Pediatric Assessment Report Assessment techniques need to be modified to accommodate pediatric patients at different developmental stages. For infant patients, you will want to start the assessment with less invasive, quiet procedures like vitals and heart, lung, and bowel sounds. You may also want to consider performing procedures in the parent’s lap for security and controlling mobility in older infants (6-12 months). Younger infants should be placed on padded exam tables. Always remember to keep the parent close and within infant’s range of vision.
Infants are also soothed by calming voices, warm hands, eye contact, and smiling faces. When assessing preschooler-aged children, one should consider using some of the similar techniques as used with an infant such as assessing while in the parent’s lap for security, and doing the least intrusive steps first (saving the mouth, ears, and nose, throat for last). Explain procedures in a simple way to the child first. It is also helpful to demonstrate the procedure first on a stuffed animal or doll, to make the activity a game, and to let the child interact with the equipment and try it on themselves first.
Compliment child on cooperative behaviors and provide needed feedback and reassurance, “your tummy feels fine. ” While obtaining a history from the parent note the child’s ability to self amuse, their gross/fine motor skills, and interaction/relationship with the parent. Then also interact with and note the behavior, appearance, posture, speech, vision/hearing, and social interaction of the patient. When assessing the school age patient, respect the modesty of the patient and answer questions honestly. Address questions more directly to patient over parent, and explain procedures in more concrete terms than the younger children.
The child should be sitting or lying on the exam table. Offer to examine older children (ages 11-12) without parent present. Break the ice with small talk about school, family, friends, sports, or music. Progress through the exam from head to toe, as with an adult. Medical diagrams and teaching dolls are helpful techniques as well as eliciting active participation from the child in the history, exam, and care plan. When assessing an adolescent patient, do not treat the patient like a child, but do not overestimate and treat them like an adult either.
Progress through the exam from head to toes, as with an adult. Remember that confidentiality, privacy, and protection are important. Explain the parameters of this confidentiality to patients. Offer to examine the patient alone, without the parent present and the patient should be sitting on the exam table. Address questions directly to patient. Keep in mind, depression is more common in adolescents, especially girls. Also be aware of the female patient’s view of body image, weight, and satisfaction level.
It is important to look for social withdrawal, irritability, and changes in school performance in male patients. Be open and nonjudgmental to questions about the adolescent’s changing body and during exam provide feedback that changes are normal. Remember to utilize the opportunity for health teaching and promotion. SOAP Note Subjective: Patient states “it hurts to swallow”. Patient tugs at ears and mother states she has a fever and chills. Objective: Tonsils appear bright red and swollen bilaterally. Tonsils enlarged to 3+ bilaterally. White spots visible on tonsils bilaterally.
Temperature of 103. 5° indicating fever. Blood pressure of 90/52, respiratory rate of 22, and pulse of 100. Height of 42″ and weight of 63 lbs. Heart sounds are regular and lung sounds are clear bilaterally. Assessment: Patient is having difficulty and pain when swallowing due to inflammation of the tonsils, tonsillitis, which is associated with a fever due to the infection. Patient is also in the 90th percentile for height, but above the 97th percentile for weight. BMI is also above the 97th percentile indicating that she is considered overweight for her age.
Plan: The patient should be evaluated for the type of infection with a throat culture of the bacteria and should be taught on proper use of antibiotics, the use of analgesics to relieve pain and antipyretics to reduce the fever such as acetaminophen or ibuprofen. Teach parent not to give the child aspirin and the risks of doing so (Reye syndrome). Offer therapeutic remedies such as warm salt water gargles and drinking cold liquids and popsicles to relieve pain. The patient should allow for rest and adequate fluid intake. The patient should follow-up care if the fever and welling of tonsils does not reduce after intervention within 2-3 days. Patient should also notify their provider if the child presents with excessive drooling, prolonged high fever, red rough rash and increased redness to skin folds, or severe difficulty swallowing or breathing. The patient should also be evaluated and consider follow-up care concerning her weight. Assessment and teaching should be done on nutrition and obtaining a healthy lifestyle including diet and exercise as well as stressing the serious health risks associated with childhood obesity. Care Plan
Medical Diagnosis: Tonsillitis and Childhood Obesity Nursing Diagnosis: Swallowing difficulty and pain related to inflammatory process. Altered nutrition: more than body requirements secondary to obesity, BMI exceeds 95th percentile. Goals: To relieve pain, swelling, and reduce fever due to inflammation. To decrease excessive weight through adjusting nutrition and increasing activity level. Interventions: Teach patient’s parent on properly taking antibiotics if needed and on taking over-the-counter analgesic to reduce pain, fever, and inflammation. Instruct against aspirin in children.
Inform that patient must have adequate rest and fluid intake. Offer therapeutic remedies such as warm salt water gargles and drinking cold liquids and popsicles to relieve pain. Let patient know to follow-up if symptoms don’t decrease in 2-3 days and the complications which would require notifying the provider. Teach patient on the serious health risks of childhood obesity and interventions that can be taken on decreasing weight through healthy diet and exercise. Follow-up with provider to check for metabolic disorders causing excessive weight and with nutritionist to promote healthy lifestyle.
Self-Evaluation This assignment was very informative on how to asses pediatric patients. In lab and clinical we have not yet had exposure to pediatric patients and have, therefore, not had to be concerned with any special considerations that we may need when assessing them. The information I learned in this report was extremely helpful and pertinent because it exposed me to elements I have not encountered prior. I do not have much experience with children and found the tips and adjustments for assessing the pediatric patient new and useful.
I don’t think I would have considered many of the adjustments on my own, especially considering my lack of prior exposure to children of these age groups. I feel like I did a sufficient amount of research and preparation for this report by looking through both the videos and readings, as well as lectures, to provide me with the information needed to perform an accurate assessment on a pediatric patient and the proper documentation of patient information. I do still worry about whether my documentation is as concise and thorough as it could be and whether it is documented in a way that a nurse would properly document the information.
Creating the nursing care plan was still fairly new to me, especially when applying it to one specific medical diagnosis. Because this was new to me, however, it was also good experience in creating these sort of care plans and in proper documentation. The techniques I learned through this report are extremely important for providing patient comfort and promoting more accurate findings by keeping a comfortable and trustworthy environment. The documentation experience I gained will help to support accurate recording of patient findings and, as a result, promote proper and complete care of patients.