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Pediatric Assessment for School Nurses: Respiratory, Eyes, Ears, Nose, and Throat

Pediatric Assessment for School Nurses: Respiratory, Eyes, Ears, Nose, and Throat. Jennifer Goldman-Luthy, MD, MRP, FAAP Assistant Professor of General Pediatrics, University of Utah October 25, 2013. Objectives.

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Pediatric Assessment for School Nurses: Respiratory, Eyes, Ears, Nose, and Throat

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  1. Pediatric Assessment for School Nurses:Respiratory, Eyes, Ears, Nose, and Throat Jennifer Goldman-Luthy, MD, MRP, FAAP Assistant Professor of General Pediatrics, University of Utah October 25, 2013

  2. Objectives • Perform a focused assessment of the respiratory system, eyes, ears nose and throat/oral cavity. • Recognize normal and abnormal findings on physical exam • Use physical exam and history to distinguish various causes of abnormalitiesseen in the school setting

  3. Pediatric Exam Principles • Kids may need some coaching and playing to be examined successfully • Distraction, toys, stickers • Explain what you need to do • For anxious kids, counting during the exam gives some control • Be aware of modesty

  4. Pediatric Assessment Triangle • Normal versus abnormal, minor versus life-threatening • If abnormal proceed to intervention (ABC’s/PALS/EMS) Normal or Abnormal Normal or Abnormal Normal or Abnormal http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-1413466-1948389-2040427tn.jpg

  5. RESPIRATORY SYSTEM • Anatomy • Examination • Special Situations • Common Conditions • Practice Time

  6. Respiratory System

  7. Respiratory Rate Normal respiratory rate: • Preschool 22-34 • Elementary 18-30 • Older 12-20 • A full minute count is the most reliable, but a 15 sec count x 4 gives a decent estimate • Bradypnea and tachypnea (slow and fast) can both be worrisome

  8. Respiratory Exam: Observation • Normal work of breathing: calm, even respirations with full expansion on either side, normal rate • Abnormal: • Accessory muscle use (need to look under shirt) • Nasal flaring • Skin color, perfusion, and moisture changes • Anxious or decreased level of consciousness • Abnormal positioning

  9. Respiratory Exam: Auscultation • Place diaphragm of stethoscope over all lung fields and above sternal notch • Listen for stridor, wheezing, crackles, grunting, decreased or absent breath sounds, asymmetry • May need to reassess after having child cough/blow nose to clear upper airway

  10. Respiratory Exam: Percussion • In the school setting, would be optional • Perform by tapping over the lung fields • Symmetry is what you expect; asymmetry is worrisome for fluid or air collection

  11. Special Situations • Tracheostomy – at baseline you will hear lots of referred sounds from the upper airway. Consider listening again after suctioning. • http://www.medicalhomeportal.org/clinical-practice/medical-technology/tracheostomy

  12. Coughing • Watch for: • Seal bark coughing (think croup) • Paroxysmal coughing (prolonged bouts with whoop on inhale at end, think pertussis/whooping cough) • Cough-variant asthma (exercise/allergic/etc) • Cough with postnasal drip (treat nasal sx) • Cough with URI (bronchitis – often self resolves) • Ongoing/worsening cough with fever, tachypnea, possible crackles (think pneumonia) • Cough drops, honey, frequent sips > OTC cough meds. Also nasal saline, nasal decongestants

  13. Crackles • Caused by fluid in the airways (mucous, pus, blood) • Can be challenging to distinguish referred upper airway from lower airway sounds • Recheck after nose blowing and coughing • Can use percussion • Viral and bacterial causes; should see a doctor promptly to evaluate for pneumonia

  14. Stridor • Upper airway obstruction: think croup, foreign body • Tends to affect inspiration > expiration but can affect both • Prominent in upper airway • Position child comfortable and keep him/her calm • If child looks toxic (drooling, leaning forward, frightened) this is an emergency (epiglottitis)

  15. Wheezing • Lower airway obstruction: think asthma or reactive airways • Prolonged expiratory phase • Wheezes usually start expiratory, can become inspiratory and expiratory. • Diminished sounds are even more progressive • Listen for changes after albuterol • Keep the child calm • Viral and allergic triggers, also cold, stress, emotions, exercise • If not clearing, should see a doctor promptly

  16. Asthma Resources • Utah Department of Health Asthma Program: http://health.utah.gov/asthma/ includes specific resources for schools, e.g. Asthma Action Plan combined for physician, school, and family use • Medical Home Portal: http://www.medicalhomeportal.org/diagnoses-and-conditions/asthma/ (updated version due for release any day, with Quick Reference links)

  17. Practice Time • Practice a respiratory exam on a partner. Notice the different sounds between upper and lower airways. For added challenge, try percussion!

