Pediatric Nursing Procedure Manual A Padmaja
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Pediatric History Taking and Physical Examination1

ABSTRACT

A number of factors distinguish the pediatric from adult history and physical examination. Depending on the age of the patient, the primary historian may be the patient and/or another person, usually the parent. Developmental factors are commonly considered. The differential diagnosis of a condition may vary depending on the age of the patient. Health care maintenance (e.g. immunization, and safety issues) and social issues play a major role in emergent and routine care. A non-threatening touch can facilitate a physical examination. In contrast to examining older patients, the pediatric examination should start with the organ systems requiring the greatest amount of cooperation. This may vary depending on the type of examination required. In the normal infant, this is usually the cardiovascular and pulmonary examination. The head and neck examination tends to be the most disturbing to the patient and should be deferred until the end of the examination. In older infants and toddlers most of the examination can be more successfully accomplished in the patients lap than on a cold examination table. Telling a story, examining a doll the patient brought to the clinic or engaging the patient in a conversation can significantly decrease the stress associated with the examination for both the patient and examiner, older children and adolescents should be addressed and treated as individuals. The present chapter designed for nursing students to perform the pediatric clerkship. It is designed to take a history and performing physical examination on children of varying ages and to plan nursing process.
Key words: Developmental stage, family tree, body built, anthropometric measurements, reflexes, case presentation, nursing process, pedigree charts, consanguineous marriage  
PROFILE OF THE CHILD
Name of the child
:
Master or baby's name
Age
:
In months or years
Gender
:
IP No.
:
Ward
:
Developmental stage
:
Whether infant or toddler or preschooler or school age child.
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Name of the father
:
Occupation of father
Name of the mother
:
Occupation of mother
Income
:
Address
:
Introduction to child
:
A brief note about the child, siblings, family position of child in the family, religion, language, schooling and note about the first encounter with the child and the significant others.
Current complaints
:
Complaints at present
Past health history
:
History of any life threatening or chronic problem, which needed admission to hospital, treatment given, prognosis and follow up measures taken.
Birth history
:
Antenatal
:
Whether the child's mother during pregnancy had taken folic acid tablets, TT injection, regular antenatal checkups, and any other medicine used by her.
Intranatal
:
The child delivered normally or by cesarean section, APGAR score of the child, any birth trauma, and anesthesia (if known), onset of respiration, first cry, kind of labor.
Postnatal
:
History of neonatal convulsion or jaundice, rashes, congenital abnormalities.
Family history
:
describe any family health problems hereditary/communicable diseases.
Family tree
:
Mention the child's three degree generation
Sibling history
:
The siblings of the child, any illness, their relationship with each other to be mentioned.
 
IMMUNIZATION HISTORY
Name of the vaccine
Schedule time
Child's due
Inference
Development milestones
:
The child's milestones attained upto three years of age.
Play history
:
The play activity of the child to be mentioned, which games the child likes to play and with the peer group.
Personal history
:
Child's relationship with siblings, peers and family members, child's communication skill.
Habits
:
Any habits of thumb sucking, nail biting, temper tantrum, head banging, pica, etc. to be mentioned.
Dietary history
:
Breast feeding, weaning foods, vegetarian food, non-vegetarian food, likes and dislikes, number of meals taken to be mentioned.
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PHYSICAL EXAMINATION
 
