Essentials for
School Nurses
the
History
Bio-graphic Demographic Past Medical History
• Name, Date of Birth, Age •Allergies
•Past illness
• Parents & siblings info
•Trauma / hospitalizations
• Cultural practices •Surgeries
• Religious practices •Birth history
• Parents’ occupations •Developmental
• Adolescent – work info •Family Medical/Genetics
• Skin • GI
• HEENT • GU & GYN
• Neck • Musculoskeletal
• Chest & Lungs / & Extremities
Respiratory • Neuro
• Heart & • Endocrine
Cardiovascular
THIS OLD CART
O____
L_______
D_______
C______________
A__________ _______
R________ _______
T________
Patti’s Nitty Gritty Trio
• Always ABCs!
Appearance
• PAT: Pediatric Includes
Assessment LOC & Behavior
Triangle
• Ongoing Triage – PAT
• Minor vs.
• Serious vs.
Life-Threatening Breathing Changes Skin Circulation
• Problem- Focused
Examination
PAT
General Appearance
Work of Breathing
Circulation to the Skin
APPEARANCE
Tone
Interactiveness
Consolability
Look/gaze
Speech/cry
Work of Breathing
• Increased or
Decreased
Respirations
• Stridor
• Wheezing
Circulation to the Skin
• Inadequate perfusion
of vital organs
• Leads to
compensatory
mechanisms in non-
essential functions
• Ex: vasoconstriction in
the skin.
Initial Assessment (s)
• Primary • Secondary
• A = Airway • E = Exposure
• B = Breathing • F = Full Set of Vitals
• G = Give Comfort
• C = Circulation Measures including Pain
• D = Disability Assessment & Tx.
• H = Head –to-Toe
assessment & history
• I = Inspect posterior
surfaces – rashes,
bruising
Physical Assessment
• The approach is:
• Orderly
• Systematic
• Head-to-toe
• Facial expression
• Posture / movement
• Hygiene
• Behavior
• Developmental Status
Vital Signs
• Respiratory Rate
24-38 22-30 14-22 12-22
• General • Heart
• Skin, hair, nails • Abdomen
• Head, neck, • Genitalia, Tanner Scale,
lymph nodes • Rectal
• Eyes, ears, nose, • Musculoskeletal: feet,
throat legs, back, gait
• Chest, Tanner Scale
Physical Assessment
• Four Basic Skills:
1. Inspection
2. Palpation
3. Percussion
4. Auscultation
LUNGS:
Listen to all lung fields
FRONT AND BACK!
auscultate for breath sounds and adventitious sounds
“I P P A”
• Practice, Practice, Practice
• by knowing what the norm is, you’ll be able
to pick up on the abnormal, even if you
can’t diagnose it….
• The important thing is to be able to say
“This is not right”
• and refer appropriately!
H E E N T
Head
Eyes
Ears
Nose
Neck
Throat
HEENT: Head & Neck, Eyes, Ears,
Nose, Face, Mouth & Throat
• Head: Symmetry of skull and face
• Neck: Structure, movement, trachea, thyroid,
vessels and lymph nodes
• Eyes: Vision, placement, external and internal
fundoscopic exam
• Ears: Hearing, external, ear canal and
otoscopic exam of tympanic membrane
• Nose: Structure, exudate, sinuses
• Mouth: Structures of mouth, teeth and pharynx
Head
• Shape:
“NormoCephalic –
ATraumatic”
• Lesions
• ? Edema
Head: Key Points
C1 - Smell
C2 - Visual acuity, visual fields, fundus
C3, 4, 6 - EOM, 6 fields of gaze
C5 - Sensory to face: Motor--clench teeth,
C5 & C7 - Corneal reflex
C7 - Raise eyebrows, frown, close eyes tight, show
teeth, smile, puff cheeks, taste--anterior 2/3 tongue
C8 - Hearing & equilibrium
C9 – say "ah," equal movement of soft palate & uvula
C10 - Gag, Taste, posterior 1/3 tongue
C11 - Shoulder shrug & head turn with resistance
C12 - Tongue movement
Reflexes
Deep tendon:
• Biceps C5, C6
• Triceps C6, C7, C8
• Brachioradialis C5, C6
• Patellar L2, L3, L4
• Achilles S1, S2
Superficial:
• Cremasteric T12, L1, L2
• Abdominal T7, T8, T9, T10, T11
Infant Automatisms:
• Primitive Reflexes
Glasgow Coma Scale
The lowest possible GCS is 3 (deep coma or death) while the
highest is 15 (fully awake person).