  18. EYES • Anatomy • Screening, Terminology, and Referrals • Examination • Common Conditions • Practice (later on)

  19. Eye Anatomy http://www.med-ed.virginia.edu/courses/pom1/pexams/HEENT/

  20. Two Minute Eye Exam • http://webeye.ophth.uiowa.edu/eyeforum/video/2-min-eye-exam.htm

  21. Vision Screening • Purpose of vision screening – catch as many students as possible who need actual testing, while minimizing “false positives” • Screening by its nature is imperfect, so refer for testing if concerns

  22. Terminology • Acuity: near (8-10” – reading), intermediate (16-40” – computer), far (>=10’ – whiteboard) • Eye Muscle Coordination: binocular fusion (2 eyes  1 image in brain), stereopsis (binocular depth perception), eye movements, and convergence (focus on near object) • Refraction: ability to focus light on retina (near and farsightedness, astigmatism) • Eye health: presence of any disease? • Color vision • Accommodation: focus at different differences • Strabismus: eyes aren’t aligned properly. Can lead to lost acuity in non-dominant eye

  23. Strabismus http://www.doctorsvisioncenter.com/what-is-strabismus-eye-health/

  24. Eye Resources • School Nurse’s Guide to Vision Screening and Ocular Emergencies: https://www.cteyes.org/CMS/customer-files/p-edu-School%20Nurses-%20Sceening.pdf

  25. Warning Signs for Referral • Learning problems • Frequent headaches • Visual complaints (child frequently won’t recognize problem) • Failed vision screen or concerns on eye exam • Acute eye injury • Worsening infection, pain, discharge

  26. Cornea • Clear covering over iris, pupil and anterior chamber • helps with refraction and flips the image onto the retina • Has no blood supply but does contain nerve endings • Most likely to see corneal abrasions and ulcers

  27. Corneal Abrasions http://www.insighteyespecialists.com/wp-content/uploads/2009/09/cornealAbrasion_50236_lg.jpg http://www.healthhype.com/wp-content/uploads/corneal_abrasion.jpg

  28. First Aid for Corneal Abrasion DO: • Rinse with saline or water • Encourage blinking • Try pulling the upper lid over the lower lid so the lashes can help remove debris on the inside of the upper lid DON’T: • Remove embedded debris • Put objects into the eye to remove debris • Allow rubbing of the eye

  29. Corneal Ulcer http://3.bp.blogspot.com/-6_Mt6maT8w4/T-N-JQpsqqI/AAAAAAAAAYs/RScCqPzJaS0/s1600/CornealUlcerJan2012.jpg

  30. Corneal Ulcer Management • Usually caused by infection (herpes, fungi, bacteria, etc) • Can be related to contact use, dry eyes, allergies, inflammatory conditions • Refer for medical attention

  31. Conjunctiva http://media.mansmed.com/data/media/4/conjunctiva_01_anatomy.jpg

  32. Conjunctiva Appearance http://www.webmd.com/eye-health/ss/slideshow-pinkeye http://img.webmd.com/dtmcms/live/webmd/consumer_assets/site_images/media/medical/hw/h9991415_002.jpg http://www.med-ed.virginia.edu/courses/pom1/pexams/HEENT/

  33. Conjunctivitis/ “Pink Eye” Infectious: • Bacterial or viral, usu start one eye then spread • If bacterial. +/- swollen lids, thick discharge.Antibiotic eye drops, back to school in 24 hrs • If viral, increased tears, watery drainage. Will self-resolve (cold symptoms). Back to school once clear. Non-infectious: • Irritants – Rinse eye thoroughly x 5 mins, call doctor • Allergic – Both eyes red, more tears. Remove offender Traumatic: • Blood in eye

