This is the act of reviewing the physical state and functions of the body. It includes all the body systems and the findings that informs the paediatric nurse on the child’s overall condition. A comprehensive head to toe assessment is done on first visit to a health facility, on admission and at the beginning of each shift. When conducting assessment with various age groups, care should be taken to adapt to health assessment task to accommodate for different developmental levels.
Aims
· Serves as baseline data
· Helps identify treatment options appropriate for the child
· Ascertain the health needs
· Assists in diagnosing the condition of the child
Types
· Complete Health Assessment
· Problem Focused Assessment
Requirements
· Pen and paper
· Child’s folder (manual or electronic)
· Conducive environment
· Table and chair
· Stethoscope
· Tape measure
· Pain scale
· Vital signs tray
· MUAC tape
· Weighing scale
· Diagnostic set
· Spatula
· Cotton wool swabs in gallipot
· Perfume
Steps
1. Perform hand hygiene
2. Ensure child’s privacy and dignity
3. Establish rapport (refer steps)
4. Explain procedure to child, caregiver/family (refer steps)
5. Carry out assessment in systematic order
6. Listen and attend to child’s cues
7. Use appropriate listening and questioning skills
8. Observe the general appearance of the child (e.g. gait, colour, facial expression activity level etc.)
9. Check vital signs (temperature pulse respiration, blood pressure, pain and oxygen saturation)
10. Measure weight, length, head and chest circumference (0-5years)
11. Measure weight and height (6-18years)
12. Examine the head for the following:
a. Shape, size, scars, swelling, bleeding, condition and distribution of hair
b. Anterior fontanel after 18 months for bulge or sunken (perform gentle palpation)
c. Eyes for symmetry, colour, vision, discharge, squint etc.
d. Nose for colour of the mucosal lining swelling, discharge, dryness, bleeding, patency of the nares, symmetry, deformity and septal deviation
e. Ear discharge from external auditory meatus, shape, lesions, position, hearing loss (visualize the ear with backwards and downwards technique for infant and up and back technique for older children)
f. Mouth and Throat: tonsils, uvular, palates, dentition, odour, etc.
g. Neck for control, swelling, lymph nodes, size, range of motion
13. Respiratory system
a. Look out for breathing: laboured, listen to breath sounds, air entry, feel respiratory rate by placing hand on abdomen or chest to feel for rise and fall or use stethoscope count for 1 min
b. Examine chest for scars, size, tenderness, masses, symmetry and vocal fremitus etc.
c. Palpate breast for lumps and nipple for symmetry
14. Cardiovascular system
a. Look for general perfusion (warmth of skin, colour of skin), swelling and oedema
b. Listen to heart rate, blood pressure, apex beat and heart sounds
c. Feel for capillary refill, femoral and peripheral pulse
15. Abdomen
a. Look for distension, symmetry, scars, birth marks, rashes, masses etc.
b. Auscultate bowel sounds, bruit of the major arteries
c. Feel the quadrants for pain, bowel distension, masses,
d. Percuss for dullness, fluid thrill and shifting dullness
16. Musculo-skeletal system
a. Examine the back area by turning the patient to the side or ask to sit up or lean forward
b. Inspect the back and spine for curvature (any scoliosis)
c. Examine for muscle weakness
d. Determine ability to ambulate (note any aids) without pain
e. Look at extremities for length, size, colour, tenderness and masses
f. Assess joints and muscles for flexion, extension, abduction, adduction and rotation
g. Inspect the symmetry and observe for any oedema
17. Examine the extremities for the following:
a. Symmetry of length and size
b. Shape of bones, temperature and colour
c. Check knees for bowlegs; and space between the knees
d. Inspect for knock knees
e. Palpate for oedema
f. Assess for muscle strength
18. Perform neurological assessment by looking out for child’s behavior, attention span, state of consciousness, sensation, balance and coordination, reflexes, verbal responses etc.
19. Genitourinary System:
a. Examine the genitalia bearing in mind the sensitivity to age groups
b. Inspect when changing the diapers or at an appropriate session
c. Examine the urine for colour(if available)
d. Observe for redness, rash, swelling, scrotal size(male), lesions, odour, urethral opening and discharge, vaginal discharge or bleeding
e. Listen or ask if there is pain on urination
f. Ask about frequency of micturition
20. Skin, hair and Nails:
a. Inspect for lesions, bruising and rashes
b. Palpate skin for temperature, texture and moisture
c. Inspect pressure areas for colour changes
d. Inspect nails for shape and colour
e. Carry out general observation for swelling or oedema
21. Communicate findings to child, caregiver/family
22. Express appreciation to child, caregiver/family for their cooperation
23. Document findings in child’s folder and nurses notes (manual or electronic)
24. Dispose off, decontaminate and clean used items
25. Report findings to Nurse Manager/Paediatrician in-charge
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