Friday, January 30, 2009

Pediatric Physical Assessment

Lecture notes

Health Assessment
Collecting Data
By observation
Interviewing the parent
Interviewing the child
Physical examination

Bio-graphic Demographic Information
Name, age, health care provider
Parents name age /siblings age
Ethnicity / cultural practices
Religion / religious practices
Parent occupation
Child occupation: If an adolescent

Past Medical History
Childhood illness
Trauma / hospitalizations
Birth history
Did baby go home with mom / special care nursery
Genetics: anything in the family

Current Health Status
Any underlying illness / genetic condition
What concerns do you have today?

Review of systems
Ask questions about each system
Measuring data: growth chart, head circumference, BMI
Nutrition: breast fed, formula, eating habits
Growth and development: How does parent think child is doing?

Physical Assessment
General appearance & behavior
Facial expression
Posture / movement
Development: grossly fits guidelines for age

Vital Signs
Temperature: rectal only when absolutely necessary
Pulse: apical on all children under 1 year
Respirations: infant uses abdominal muscles
Blood pressure: admission base line
Height and weight and head circumference for 2 years and younger

Physical Assessment
Skin, hair nails
Head, neck, lymph nodes: fontanelles
Eyes, nose, throat…look at palate and teeth
Chest: auscultate for breath sounds and adventitious sounds
Breasts: tanner scale
Heart: PMI, murmurs

Glasgow coma scale
Observe their natural state: Play games with them, especially children under 5 year
CNS grossly intact: II – XII

Newborn reflexes
Rooting: disappears at 3-4 months
Sucking: disappears at 10 to 12 months
Palmar grasp: disappears at 3 to 4 months
Plantar grasp: disappears at 8 to 10 months
Tonic neck: disappears by 4 to 6 months
Moro (startle): disappears by 3 months
Babinski: disappears by 2 years
Stepping reflex: disappears by 2 months

Infant Exam
Examine on parent lap
Leave diaper on
Comfort measures such as pacifier or bottle.
Talk softly
Start with heart and lung sounds
Ear and throat exam last

Toddler Exam
Examine on parent lap if uncooperative
Use play therapy
Distract with stories
Let toddler play with equipment / BP
Call by name
Praise frequently
Quickly do exam

Preschool Exam
Allow parent to be within eye contact
Explain what you are doing
Let them feel the equipment

School-age Child
Allow the older child the choice of whether to have a parent present
Teaching about nutrition and safety
Ask if the child has any concerns or questions
How are they doing in school?
Do they have a group of friends they hang out with?
What do they like to do in their free time?

School-age Exam
Allow choice of having parent present
Privacy and modesty.
Explain procedures and equipment.
Interact with child during exam.
Be matter of fact about examining genital area.

Ask about parent in the room
Should have some private interview time: time to ask the difficult questions
HEADSS: home life, education, alcohol, drugs, sexual activity / suicide
Privacy issues: HIPPA

Vital Signs
Choose your words carefully when explaining vital sign measurements to a young child. Avoid saying, for example, "I’m going to take your pulse now." The child may think that are going to actually remove something from his or her body. A better phrase would be "I’m going to count how fast your heart beats."

Use of tympanic membrane is controversial.
Oral temperature for children over 5 to 6 years.
Rectal temperatures are contraindicated if the child has had anal surgery, diarrhea, or rectal irritation.
Check with hospital policy.

Apical pulse for infants and toddlers under 2 years
Count for 1 full minute
Will be increased with: crying, anxiety, fever, and pain

Pulse rates
Neonate: 70 – 190
1-year: 80 – 160
2-year: 80-130
4-year: 80 – 120
6-year: 75-115
10-year: 70-110
14-year: 65 – 105 / males 60 – 100
18-year: 55-95 / males 50 - 90

Apical Pulse
Heart Sounds
Auscultate Heart Sounds at aortic, pulmonic, erbs, tricuspid and mitral points.

