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,...
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