Health Assessment Paper

Health Assessment Paper

Pediatric Assessment Lab5130

Communication Pearls

• ´Setting up the Environment
• ´Child’s Participation
  • ´Examiner
  • ´Special Consideration
  • ´Pearls to Illicit interaction
    • ´Infants
    • ´Toddlers
    • ´School Age
    • ´Adolescent
  • ´Ethnic/Cultural
  • ´Take aways

Pediatric History/Family History

• ´Chief Concern
• ´History of Present Illness
  • ´Mnemonic
    • ´Old carts
      • ´Example
        • ´Characterization of pain:
        • ´Onset
        • ´Location
        • ´Duration
        • ´Character
        • ´Aggravating/relieving
        • ´Radiation
        • ´Timing
        • ´Severity
        • ´Prior

Pediatric/Family History

• ´Medical History
  • ´Patient
  • ´Family
  • ´Personal/Social
• ´Genogram
  • ´Rules to building a genogram
    • ´https://www.genopro.com/genogram/rules/
  • ´Example of genogram symbols
    • ´http://wellsk.faculty.mjc.edu/genogramdetailed.pdf

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Pediatric/Family History

• ´Review of Systems
  • ´CONSTITUTIONAL:No weight loss, fever, chills, weakness or fatigue.
  • ´HEENT:Eyes:No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose,Throat:No hearing loss, sneezing, congestion, runny nose or sore throat.
  • ´SKIN:No rash or itching.
  • ´CARDIOVASCULAR:No chest pain, chest pressure or chest discomfort. No palpitations oredema.
  • ´RESPIRATORY:No shortness of breath, cough or sputum.
  • ´GASTROINTESTINAL:No anorexia, nausea, vomiting or diarrhea. No abdominal pain orblood.
  • ´GENITOURINARY:Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.
  • ´NEUROLOGICAL:No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling inthe extremities. No change in bowel or bladder control.
  • ´MUSCULOSKELETAL:No muscle, back pain, joint pain or stiffness.
  • ´HEMATOLOGIC:No anemia, bleeding or bruising.
  • ´LYMPHATICS:No enlarged nodes. No history of splenectomy.
  • ´PSYCHIATRIC:No history of depression or anxiety.
  • ´ENDOCRINOLOGIC:No reports of sweating, cold or heat intolerance. No polyuria orpolydipsia.
  • ´ALLERGIES:No history of asthma, hives, eczema or rhinitis.

Pediatric Exam Techniques

• ´Inspection
  • ´Sight, Hearing, Smell
  • ´Starts as soon as you walk in the room
  • ´Initial impression sets the tone
  • ´Inspection
  • ´Palpation
  • ´Percussion
  • ´Auscultation
  • ´Examination of the Child
  • ´Special Considerations

Preparation For Examination

• ´Examination Space
  • ´Avoid
  • ´Provide
• ´General Guidelines
• ´Exam
  • ´Age Related Approaches
    • ´1 month to 1 year
    • ´Toddler—12 months to 3 years
    • ´Preschool 3-5 years
    • ´School age 6-12
    • ´Adolescents 12 and older

Pediatric Vital Sign Specifics

Pediatric Growth and BMI

Developmental Exam—1month to 5months

• ´History
  • ´Mothers pre pregnancy history
  • ´Pregnancy history
  • ´Birth Information
  • ´Post Natal information
  • ´Family History
• ´I month
  • ´30 grams per day
• ´2 month
• ´3 months
• ´4 Month
• ´5 month

Developmental Exam—6 to 12 months

Developmental Exam: 1-4 yearsam-1-4years

Developmental Exam—5-10 years

DevelopmentalExam 11-20 years