Count for one full minute
May want to do before you wake the infant up
Rate will be elevated with crying / fever
Pre-term: 40 – 60
Newborn: 30 – 40
Toddler: 25
School-age: 20
Adolescent: 16
Panic levels: <> 60
Clinical Tip
To accurately assess respirations in an infant or small child wait until the baby is sleeping or resting quietly.
You might need to do this before you do more invasive exam.
Count the number of breaths for an entire minute.

Blood Pressure
The width of the rubber bladder should cover two thirds of the circumference of the arm, and the length should encircle 100% of the arm without overlap.
Crying can cause inaccurate blood pressure reading.
Consider norms for age.
Blood Pressure Cuff

Needs to be recorded on a growth chart
Gain about an inch per month
Deviation of height on either extreme may be indication for further investigation: endocrine problems
Height Measurement
Height Measurement

Needs to be recorded on a growth chart
Newborn may lose up to 10% of birth weight in 3-4 days.
Gains about ½ to1 oz per day after that
Too much or too little weight gain needs to be further investigated.
Nutritional counseling

Weight norms
Double birth weigh by 5-6 months
Triple birth weight by 1 year

How much formula?
How often being breast fed?
Solid foods: 4 to 6 months of age
What are they eating?
Over 1 year: How much milk vs solid foods. They can have whole milk.

School age: typical diet
Favorite foods
I always ask the child if I were to ask their mom what do they need to eat more of what would she say?

Most common nutritional problems:
Iron deficiency anemia

Head Circumference
Head Needs to be measured until age 2 years
Plot on growth curve
Check fontales:
Anterior: closes by 12 to 18 months
Posterior: closes by 2-5 months
Shape: flat headed babies due to back-to-back sleep position

Condition of teeth
Number of teeth
No teeth eruption by 12 months think endocrine disorder
Brushing / visit to dentist

Check for red-reflex: lack of this may mean retinoblastoma
Can the infant see: by parent report
Alignment of eye important due to correlation with brain development
May need to corrected surgically
5-year-old and up can have vision screening
Refer to ophthalmologist if there are concerns

Common eye infections:
A red-flag in the newborn may be STD from travel down the birth canal
Pre-school: number one reason they are sent home: wash with warm water / topical eye gtts
Inflammation of eye: history of juvenile arthritis

Ear Exam
Otitis Media
Most common reason children come to the pediatrician or emergency room
Fever or tugging at ear
Often increases at night when they are sleeping
History of cold or congestion

ROM: right otitis media
LOM: left otitis media
BOM: bilateral otitis media
OME: Otitis media with effusion
(effusion means fluid collection)
Pleural effusion, effusion of knee

Why a problem?
Infection can lead to rupture of ear drum
Chronic effusion can lead to hearing loss
OM is often a contributing factor in more serious infections: mastoiditis, cellulitis, meningitis, bacteremia
Chronic ear effusion in the early years may lead to decreased hearing and speech problems
Oral antibiotics: re-check in 10 days
Tylenol for comfort
Persistent effusion:
PET: pressure equalizing tubes

Outpatient procedure
Need to keep water out of ears
Hearing evaluation
Speech evaluation
Head, chest, and abdominal circumference.

Chest exam
A high percentage of admissions to hospital are respiratory: croup, bronchitis, pneumonia, and asthma
In the infant it is hard to separate upper air-way noises from lower air-way noises.
How does the child look? Color, effort used to breathe
Possible Sites of Retractions

Chest assessment

Red flags: grunting / nasal flaring
Wheeze or Stridor
Wheezes occur when air flows rapidly through bronchi that are narrowed nearly to the point of closure.
Wheezes is lower airway
Asthma = expiratory wheezes
A stridor is upper airway
Inflammation of upper airway or FB
Abdominal Girth

Abdominal Assessment
Clinical Tip
Inspection and auscultation are performed before palpation and percussion because touching the abdomen may change the characteristics of the bowel sounds.

Bowel Sounds
Normally occur every 10 to 30 seconds.
Listen in each quadrant long enough to hear at least one bowel sound.
Absence of bowel sounds may indicate peritonitis or a paralytic ileus.
Hyperactive bowel sounds may indicate gastroenteritis or a bowel obstruction.