  34. Other Eye Concerns http://www.emedicinehealth.com/slideshow_eye_diseases/article_em.htm http://www.emedicinehealth.com/slideshow_eye_diseases/article_em.htm Chalazion – Inflamed gland, cyst. Hot compresses 4-6x day, refer if not improving. Stye or Hordoleum – Clogged duct, infected. Hot compresses 4-6x day, refer if not improving

  35. More Eye Concerns http://www.med-ed.virginia.edu/courses/pom1/pexams/HEENT/ http://opticianworld.com/wp-content/uploads/2010/06/blepharitis_l.jpg/ Ptosis of Eyelid – Neurological, Refer Blepharitis of Lashes – Increase hygiene of lids (gentle soap and water), Refer if not improving

  36. EARS • Anatomy • Examination • Special Situations • Practice (later on)

  37. External Ear/Auricle Anatomy http://dnbhelp.files.wordpress.com/2011/08/auricle1.jpg

  38. Inner Ear Anatomy http://3.bp.blogspot.com/-ZMO9aQzaBHM/TacQR0ILkSI/AAAAAAAAAH0/Sc_8_dOvcAo/s1600/Normal_ear_anatomy.jpg

  39. Otoscope Use • Use largest speculum tip to fit canal • Insert gradually while looking at canal • Pull ear up and back to open view • Do not push foreign bodies further in! • If wax removal is needed, use home treatments or send to MD if impacted • Can use pneumatic otoscopy to assess movement of the TM

  40. Healthy Anatomy http://img.webmd.com/dtmcms/live/webmd/consumer_assets/site_images/articles/health_tools/ear_infection_slideshow/phototake_rm_photo_of_healthy_eardrum.jpg

  41. Home Treatment for Wax • Insert 2 drops of warm mineral or olive oil or ½ and ½ Hydrogen peroxide and warm water, twice daily. • Once soft, use shower to rinse wax out then cool blow dry • If no success, try OTC wax drops for 1-2 weeks with gentle ear syringe irrigation (warm water) • Avoid ear candles, Q tips, dental irrigators • Especially important if using hearing aids!

  42. Otitis Externa (Swimmers Ear) • Affects canal and/or auricle (outer ear) • Prevention through drying ears, limiting Q tips • Home remedy: ½ and ½ rubbing alcohol and white vinegar • Olive oil and warm compresses help pain • Infections may require medication http://www.stuedeli.net/reto/medizin/kdb/content/HNO/Bilder/Ohren/OtitisExterna_SMF.jpg

  43. Otitis Media – Multiple Types • Acute OM – bulging, red, opacified TM • Ibuprofen, tylenol, pain drops in ear canal • Doesn’t always need antibiotics! Refer if ill, pain not resolving, condition worsening http://me.hawkelibrary.com/albums/acute-otitis-media/AOM_4.jpg

  44. OM With Effusion • http://medicalpicturesinfo.com/wp-content/uploads/2011/09/Otitis-media-3.jpg • Serous fluid collection behind TM. • Needs time to resolve. • Refer if hearing difficulties

  45. AOM with perforation of TM • Otorrhea is observed • Antibiotics indicated http://www.rihes.cmu.ac.th/Ped_HIV/06-cli_present/s2_10.html

  46. Tympanostomy tube drainage • Antibiotics if ill or if not improving http://www.ent-specialist.org/client_files/ear%20tube(1).jpg http://otitismedia.hawkelibrary.com/albums/tubes/6_9.sized.jpg

  47. Hemotympanum • Worry about basilar skull fracture – trauma hx • Can occur after infection http://me.hawkelibrary.com/new/main.php?g2_view=core.DownloadItem&g2_itemId=1667&g2_serialNumber=2 http://me.hawkelibrary.com/albums/hemotympanum/25_L.jpg

  48. Piercings • New piercings – warm wet compresses, not hydrogen peroxide or alcohol • Infections -- Watch for fever, streaks, swollen lymph nodes, pus • Allergic response – irritated, red, itchy, painful http://1.bp.blogspot.com/-GClpozR-2Sk/UNGi1yivUuI/AAAAAAAACOw/rsu45h8kHto/s1600/ear+piercing.jpg

  49. Hearing Aids • Need regular care and cleaning • Ears may have wax build-up and impacted cerumen • http://www.medicalhomeportal.org/living-with-child/assistive-technology/hearing-aids

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