Physical Assessment 0-4 Years

Community Health Clinical Nursing Manual GUIDELINE Physical Assessment 0-4 years Scope (Staff): Community health staff Scope (Area): CAHS-CH, WACHS Child Safe Organisation Statement of Commitment CAHS commits to being a child safe organisation by applying the National Principles for Child Safe Organisations. This is a commitment to a strong culture supported by robust policies and procedures to reduce the likelihood of harm to children and young people. This document should be read in conjunction with this disclaimer Aim To conduct comprehensive and systematic physical assessments that focus on identifying key risk and protective factors and implementing early interventions according to client need, to maximise optimal health and developmental outcomes. Risk Where there are delays in identifying health and developmental concerns, this negatively impacts on children developing to the best of their ability.1 Background There is compelling evidence that early childhood is a sensitive period for child development and functioning.2 Community health nurses conduct comprehensive cephalocaudal physical assessments as a component of a holistic assessment, using evidence informed knowledge and skills, and clinical judgement through: • Eliciting and responding to parental concerns • Gathering information about the child’s current abilities and functions • Identifying risk and protective factors • Using evidence informed assessment methods and tools that are age appropriate.3 4 Physical Assessment 0-4 Years The Pediatric Physical Examination: An Illustrated Handbook and Mary Sheridan’s from birth to five years: Children’s developmental progress, have guided the content for specific body systems assessments for the following age parameters: • Appendix A: Neonate – Birth to four weeks • Appendix B: Infant – One month to twelve months • Appendix C: Children – Twelve months to four years Key points • Comprehensive physical assessments will be conducted at Universal contacts according to Universal Contact Guidelines and at other times, as required. • Commence parts of the physical assessment that require the child to be in a quiet and alert state, prior to undertaking a comprehensive assessment. • The child is the focus of care and their best interests are the primary consideration in all decisions. • Nurses think critically and use the best available evidence and relevant policy documents, in making decisions and providing care that is safe, appropriate and responsive. • Nurses will provide additional contacts for monitoring of deviations from normal and/or will refer to a General Practitioner or other appropriate medical service, for further management. • The Guidelines for Protecting Children 2020 publication will guide practice when nurses have concerns that a child is being, or has been, abused.5 Documentation • Nurses maintain accurate, comprehensive and contemporaneous documentation of assessments, planning, decision making and evaluations; in electronic and/or MR600 child health records. References 1. Sharma A, Cockerill, H.,. From Birth to Five Years: Children's Developmental Progress. 4th ed. Abingdon, Oxon: Routledge; 2014. 2. Department of Health. National Action Plan for the Health of Children and Young People: 2020-2030. Perth: Government of Western Australian 2019. 3. Duderstadt K. Pediatric Physical Examination: An Illustrated Handbook. 3rd Edition ed: Elsevier Health Sciences; 2019. 4. Sharma A, Cockerill H. From Birth to Five Years: Practical Developmental Examination: Taylor & Francis; 2014. 5. Department of Health: Child and Adolescent Health Services. Guidelines for Protecting Children: 2020. Perth: Government of Western Australia; 2020. Page 2 of 82 Clinical Nursing Manual Physical Assessment 0-4 Years 6. Dietitians of Canada, Canadian Paediatric Society, The College of Family Physicians of Canada, Community Health Nurses of Canada. Promoting optimal monitoring of child growth in Canada: Using the new World Health Organization growth charts – Executive Summary. Paediatrics & Child Health. 2010;15(2):77-9. Related policies, procedures and guidelines The following documents can be accessed in the Clinical Nursing Manual via the HealthPoint link, Internet link or for WACHS staff in the WACHS Policy link Universal contact guidelines (0-14 days, 8 weeks, 4 months, 12 months, 2 years, SEHA) Related CAHS-CH forms The following forms can be accessed from the CAHS-Community Health Forms page on HealthPoint Breastfeeding Assessment Guide form (CHS012) Related CAHS-CH resources The following resources can be accessed from the CAHS-Community Health Resources page on HealthPoint Early Parenting Groups: Facilitator Guide How children develop Indicators of Need Practice guide for Community Health Nurses Related external resources Advance Pediatric Assessment. 