A. Head to Foot Assessment
Nourishment
:
Body built
:
The child's body built whether mild, moderate or severe to be mentioned.
Activity
:
The child is dull, active or very active.
Mental status
:
Whether the child is in conscious, semi-conscious or unconscious stage to be mentioned.
Head
:
Size, shape, circumference, asymmetry, cephalhematoma, craniotabes, molding, fontanel (size, tension, number, abnormally late or early closure), sutures, dilated veins, scalp, hair (texture, distribution, parasites) face.
Face
:
Symmetry, paralysis, distance between nose and mouth, depth of nasolabial folds, bridge of nose, distribution of hair, size of mandible, swellings, hypertelorism, chvostek's sign, tendernesss over sinuses.
Eyes
:
Photophobia, visual acuity, muscular control, nystagmus, epicanthic folds, lacrimation, discharge, lids, exophthalmos or enophthalmos, conjunctiva, papillary size, shape, reaction to light and accommodation, media (corneal opacities, cataracts), fundi, visual fields (in older children). At 2–4 weeks an infant will follow light. By 3–4 months, coordinated eye movements should be seen.
Nose
:
Exterior, shape, mucosa, patency, discharge, pressure over sinuses, flaring of nostrils, septum.
Mouth
:
Lips (thinness, down turning, fissures, color, cleft), teeth (number, position, caries, mottling, dis-coloration, notching, maloculusion or malligment), mucosa (color, redness of stenen's duct, epsteins pearls). Gum, palate, tongue, uvula, mouth, breathing.
Throat
:
Tonsils (size, inflammation, exudates, crypts, inflammation of the anterior pillars), mucosa, hypertonic lymphoid tissue, epiglottis, voice (hoarseness, stridor, grunting, type of cry, speech). The number and condition of the teeth should be recorded.
Ears
:
Pinnas (position, size), tympamic membranes (landmarks, mobility, perforation, inflammation, discharge). Mastoid tenderness and swelling, hearing (including hearing screen).
Neck
:
Position (torticollis, opistholonos, inability to support head, mobility), swelling, thyroid (size, contour, bruit, isthmus, nodules, tenderness), lymphnodes, veins, position of trachea, sternocleidomastoid (swelling, shortening), webbing, edema, auscultation, movement, tonic neck reflex.
Thorax
:
Shape and symmetry, veins, retractions, and pulsations, beading, Harrison's groove, flaring of ribs, pigeon chest, funnel shape, size and position of nipples, breasts, length of sternum, intercostals and substernal retraction, asymmetry, clavicles.
Lungs
:
Type of breathing, dyspnea, prolongation of expiration, cough, expansion, fremitus, flatness or dullness to percussion, resonance, breath and voice sounds, rales, wheezing.
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Heart
:
Location and intensity of apex beat, precardial bulging, pulsation of vessels, thrills, size, shape, auscultation (rate, rhythm, force, quality of sounds compare with pulse rate and rhythm friction rub) murmurs (location, intensity, position in cycle, pitch, effect of change of position, transmission, effect of exercise).
Abdomen
:
Size and contour, visible peristalsis, respiratory movements, veins (distension, direction of flow), umbilicus, hernia, musculature, tenderness, rigidity, tympany, shifting, dullness, tenderness, rebound tenderness, pulsation, palpable organs or messes (size, shape, position, mobility) fluid wave, femoral pulsations, bowel sounds.
Male genitalia
:
Circumussion, meatal opening, hypospadias, phimosis, adherent foreskin, size of testes, cryptorchidium, scrotum, hydrocele, hernia, pubertal changes.
Female genitalia
:
Vagina (imperforate, discharge, adhesions), hypertrophy of clitoris, pubertal changes.
Rectum and anus
:
Irritation, fissures, prolapsed, imperforated anus, rectal examination should be performed with the little finger (inserted slowly). Note the muscle tone, character of stool, masses, tenderness, sensation, examine stool on glove finger (gross, microscopic, culture) as indicated.
Extremities
:
Deformity, hemiatrophy, bowlegs (common in infancy), knock knees, paralysis, edema, coldness, posture, asymmetry, extra digits, gait, clubbing, curvature of little finger, deformity of nails, splinter hemorrhages, abnormalities of feet, dermatoglyphics, width of thumbs and big toes, syndactyly, dimpling of dorsa, temperature.
Spine and back
:
Posture, curvatures, rigidity, webbed neck, spine bifida, pilonidal dimple or cyst, tufts of hair, mobility, Mongolian spots, tenderness over spine, pelvis or kidneys.
 
B. Basic Physiological Data
Vitals
Normal value
Child's value
Inference
Temperature
Pulse
Respiration
 
Anthropometric Measurements
Name of the measurement
Child's value
Normal value
Inference
Height
Weight
Head circumference
Chest circumference
Abdominal circumference
Reflexes: Need to be assessed if the child is new born or neonate.5
 
C. Summary of Physical Examination
 
Investigations
Sl. No.
Name of the Investigation
Child's value
Normal value
Inference
 
Drug Regimen
Sl. No.
Drug name
Dose and route
Action
Indications
Contraindications
Side- effects
Nursing implications
Time plan
:
Note: Time plan can be changed according to hospital policies, doctors’ rounds and condition of the child.
 
List out Nursing Diagnoses: (As per NANDA)
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Nursing Process: (As per priority)
Assessment
Nursing diagnosis
Goal
Planning
Implementation
Rationale
Evaluation
Subjective data:
Objective data:
Case Presentation
Apart from the above following need to be included,
Review of Literature (detailed description of the disease):
• Definition
• Incidence
• Etiology
• Pathophysiology
• Clinical features
Book features
Child's features
  • Complications
  • Investigations
Book features
Child's features
  • Treatment: Medical Management, Surgical Management, Nursing Management need to be mentioned
Book features
Child's features
Nursing process: As given above
Brief summary of the care given with evaluation
:
Conclusion and self evaluation of care given
:
Bibliography
:
Note: Select a patient who is acute/subacute stage of illness. Continued care must be given for a minimum of 5 days. Nursing process for the first day should be submitted within 24 hours.7
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