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Pediatric History and Physical Examination

الكلية كلية التمريض     القسم قسم التخصصات التمريضية     المرحلة 3
أستاذ المادة عبد المهدي عبد الرضا حسن الشحماني       17/11/2016 08:13:40
Pediatric History and Physical Examination




Introduction
Obtaining the Child s History
Interview is a very personal conversation with a parent, caretaker, and child/ adolescent during which private concerns and feelings are shared.
Communication Strategies
Careful listening

Strategies to Build a Rapport with the Family

Make a self- introduction
Explain the purpose of the interview (NCP)
Provide privacy and remove as many distractions as possible during the interview
Direct the focus of the interview with open-ended questions. Use close-ended questions or directing statement to clarify information
Ask one question at a time
Involve the child in the interview by asking age appropriate questions
Be honest with the child when answering questions or when giving information about what will happen. Children need to learn they can trust their nurse.
Careful Listening
Complete attention is necessary to "hear" and accurately interpret information the parents and child give during the nursing history
pay attention to the parent s attitude or tone of voice when the child s problems are discussed the tone of voice can reveal anxiety, anger, or lack of concern
Observe the parent s nonverbal behavior (posture, gestures, body movements, eye contact, and facial expression)
History taking Outline (Subjective Data)
Identifying data/ Chief Complain
Present illness
Past Medical History
Birth history, childhood illnesses, immunizations, hospitalizations and surgeries, allergies, and medications
Family Medical History
Social History
Habits/ Activities of daily living (Nutrition, dental, sleep, elimination pattern (toilet training), safety/ injury prevention, activity and exercise, Discipline)
cognitive/ perception ( value and believe, pain)
Developmental behavior
Review of Systems (ROS)
Case Study
Group work
Read the case study and find
Identifying data
Chief complain
Past medical history
Family medical history (draw a genogram)
Social history
Habits/ Activities of daily living
Mile stones that Maria achieved
ROS





Physical examination

Sequence of the examination
The sequence of children examination follows head-to-toe direction. The main function of such systemic approach is to provide a general guidelines for assessment of each body area to minimize omitting segments of the examination.





Holding toddler for mouth exam




Pediatric physical Examination
Outline

Physical Growth measurement
Physiologic measurements
General appearance
Skin - head and neck -eyes – ears- nose, mouth and throat - lungs-heart – abdomen - genitalia- back and extremities - neurologic assessment




CDC Growth Charts

The available clinical charts include the following:


Infants, birth to 36 months:
Length-for-age and Weight-for-age percentiles
Head circumference-for-age and Weight-for-length percentiles

Children and adolescents, 2 to 20 years
Stature-for-age and Weight-for-age percentiles
BMI-for-age percentiles

Preschoolers, 2 to 5 years
Weight-for-stature

www.cdc.gov

Is Ameena growing normally??
Ameena is nine-month-old girl.
Ameena’s length= 69 cm, weight =9 kg, and Head circumference = 45 cm.
The mother asks you if Ameena’s length, weight, and head circumference are normal for her age or not?? Explain
Is Ahmad growing Normally??
Ahmad is 5-year-old boy
Height = 112 cm
Weight = 23 kg
Find Ahmad’s BMI and if he is growing normally?
Physiological parameters
Temperature: can be easily measured at several body sites via oral, rectal , axillary, ear canal or skin.
Substitutes for the no-longer-used mercury glass thermometer are electronic thermometers, infrared ear-based thermometers, chemical indicator thermometers, skin plastic strips, and digital thermometers.
All of which offer advantages: rapid temp taking, minimal intrusion, and reduced cross contamination.
Recommendation based on research vary
From 2-3 min for oral. Normal 37.0c*
1-2 min for rectal. 1 degree higher than oral (subtract)
5-7 min for an axillary reading. 0.5 degree lower than oral (add)


Physiological parameters
Respiration count in the same manner as for the adult patient
In infant observe abdominal movements because respiration are primarily diaphragmatic.
Count respiration for 1 full min for accuracy



Pulse:
Can be taken radially in children older than 2 years.
In infant and young children the apical impulse (heard through a stethoscope) is more reliable
Count the pulse for 1 full minute in infant and young children because of possible irregularities in rhythm .
For greater accuracy, measure the apical rate while the child is a sleep.
Compare brachial and femoral pulses at least once during infancy to check for coarctation of aorta.



Blood pressure:
Measure using noninvasive method
BP should be measured annually in children 3 years of age through adolescence
Use an appropriate cuff size.
Position limb at level of heart
Rapidly inflate cuff to about 20 mm hg above blood pressure baseline
BP is classified by systolic BP and diastolic BP percentiles for age/sex/height.




Is my child BP Normal???
Nagham is 4-year-old girl with a height of 103 cm and BP of 100/65. Nagham’s mom ask you if her child BP is normal?
Nagham Height: 103 ? 75 percentile
Nagham BP:
According to BP levels for girls by age and height percentile normal BP is between
110/71- 92/52
This means that Nagham has Normal BP

Pain (the fifth vital signs- Subjective)


Pain (the fifth vital signs- objective)


Skin
Skin Color (Mongolian spot, erythema toxicum, acrocynosis, jaundice)
Texture
Thickness
Mobility and turgor ? over abdomen
Hair (lanugo)


Palpate the skull for patent sutures, fontanels (anterior closed at 12-18m, posterior closed at 2nd- 3rd m), fracture and swelling.
Observe the face for symmetry, movement and general appearance.
Inspect the neck for size and palpate it for associated structures: normally short with skinfolds between the head and shoulders during infancy, it lengthens during next 3-4 years.
Eyes : red reflex. Absence of red reflex can indicate retinoblastoma


Ears:
Ear abnormalities are commonly associated with renal anomalies. Low set ear can be associated with down syndrome
Examination of the tympanic membrane:
Pull pinna down and backward in children younger than 3 years old and Up and backward in children older than 3 years old.
Nose, mouth, and throat: Encouraging opening the mouth to Inspect the teeth, gum, tongue, hard and soft palate and tonsils.
Examine paranasal sinuses: only the maxillary and ethmoid sinuses are present at birth.









Chest
Inspect the chest for size, shape, symmetry, movement, breast development and the presence of bony landmarks formed by ribs and sternum

During infancy the chest normal to be rounded (By 2 years of age the lateral diameter is greater than the anteroposterior diameter)
Costal angle 45-50 degree.
Assess breathing sound.


Child rib cage
Auscultate the breathing sound

Heart
Position:
Use palpation to determine the location of the apical pulse :
Just lateral to the left MCL and fourth ICS in children younger than 7 years of age.
At the left MCL and fifth ICS in children older than 7 years of age.
Auscultate origin and differentiating of heart sound.
Infant apical pulse
Child apical pulse
Direction of heart sounds for anatomic valve sites and areas (circled) for auscultation
Assess heart sound
Abdomen
Examination orders: inspection, auscultation, percussion and palpation.
Inspect for abdominal hernia (umbilical, internal or external inguinal canal, femoral hernia).
Male genitalia: examine the penis, glans and shaft, urethral meatus (hypospadias), scrotum (undescended tests).
Female genitalia: examine for external structure (ambiguous genitalia).
Infant s Abdominal palpation
Umbilical hernia

Back and extremities
Spine: examine for curvature (scoliosis).
Inspect the back for any tufts of hair.
Inspect the extremity for symmetry of length and size.
Count the fingers and toes to be certain of normal number ( polydactyly, synductyly)
Back and extremities
Joints: palpate for heat, tenderness, swelling, and range of motion.
Note symmetry and quality of muscle development, tone, and strength.

Spina bifida





THANK YOU


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