chapter 9 the pediatric examination. elsevier items and derived items © 2008 by saunders, an...

CHAPTER 9CHAPTER 9THE PEDIATRIC EXAMINATION

Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 2

Introduction to the Pediatric Examination

Introduction to the Pediatric Examination

1. Pediatrics deals with:a. Care and development of children

b. Diagnosis and treatment of diseases in children

2. Pediatrician: medical doctor who specializes in pediatrics


Well-child visit (health maintenance visit)

Well-child visit (health maintenance visit)

1. Componentsa. Evaluation of growth and development of child

b. Physical examination• To detect any abnormal conditions associated with

child's stage of development

c. Anticipatory guidance• Provides parents with information to prepare for

anticipated developmental events• Assists parents in promoting child's well being

d. Immunizations


Topics of a well-child VisitTopics of a well-child Visit

Topics included are:1) safety2) nutrition3) sleep4) play

5) exercise6) development7) discipline


Typical schedule for well-child visits



• 1 month• 2 months• 4 months• 6 months• 9 months

• 15 months• 18 months• 24 months• Yearly thereafter


Sick-child visit Sick-child visit

Sick-child visit: child exhibits signs and symptoms of diseasea. Physician evaluates patient's condition to arrive

at a diagnosis and prescribe treatment

Procedures performed by MA during pediatric office visits:b. Vital signs

c. Weight

d. Visual acuity

e. Assisting with physical examination


Developing a RapportDeveloping a Rapport

1. Important to establish rapport with child

2. If trust and confidence gained:

a. Child more likely to cooperate during examination

3. Requires special techniques (based on age)

4. Explain procedure to children who are able to understand

5. Approach child at his/her level of understanding

a. Know what to expect from a child at a particular age

6. Realize that a child may regress when ill


Developing a Rapport, cont. Developing a Rapport, cont.

a. Toddlers: respond well to making a game of the procedure

b. School-age children: explain purpose of an instrument


Carrying the InfantCarrying the Infant

Lift and carry infant in a manner that is safe and comfortable

1. Cradle positiona. Infant is cradled with his/her

body resting against MA's chest


Carrying the Infant, cont. Carrying the Infant, cont.

2. Upright positiona. Infant is held upright

while resting against the MA's chest


Growth MeasurementsGrowth Measurements

1. One of the best methods to evaluate progress of child

2. Measured at each office visit and plotted on growth chart:a. Weight

b. Height (length)

c. Head circumference (up to 3 years)


Measuring Weight Measuring Weight

Use:• Determine

nutritional needs• Calculate proper

med dosage

Infants: measured in supine position

Older children: measured in standing position


Length Length

Length and Heighta. Length

• Measured in children younger than 24 months

• Measured from vertex of head to heel in supine position

• Two people are needed to accurately determine length


Height Height

b. Height (stature)• Older children: measured

in standing position


Head Circumference (HC) Head Circumference (HC)

a. Infancy: period of rapid brain growth• Important to measure HC

in children under age 3– Plot on a growth chart

b. Newborn HC range: 32 to 38 centimeters (12.5” to 15”)

c. 4-inch (10-cm) increase in HC occurs in first year of life

d. Important screening measure for:• Macroencephaly• Microencephaly


Chest Circumference (CC) Chest Circumference (CC)

1. At birth: HC is approximately 2 cm larger than CC

2. Chest grows at faster rate than cranium

b. Between 6 months and 2 years: measurements are about the same• After age 2: CC is greater

than HC

3. CC not typically measured on routine basis

a. Only when heart or lung abnormality is suspected


Growth ChartsGrowth Charts

1. Should be part of child's record

2. Developed to determine if child's growth is normal

3. Identifies children with growth or nutritional abnormalities

4. MA responsible for plotting child's measurements on growth chart


Purpose of Growth ChartsPurpose of Growth Charts

a. Compares child's weight and length (or height) with other children of same age• Example: 18-month-old boy: Weight: 25th percentile;

