Can they walk? Crawl? Is their behavior THEIR normal ? Musculoskeletal Assessment: Cast and Splint Care Many of our patients will be in casts. With every assessment we must check AND DOCUMENT the affected extremity for: o SENSATION: can they child feel you touch? o PERFUSION: capillary refill time (2-3 seconds or less) o CIRCULATION: pulse present o MOVEMENT: can the child move fingers/toes/arm/ etc. Wiggle finger/toe It is never appropriate to remove a splint, create hole, etc in order to assess a pulse, unless there is an order to do so. If concerned, call the doctor. Respiratory Assessment Obtain first and while listening/getting vital signs Listen to lungs sounds anteriorly and posteriorly Watch how the child breathes o Laboring , working hard, retracting? o Tripod sit - Leaning over
o Any extra noises while breathing (grunting, stridor)? Noisy breathing o Drooling – cant control saliva because focused on breathing Drooling, talking, crying (can breath) Respiratory Assessment: Retractions 88% Nasal cannula - up to 6L 60% non- rebreathing – 6-10L 75% simple face mask – 10-15L Oxygen hood – O pumped into environment – more in NICU, pt cant ₂ tolerate NC Cardiac Assessment Try to do first Feel pulses in upper and lower extremities (brachial pulse until age 2 years) Rate and rhythm of heart sounds o Lub/dub o Abnormal = murmurs Assess skin color o Look at mouth! Circumoral cyanosis! o Capillary refill Pulses brachial/radial & feet Any sweating? o Heart working too hard… Gastrointestinal Assessment Auscultate bowel sounds first Gently palpate abdomen (unless suspected or diagnosed Wilm’s Tumor ) o Hard = probs stool Note last BM and if potty trained Note child’s diet (NPO, regular, diabetic, etc.) o Ordered AND what they eat Note how child eats (bottle, sippy cup, breast fed, self-feed vs other)
Genitourinary Assessment Explain to child safety of exam o Have to look at privates vs bottom – have to do it because it is part of your body and have to make sure its ok, mom/parent right here, I am a nurse and it is not a secret. Do in presence of parent/caregiver unless child wants parent out of room (generally after puberty) Tanner Staging May be able to defer on subsequent exams IF no GU/perineal complaints o May have to check once /shift o If diapered, HAVE to check o Potty trained & no complaints = no more checks If child is diapered (no matter the age) MUST do a GU exam and assess skin Note how child voids (diaper, potty chair, etc.) Look in diaper to see whats in it, no wipes, observe poops Weigh all diapers WITHOUT wipes in them (remind parents) o Weight is in grams (1 mL =1 gram ) Head, Eyes, Ears, Nose, Throat Generally more advanced exams More observational in nature Note the general shape, size, contour of the head Note abnormal coloring, drainage, shape of eyes, ears nose, throat Eyes Eyes symmetrical, conjugate gaze, any abnormal color?
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- Spring '17