physical assessment ball & bindler donna hills rn edd
TRANSCRIPT
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Physical AssessmentPhysical AssessmentPhysical AssessmentPhysical Assessment
Ball & BindlerBall & Bindler
Donna Hills RN EdDDonna Hills RN EdD
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Parts of the Physical Exam
• History• Physical• Developmental Assessment• Parent/Child Interaction• Immunizations
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History• Birth History incl. Prenatal Care• Past medical history incl.
Injuries/accid/hosp• Well child care: Immuniz/illnesses• G & D Milestones
– primitive reflexes
• Nutrition/Sleep/Elimination/Socialization• Dental health/fluoride
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History (cont.)• Home environment:lead risk/basic
resource availability• Parent’s perceptions of the child• Safety: car sears/helmets• Social hx: peers/group
activities/after school care/day care
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History (cont.)• Responsibilities:chores in the
home/job• Family hx: risks and concerns• Review of lab data: assess what is
needed
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Physical Assessment in the Ambulatory Care
Setting• general approaches accd to dev.level.• Height/weight/head circ./plot on the growth
curve• observe the general behavior of the
infant/parent• assessment by systems(or problem oriented)
– neurologic assessment– chest to toes then head.
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Developmental Assessment in the Acute
Hospital Setting• vital signs at assigned times;move
often as needed• assess pain Q1-2hr as appropriate• body system assessment (s) as
related to the pt’s condition• assessments to determine nursing
diagnoses/interventions
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Developmental Assessment
• multiple tools to assess parameters of development
• Denver II:fine/gross motor, lang., personal/social
• Ballard Scale assesses gestational maturity• Preterm infant growth charts for
gestational age and for corrected age for premies<2yr.
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Parent/Child Interaction• How does the parent respond to
the child’s needs?• Is there eye-contact?• Is there communication with sibs?• Do the parents communicate to
each other/pt with sensitivity and respect?
• Does the parent handle and respond to the child in a developmentally appropriate way?
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FIGURE 8–2 Children are not just small adults. There are important anatomic and physiologic differences between children and adults that will change based on a child’s growth and development. Can you identify which of these differences are of greatest concern for the hospitalized child and why?
Jane W. Ball and Ruth C. BindlerChild Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
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How are children different?
• See figure 8-2 p. 236 (B&B)• proportionately greater body surface
area for weight• large tongue, short narrow trachea• myelinization (mostly) completed by
1st yr• higher BMR, O2needs, caloric needs
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Measurement• Head circumference
– Technique– Measure until age 2 yrs or closure of
anterior fontanel.• Length: lying until age 2yr
– Then standing.• Weight: consistency for time and
clothing.
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Skin• Mongolian Spots
– Variation of normal coloration in the skin.– Misinterpreted as bruises.
• Turgor and Capillary Refillnormal skin is elastic; dehydrated skin will tent.
• Lice– inspect the hair shaft for nits that adhere
to the hair.
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HEENT• Fontanels; should be flat. Bulging indicates
increased intracranial pressure. Sunken indicates dehydration. – Posterior closes 2-3 mos of age– Anterior closes 12-18 mos of age.
• Down Syndrome facies• Strabismus; ocular asymmetry due to muscle
imbalance.• Red Reflex: indicates clear lens (lack of
cataracts)
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Chest• Inspection: observe for increased
work of breathing, retractions, respiratory rate.
• Auscultate: R and L; anterior and posterior.– Crackles/rales– Course breath sounds or wheezes – Listen (with ear) for stridor with
inhalation
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Heart• Auscultate with diaphragm and then bell
at 4th intercostal interspace in infants and 5th intercostal interspace in older children.
• Determine rate per minute• Determine if rate is regular and WNL for
age and activity level.• Try to identify the heart sounds S1 and S2.• Obtain BP using approp.size cuff.
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Abdomen• Inspection: shape and contour• Auscultation: presence or absence of
bowel sounds• Palpation: soft/ firm/ hard
– Lightly first to assess for pain in all quadrants, then deeper.
– Palpate liver along R costal margin– Palpate for spleen (if applic) under L costal
area.
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Genitalia• In acute care setting, will probably
not be part of your assessment unless condition requires it or changing a diaper.
• Be aware of Tanner stages of pubertal development.
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Musculoskeletal• Spine: screen for posture and
scoliosis• Muscle strength and tone• Hip range of motion Fig.8-60 p.287• Gross motor milestones Table 8-18
p.284.
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Neurologic• Cognitive function for age• Language development for age
– Table 8-19 p.287
• Gait and balance milestones Table 8-20 p.288
• Fine motor milestones Table 8-21 p. 289• Primitive reflexes Table 8-23 p.291-4.
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Case Study #1• Adam is a 4mo old admitted for 3 days of
fever, 8 diarrhea stools per day, and vomiting with each feeding. His mother reports 3 wet diapers in past 24 hrs. He cries alot and has to be wakened to be fed.
• What would your assessment of Adam include?
• What would you list for nursing diagnoses?
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Adam• Assess:
• Nursing Diagnoses:
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Case Study #2• Cassie is a 9 yr old, first day post-
op with a ruptured appendectomy.• What would your assessment of
Cassie include?• What would you list for nursing
diagnoses?
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Cassie: s/p appendectomy
• Assess:
• Nursing Diagnoses:
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Case Study #3• Jarod is an 8yr old admitted with
acute asthma exacerbation.• What would your assessment of
Jarod include?• What would you list for nursing
diagnoses?
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Jarod: asthma• Assess:
• Nursing Diagnoses:
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Case Study #4 • Brian is 9yrs old and admitted to
R/O meningitis.• What would your assessment of
Brian include?• What would you list for nursing
diagnoses?
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Brian: meningitis• Assess:
• Nursing Diagnoses: