CH. 34 Part 2 Learning Outcome 34-3 Demonstrate strategies to gain cooperation of a young child for assessment.

Facilitating Examination of Infants Under 6 Months of Age What are nursing interventions and strategies that help facilitate successful examination of infants under 6 months of age? praise the parent for being present and assisting and participation promote physical comfort and relaxation of parents and children distract the infant using colorful toys be gentle, make sure hand and stethoscope are warm auscultate when quiet or sleeping save anything invasive until the end, so they cry only at the end Facilitating Examination of Infants Over 6 Months of Age What are nursing interventions and strategies that help facilitate successful examination of infants over 6 months of age? remember at 6 months they are starting to experience stranger anxiety keep infant as close to parents as possible, can do much of exam in parents lap promote comfort and relaxation Facilitating Examination of Toddlers What are nursing interventions and strategies that help facilitate successful examination of toddlers? keep the child close to parent, peak age for separation anxiety is 18 months demonstrate on parent or sibling first give them choices, allow them as much control/choice as possible (reasonable) invasive things toward the end Facilitating Examination of Preschoolers What are nursing interventions and strategies that help facilitate successful examination of preschoolers? Child can be included in exam, make choices about sequence on exam allow child to touch and play with equipment play games give positive feedback

Facilitating Examination of Older Children and Adolescents What are nursing interventions and strategies that help facilitate successful examination of older children and adolescents? they are starting to become modest, ensure privacy offer choices and allow participation explain things in greater detail offer parents presence or absence reassure adolescents that they are developing normally if possible Learning Outcome 34-4 Describe the differences in sequence of the physical assessment for infants, children, and adolescents. Sequence of Examination What is the sequence of examination for young children? foot to head sequence which allows for least distressing parts of the examination to happen first (book recommendation) depends on whats going on. For example, when child is sleeping you are going to do things like respirations and heart rate first.(Theresa recommendation) What is the sequence of examination for older children? Head to toe examination Table 34-6 Examination Techniques

Learning Outcome 34-5 Modify physical assessment techniques according to the age and developmental stages of the child. General Appraisal What should the nurse be assessing with a general appraisal? Appearance of child, appearance of parent, behaviors, is it appropriate? Does the adult look stressed? Can they handle the child? What are the interactions between the child and the adult and with you. Anthropometric Measurements What are the primary components that nurses assess regarding anthropometric measurements? Length: birth-24 months use measuring board, recumbent. from 2 years old standing Weight: in k,g,lb,oz, use an infant scale, then standing scale, make sure youre weighing them with just a dry diaper on, same time of day head circumference or FOC: measured by paper tape in cm, measure twice FOC done until 2-3 years old. At largest part of the head just above eyebrows BMIs start around anywhere from 3-5 years old, BMI less than 5% is of concern or greater than 85% (overweight) or 95% (obesity) skinfold test-if BMI or weight is a concern all measurements plotted on growth chart. Skin and Hair What should the nurse be assessing in a skin assessment? looking at color of skin temperature of skin, is it moist, any rash lesions, skin turgor? What should the nurse be assessing in a hair assessment? texture, amount, is hair breaking or looking brittle, head lice: significant in ped population, not an indication of socioeconomic status

Pathophysiology Illustrated Common Primary Skin Lesions and Associated Conditions

Pathophysiology Illustrated (continued) Common Primary Skin Lesions and Associated Conditions

Pathophysiology Illustrated (continued) Common Primary Skin Lesions and Associated Conditions

Head and Face What should the nurse be assessing for in a head and face assessment? Looking at the shape of the head and face symmetry, is the childs face similar on left and right when resting, smiling, talking/crying, assessing cranial nerves spacing of eyes, anything disproportionate, any tics, tremors or twitching assessing skull, palpate looking for sutures and fontanels. Anterior fontanel: less than 5 cm closes sometime after 12-18 months. Posterior fontanel: closes between 2-3 months of age Figure 34-5 Inspecting for facial symmetry. Draw an imaginary line down the middle of the face over the nose and compare the features on each side. Significant asymmetry may be caused by paralysis of cranial nerve V or VII, in utero positioning, or swelling from infection, allergy, or trauma.

p. 891 in book
As Children Grow Sutures p. 891 Eyes What should the nurse be assessing and inspecting for in an eye assessment? Equipment: opthalmoscope, vision chart, penlight, Assessing cranial nerves 2,3,4,6, looking at the structures of the eye, external, (34-6 p. 892) look at eyes: the same size? not too big or small? Bulging or sunken? appropriately distanced from each other? eyelids for color, size and mobility, appearance of eyelashes, any swelling or inflammation, look at the conjunctiva, pink and glossy, look at the level where upper and lower leds cross the eye, palpebral slant, eye color, and the sclera & iris, is the sclera white/ivory, newborns less than 6 months iris is blue or light colored then changes, pupils, testing for accommodation, constrict with near, dilate with far, age appropriate vision assessment, penlight for red reflex

Figure 34-7 Inspecting for palpebral slant. Draw an imaginary line across the medial canthi and extend it to each side of the face to identify the slant of the palpebral fissures. When the line crosses the lateral canthi, the palpebral fissures are horizontal and no slant is present. When the lateral canthi fall above the imaginary line, the eyes have an upward slant. A downward slant is present when the lateral canthi fall below the imaginary line. Look at Figures 346, 348, and 3411. Which type of eye slant do these children have? Are epicanthal folds present?

Figure 34-8 slant.

The eyes of this boy with Down syndrome show an upward

Figure 34-9 Assessing extraocular movements. Have the child sit at your eye level. Hold a toy or penlight about 30 cm (12 in.) from the childs eyes and move it through the six cardinal fields of gaze. Both eyes should move together, tracking the object. This procedure tests cranial nerves III, IV, and VI.

Figure 34-10 Coveruncover test. With the child at your eye level, ask the child to look at a picture on the wall. A, Cover one eye with an index card or paper cup and simultaneously watch for any movement of the uncovered eye. If the uncovered eye jumps to fixate on the picture, it has a muscle weakness. B, Remove the cover from the eye and simultaneously watch the eye that was covered for any movement to fixate on the picture. If the eye has a muscle weakness, it drifts to a relaxed position once covered.

Ears What should the nurse be assessing and inspecting with an ear assessment? Equipment: otoscope, noisemaker, bell rattle, tuning fork, inspect external ear, see if pinna is low-set (associated with congenital renal disorders) any malformation, open auditory canal, any swelling, discharge, foul-smelling or purulent, inspect tympanic membrane using otoscope, in under three years old, pull pinna down and back, over three pull pinna up and back hearing assessment: newborns before leave hospital, preschool/entrance to school, hearing is checked, noisemakers/rattle for infants, stand behind infant and make sounds see if they turn preschool: whisper test, bone and air conduction of sounds tests: Weber and Rinne tests. These tests use a tuning fork. Figure 34-12 Inspecting the tympanic membrane. To restrain an uncooperative child, place the child on the parents lap with the childs head and chest held firmly against the parents chest. Keep your hands free to hold the otoscope and position the external ear. -this is a child under three. Pull the pinna down and back and the handle of the otoscope is pointing up. This is proper technique. Figure 34-13 To straighten the auditory canal, pull the pinna back and up for children over 3 years of age. Pull the pinna down and back for children under 3 years of age. -The handle of the otoscope is down. Figure 34-14 The tympanic membrane normally has a triangular light reflex with the base on the nasal side pointing toward the center. The bony landmarks, the umbo and handle of malleus, are seen through the tympanic membrane.

Table 34-7 Unexpected Findings on Examination of the Tympanic Membrane and Their Associated Conditions

Figure 34-15 Testing bone and air conduction. A, Weber test. Place vibrating tuning fork on midline of the childs head. Figure 34-15 (continued) Testing bone and air conduction. B, Rinne test, step 1. Place vibrating tuning fork on mastoid process. Figure 34-15 (continued) Testing bone and air conduction. C, Rinne test, step 2. Reposition still vibrating tines between 2.5 and 5 cm (1 and 2 in.) from ear. Nose and Sinuses How should the nurse perform assessment of the nose and sinuses? inspect the nares palpate sinuses for tenderness or swelling percussing assessing patency of nares, essential for infants to breathe assessing the ability to smell. Figure 34-16 Technique for examining the nose.