2019. Ellen M Chiocca. Guidelines for Protecting Children 2020. Statewide Protection of Children Coordination Unit, Child and Adolescent Community Health. Page 3 of 82 Clinical Nursing Manual Physical Assessment 0-4 Years Nursing and Midwifery Board of Australia. Code of conduct for nurses and Code of conduct for midwives. 2018 Nursing and Midwifery Board of Australia. Registered Nurses Standards for Practice. 2016. This document can be made available in alternative formats on request. Document Owner: Nurse Co-Director, Community Health Reviewer / Team: Clinical Nursing Policy Team Date First Issued: 2007 Last Reviewed: May 2021 Amendment Dates: Next Review May 2024 Date: Approved by: Community Health Clinical Nursing Policy Date: 23 April 2021 Governance Group Endorsed by: Executive Director of Nursing and Date: 10 May 2021 Executive Lead Community Health Standards Applicable: NSQHS Standards: Child Safe Standards: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 Printed or personally saved electronic copies of this document are considered uncontrolled Page 4 of 82 Clinical Nursing Manual Physical Assessment 0-4 Years Appendix A: Neonate - Birth to four weeks Birth to 4 weeks - Area Within the Norm Common Deviations Possible Causes Specific Strategies General Appearance • Facial expressions • Initial presentation of • Deviations from the • Genetic conditions Concerns will be the neonate is norm may be initially documented and • Posture • Pregnancy complications consistent with the identified through noted for additional • Hydration and situation (e.g. crying assessing the general • Birth trauma monitoring and/or nutritional health due to hunger) appearance of the referral to a medical • Congenital or non- neonate practitioner • Activity level • Neonate is healthy congenital conditions and developing • Recognise indicators • Temperament • Child abuse appropriately for child abuse, Refer to the • Responsiveness including but not Guidelines for limited to: injury, • Interaction with protecting children bruising, burns, retinal others 2020 publication for haemorrhages, bite • Proportion of body marks, fractured more information. parts bones, bleeding, pain or physical discomfort • Symmetry of body or poor standard of parts hygiene. • Movement and • Assess appearance of capacity child with • Skin integrity consideration of their age, level of mobility Observe appearance 1 prior to comprehensive and development. assessment Page 5 of 82 Clinical Nursing Manual Physical Assessment 0-4 Years Birth to 4 weeks - Area Within the Norm Common Deviations Possible Causes Specific Strategies Head (continued next page) Visual inspection with • Rounded • Elongated • Birth trauma Parent education and the neonate resting support may include: • Symmetrical • Asymmetrical o Instrumental delivery supine, and head in • Postural exercises midline, noting: Head circumference • Misshapen • Genetic conditions and repositioning averages: o • General shape • Measurements outside Achondroplasia • Handling • males: 32-39.5cm of expected norm o Noonan syndrome • Size strategies • females: 31.5–39.cm6 o Microcephaly • Hydrocephalus • Circumference o Macrocephaly • Massage When in supine position, • Craniosynostosis • Symmetry • Positioning of toys head will comfortably sit • Lesions, nodules, • Uterine placement to non-favoured • Alignment in the midline masses, birth marks • Intrauterine growth side • Positional head conditions and exposure • Variable preference to tetragons positioning of head • Persistent head tilt • Plagiocephaly when put down to (lateral flexion) sleep Visual inspection and • Anterior fontanelle • Bulging anterior • Birth trauma Monitor premature palpation of: should be open, soft, fontanelle o Caput succedaneum closure of sutures flat, an average of • Suture lines • Sunken anterior o Cephalohaematoma 2cm long by 2-3cm fontanelle • Scalp wide, but can be up to • Changes in intracranial 3 Overriding sutures pressure • Bony structures 5cm long • Bruising • Dehydration • Fontanelles • Posterior fontanelle • should be smaller, • Oedema • Genetic conditions triangular and 0.5 cm long by 1 cm wide 3 • Pitting o Alpert’s Page 6 of 82 Clinical Nursing Manual Physical Assessment 0-4 Years Birth to 4 weeks - Area Within the Norm Common Deviations Possible Causes Specific Strategies o Crouzon • Suture lines can be • Premature closure of overlapping or sutures • Craniosynostosis protuberant Neck (continued next page) Visual inspection • A short neck, which is Movement deviations: • Intrauterine growth Parent education and through the following creased with skin conditions support may include: • Limited range of process: folds motion • Plagiocephaly • Postural exercises • Controlled pulling up • The neck rotates and

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