1 2 3 4 5 6
Does not Opens eyes Opens Opens eyes N/A N/A
EYES
open eyes in response eyes in spontaneously
to painful response
stimuli to voice
Source :Wikipedia
Bacterial Meningitis
Clinical Manifestations in an Older Child
• High fever
• Headache
• LOC Changes / GCS
• Nuchal rigidity / stiff neck
• + Kernigs = inability to extend legs
• + Brudzinski sign = flexion of hips when neck is
flexed
• Purple rash (check for blanching)
• “Looks Sick”
HEAD INJURY
• Very common in pediatrics
• Most often not serious
• requires observation only
• Symptoms
- headache
- vomiting
- lethargy
- altered behavior
•Altered mental status: GCS
HEAD INJURY - Physical Findings
• PUPILS
• PAPILLEDEMA
• CUSHING TRIAD:
• bradycardia, irregular respirations and
hypertention
Minimum time
Grade Confusion Amnesia LOC to return Time
to play asymptomatic
Sinusitis:
• Fever
• Purulent rhinorrhea
• Facial Pain – cheeks, forehead
• Breath odor
• Chronic cough – could be day and night
• (+) Post-nasal drip
Mouth & Pharynx: Key Points
• Lips: color, symmetry, moisture, swelling, sores,
fissures
• Buccal mucosa, gingivae, tongue & palate for
moisture, color, intactness, bleeding, lesions.
• Tongue & frenulum - movement, size & texture
• Teeth - caries, malocclusion and loose teeth.
• Uvula: symmetrical movement or bifid uvula
• Voice quality, Speech
• Breath - halitosis
Ears, Nose and Throat
Sore Throats
Is it strept or is it viral
or could it be mono?
Lymph nodes
& ROM
Neck: Key Points
• √ position, lymph nodes, masses, fistulas,
clefts
• Suppleness & Range of Motion (ROM)
• Check clavicle in newborn
• Head control in infant
• Trachea & thyroid in midline
• Carotid arteries (bruits)
• Torticollis
• Webbing
• Meningeal irritation
Chest Assessment
•How does the child look?
•Color
•Work of Breathing: Effort
used to breathe
Auscultation
• All 4 quadrants
• Front and back
• Take the time to listen
• Be sure about “lungs CTAB”
(clear to auscultation bilaterally)
Lungs & Respiratory: Key Points
• Quality of Respirations:
• Symmetry, Expansion, Effort, Dyspnea
• S & S Respiratory Distress:
• Color: cyanosis, pallor, circumoral cyanosis, mottling
• Tachypnea
• Retractions
• Nasal flaring
• Grunting (expiratory)
• Stridor - inspiratory: croup
• Adventitious sounds:
• Crackles / Rales
• Rhonchi - course breath sounds
• Wheeze – inspiratory vs. expiratory
Lungs & Respiratory: Key Points
• Clubbing
• Snoring (expiratory): upper airway
obstruction, allergy,
• Fremitus:
• Increased in pneumonia, atelectasis, mass
• Decreased in asthma, pneumothorax or FB
• Dullness to percussion: fluid or mass
Work of Breathing
• Increased or
Decreased
Respirations
• Stridor
• Wheezing
Chest Assessment
• Auscultation
• Wheezing
• Retractions
• Subcostal
• Intercostal
• Sub-sternal
• Supra-clavicular
Red Flags:
• grunting
• nasal flaring
• stridor
All that Wheezes
isn’t always Asthma…
Think:
• Infection
• Foreign body aspiration
• Anaphylaxis
• Insect bites/stings,
medications, food
allergies
And all Asthma
doesn’t always Wheeze!
• Cough
• Fatigue
• Reduced
exercise
tolerance
Coughs
• Allergies
• Asthma
• Infections – pneumonia, bronchitis,
bronchiolitis
• Sinusitis – Post-nasal drip
• GERD
• Cigarette smoking
• Exposure to secondhand smoke,
• Other pollutants
Cough - Characteristics
• Dry, non-productive
• Mucousy – productive
• Croupy
• Acute – less than 2-3 weeks
• Chronic – more than 2-3 weeks
• Associating Symptoms
Chest Pain
• Call 911 if severe, acute, unremitting –
needs immediate attention - very rare
• Non-cardiac – most common
• Musculoskeletal: costochondritis
• Pulmonary
• Gastrointestinal e.g. GERD
• Psychogenic
• Often no significant physical findings
• Must rule out Cardiac origin – refer to PCP or
pedi cardiologist
Circulatory
•Auscultating Heart Sounds
The Auscultation Assistant – Hear Heart Murmurs, Heart Sounds,
and Breath Sounds. http://www.wilkes.med.ucla.edu/inex.htm
Pillitter
Pillitteri
Abdomen: Key Points
• Contour
• Bowel Sounds & Peristalsis
• Skin: color, veins
• Umbilicus
• Assess for Tenderness, Ridigity, Tympany,
Dullness
• Hernias: umbilical, inguinal, femoral
• Masses - size, shape, dullness, position,
mobility
• Liver, Spleen, Kidneys, Bladder
Bowel Sounds
• Normal: every 10 to 30 seconds.