Height: 80th percentile• Interpretation

– 75% of 18-month-old boys weigh more; 25% weigh less

– 20% of 18-month-old boys are taller; 80% are shorter

b. Look at child's growth pattern (primary use)• Physician investigates significant changes in growth

pattern:

– Rapid rise or rapid drop


Growth ChartGrowth Chart


Pediatric Blood Pressure Measurement

Pediatric Blood Pressure Measurement

1. American Academy of Pediatrics recommends:a. Children 3 years of age and older: measure blood

pressure (BP) annually

2. Purpose

a. Identify children at risk for developing hypertension as adults

b. Identify children with kidney disease or heart disease• Once treated: BP usually returns to normal

3. Overweight children: usually have higher BP than those of normal weight

a. To reduce BP: Weight loss through a prescribed diet and physical activity


Blood Pressure Cuff SizeBlood Pressure Cuff Size

1. Cuff too small: BP may be falsely high

2. Cuff too large: BP may be falsely low

3. Cuffs come in a variety of sizes

a. Measured in centimeters

b. Size of cuff: refers to inner inflatable bladder (not cloth cover)

c. Name of cuff (child, adult)• Does not necessarily imply that

it's appropriate for that age


Determining Proper Cuff SizeDetermining Proper Cuff Size

a. Assess child's arm circumference: midpoint between shoulder and elbow

b. Bladder of cuff should encircle 80% to 100% of arm


Pediatric Blood Pressure Measurement, cont.

Pediatric Blood Pressure Measurement, cont.

1. Make sure child is relaxeda. Apprehension can cause BP

to be falsely high

2. To reduce anxiety:a. Explain procedure

b. Allow child to handle equipment (if appropriate)

3. Measure BP after child has been sitting quietly for 3 to 5 minutes


Blood Pressure ClassificationsBlood Pressure Classifications

1. Pediatric BP varies depending on:a. Age

b. Height

c. Gender


Blood Pressure Classifications, cont.

Blood Pressure Classifications, cont.

• BP varies throughout the day due to normal fluctuations in:a. Physical activity

b. Emotional stress

• If child's BP elevated: a. Two or more readings must be taken at

different visits before diagnosis of hypertension can be made


Collection of a Urine SpecimenCollection of a Urine Specimen

1. Purposea. May be required as part of physical examination

• To perform a urinalysis to screen for disease

b. Assist in diagnosis of pathologic condition

c. Evaluate effectiveness of therapy

2. Pediatric urine collectora. Used for infants or young children who cannot

urinate voluntarily

b. Consists of plastic disposable bag with adhesive around the opening


Pediatric Urine CollectorPediatric Urine Collector


Pediatric InjectionsPediatric Injections

1. Experience child has with early injections influences his or her attitude toward later ones

2. Explain procedure to children old enougha. Be honest and attempt to gain trust and cooperation

• Tell child it will hurt, but only for a short time• Explain that the med will help child get better

3. Another person should be present to:a. Help position child or divert or restrain child, if

needed

4. If child struggles/fights excessively:a. Delay injection and consult physician


Types of NeedlesTypes of Needles

1. Intramuscular injectiona. Gauge and length of needle based on:

• Consistency of med (Thick, oily medications = larger lumen)• Size of child (Needle must reach muscle tissue)

b. Length of needle range: ⅝ to 1 inch

c. Gauge range: 22 to 25• Depends on viscosity of mediation

2. Subcutaneous injectiona. Length of needle range: ⅜ to ½ inch

b. Gauge range: 23 to 25


Intramuscular Injection SitesIntramuscular Injection Sites

1. Site varies based on age of child

2. Injection site: indicated in package insert accompanying meda. Dorsogluteal site

• Until child is walking, gluteus muscle is:

– Small and not well-developed

– Covered with a thick layer of fat• Injection may come close to sciatic nerve

– Danger increased: if child squirming or fighting• Do not use gluteal site until child has been walking for

at least 1 year


Dorsogluteal SiteDorsogluteal Site

Courtesy Wyeth Laboratories, Philadelphia, Penn


Vastus Lateralis Site Vastus Lateralis Site

Vastus lateralis • Recommended for

infants and young children

• Located on anterior surface of midlateral thigh• Away from major

nerves and blood vessels

• Muscle is large enough to accommodate the med


Vastus Lateralis Site, cont. Vastus Lateralis Site, cont.

