boo-boo,” “ouch” or “no”); be sure to use term that toddler is familiar with when assessing.

Can also use FLACC scale, or Oucher scale (for older toddlers)

Young Child’s Response Young Child’s Response to Painto Pain

• Loud crying, screaming• Verbalizations: “Ow”, “Ouch”, “It

hurts”• Thrashing of limbs• Attempts to push away stimulus

Pain Assessment:Preschoolers

Think pain will magically go awayMay deny pain to avoid medicine/injectionsAble to describe location and intensity of painFACES scale, poker chips and Oucher scale may be used

Photo Source: Del Mar Image Library; Used with permission

School-Age Child’s School-Age Child’s Response Response

to Painto Pain

• Stalling behavior (“wait a minute”)• Muscle rigidity• May use all behaviors of young

child

Pain Assessment:Older Children

Older children can describe pain with location and intensity

Nonverbal cues important, may become quiet or withdrawn

Can use scales like Wong’s FACES scale, poker chips, visual analog scales, and numeric rating scales

AdolescentAdolescent• Less vocal protest, less motor

activity• Increased muscle tension and

body control• More verbalizations (“it hurts”,

“you’re hurting me”)

Let’s ReviewThe nurse begins a full assessment on a 10 year-old patient. To ensure full cooperation from this patient it is most important for the nurse to:

A. Approach the assessment as a game to play.B. Provide privacy for the patient.C. Encourage the friend visiting to stay at the bedside to observe.D. Instruct the child to assist the nurse in the assessment.

Let’s ReviewDuring a routine health care visit a parent asks the nurse why her 10 month-old infant is not walking as her older child did at the same age. Which response by the nurse best demonstrates an understanding of child development?

A. “Babies progress at different rates. Your infant’s development is within normal limits.” B. “If she is pulling up, you can help her by holding her hand.”C. “She’s a little behind in her physical milestones.”D. “You can strengthen her leg muscles with special exercises to make her stronger.”

Let’s Review

When assessing a toddler identify the order in which you would complete the assessment:

1. Ear exam with otoscope2. Vital signs3. Lung assessment4. Abdominal assessment

Let’s Review

When assessing pain in an infant it would be inappropriate to assess for:

A. Facial expressionsB. Localization of painC. CryingD. Extremity movement