• Listen in each quadrant long enough to
hear at least one bowel sound.
• Absent
• Hypoactive
• Normoactive
• Hyperactive
Stomachaches and
Abdominal Pain
• Excessive gas • Heartburn or
• Chronic constipation indigestion
• Lactose intolerance • GERD
• Viral gastroenteritis • Food allergy
• Irritable bowel • Parasite infections
syndrome (Giardia)
• Appendicitis • Hernia
• Bowel obstruction --
Cholecystitis with or without
• Intussusception
gallstones • Kidney stones
• Food poisoning • Pancreatitis
(salmonella, shigella) • Sickle cell crisis
• Inflammatory Bowel • Ulcers
Disease –
• Crohn's disease
• Urinary tract
• Ulcerative colitis
infections
Signs and Symptoms
Soft, non-tender,
non-distended
no rebound, no HSM,
no mass,
BS NA x 4Q
Key Points:
•Barefoot
Medline.com
•Feet Together
•Bend Over –”Diving Of a Diving Board”
•Check Hips
Assessment
• Bacterial infections
• Abscess formation
• Severity varies with skin integrity,
immune and cellular defenses
• Examples:
• impetigo
• cellulitis
Viral Skin Infections
• Urticaria
• Psoriasis
• Alopecia
• Intertrigo
• Stevens-Johnson syndrome
• Neurofibromatosis
Atopic Dermatitis
Goals:
• Relieve pruritus
• Hydrate skin
• Reduce inflammation
• Prevent or control secondary infection
WOUND CLASIFICATION
CLINICAL NON-TETANUS- TETANUS-PRONE
FEATURES PRONE WOUNDS WOUNDS
Age of wound <6 hours >6 hours
configurations Linear wounds, Stellate, avulsion
abrasions
depth <1cm >1cm
Mechanism of injury Sharp surface Crush, burn, missile
Sings of infection absent present
Devitalized tissue absent present
Contaminants (dirt, absent present
feces, soil, saliva )
Denervated/ischemic absent present
tissue
The School-Age Child
• Privacy and
modesty.
• Explain procedures
and equipment.
• Interact with child
during exam.
Adolescent
PAT
and
Breathing Changes Skin Circulation
• Allergic
Reactions
• Asthma
• Head
• Abdomen
• Limb
• Other
The Frequent Fliers
• Headaches
• Stomachaches
• Nosebleeds
• Chest Pain
• Coughs
• & Fevers
Frequent Fliers
• Developmental Delays
• Depression
• Aggressive Behaviors
• Suicide Risks
• Other Mental Health
Issues
Chronic Conditions &
Special Needs
• Asthma
• Diabetes
• Neuro – seizures
• Sickle Cell Anemia
• Cerebral Palsy
• ADHD
Additional “To – Do’s”
• Documentation
• –SOAP Notes
• Quality Improvement
– - chart reviews
• Confidentiality –
seriously!
Resources and References
• Jan Chandler RN, MSN, CNS, PNP Pediatric Nursing: Nursing Care of
Children and Young Adults: Pediatric Physical Assessment
• Colyar, M. Well Child Assessment for Primary Care Providers. Philadelphia,
PA: F.A. Davis Company.
• Duderstadt, K. Pediatric Physical Examination.
St. Louis, MO: Mosby, Inc.
• Engel, J. Pediatric Assessment 5th. Ed. St. Louis, MO: Mosby, Inc.
• Wong’s Essentials of Pediatric Nursing 8th ed.
• AAP Preparticipation Physical Evaluation. Available @ www.aap.org
• Resource Manual for the Nurse in the School Setting http://www.ems-
c.org/school/frameschool.htm
• American Medical Association Guidelines for Adolescent Preventive
Services (GAPS) http://www.ama-assn.org/ama/pub/category/2280.html
• American School Health Association http://www.ashaweb.org
• The Auscultation Assistant @
http://www.wilkes.med.ucla.edu/intro.html
• BMI Calculator: http://www.cdc.gov/nccdphp/dnpa/bmi /
• 2007 Asthma Guidelines:
http://www.nhlbi.nih.gov/guidelines/asthma/index.htm
We Know
It’s a Jungle Out There!
The Power of Nursing
Never doubt how vitally important you are;
never doubt how important your work is –
and never expect anyone to acknowledge it
before you do.
Every moment, in everything you do,
you are making a difference.
In fact, you are in the business of making a
difference in other people’s lives.
In that difference lies their healing
and your power.
Never forget it.
Leah L. Curtin, RN, MS, MA, DSC, FAAN