• Length of needle: depends on size of thigh

– 1 inch used most often• To administer injection:

– Infant is placed on back

– Thigh is grasped in order to:

1) Compress the muscle tissue

2) Stabilize the extremity

– Injection is administered into the compressed tissue


Deltoid SiteDeltoid Site

Deltoid muscle is shallow:

• Can accommodate only very small amount of med

To administer injection:• Muscle is grasped

between thumb and fingers

• Needle inserted pointing slightly upward toward shoulder


ImmunizationsImmunizations

1. Immunity: resistance of the body to effects of harmful agents such as pathogenic microorganisms and their toxins

2. Active, artificial immunization: process of becoming immune through use of a vaccine or toxoid

a. Vaccine: A suspension of attenuated (weakened) or killed microorganisms administered to an individual

b. Toxoid: A toxin (poisonous substance produced by a bacterium) that has been treated by heat or chemicals to destroy its harmful properties


Purpose of Childhood Immunizations

Purpose of Childhood Immunizations

a. Build body's defenses

b. Protect from certain infectious diseases

c. Administered to infants and young children during well-child visits• American Academy of

Pediatrics:– Publishes a recommended

childhood immunization schedule annually (www.aap.org)

http://www.aap.org/


Immunization ScheduleImmunization Schedule

From Department of Health and Human Services, Centers for Disease Control and Prevention, United States, 2007


ImmunizationsImmunizations

Be familiar with each immunization including:a. Use

b. Common side effects

c. Route of administration

d. Dose

e. Method of storage


Immunizations, cont.Immunizations, cont.

Package insert comes with each immunization: contains info about druga. Physician’s Desk Reference (PDR) can

also be used to locate information


Immunizations, cont. Immunizations, cont.

Immunizations administered to infants and children: a. Hep B: Hepatitis B vaccine (IM)

b. DTaP: Diphtheria and tetanus toxoids and acellular pertussis vaccine (IM)

c. Hib: Haemophilus influenzae type b (IM)

d. IPV: Inactivated polio vaccine (IM or SC)

e. MMR: Measles, mumps, and rubella vaccine (SC)

f. Varicella: Chickenpox vaccine (SC)

g. PCV: Pneumococcal conjugate vaccine (IM)


Immunizations, cont. Immunizations, cont.

Immunization record card provided to parentsa. Instruct parent to

bring to well-child visits• Child's immunizations

can be recorded

b. Instruct parents in:• Normal side effects of

immunizations• What to do if side

effects occur


National Childhood Vaccine Injury Act (NCVIA)

National Childhood Vaccine Injury Act (NCVIA)

1. Requires parents be provided with:a. Information about benefits and risks of childhood

immunization

2. CDC developed vaccine information statements (VIS)a. Explains benefits and risks of immunizations in

lay terms

3. Before a child receives an immunization:b. Appropriate VIS must be given to child's parent

or guardian

c. Parent must be given enough time to read VIS


Vaccine Information StatementVaccine Information Statement

Courtesy Centers for Disease Control and Prevention, Atlanta, GA


National Childhood Vaccine Injury Act (NCVIA), cont.

National Childhood Vaccine Injury Act (NCVIA), cont.

5. Information that must be charted in patient's medical record (required by NCVIA)a. Name and publication date of each VIS given to

parent

b. Date the VIS provided to parent

c. Date of administration of vaccine

d. Manufacturer and lot number of vaccine

e. Signature/title of health care provider who administered vaccine

f. Address of medical office where vaccine was administered

chapter 9 the pediatric examination. elsevier items and derived items © 2008 by saunders, an...

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