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Knowledge of Growth and Development
Development of a Therapeutic Relationship
Communication with children and their parents
Understanding of family dynamics and parent-child relationships: IDENTIFY KEY FAMILY MEMBERS
Knowledge of Health Promotion & Disease Prevention
Patient Education and Anticipatory Guidance
Practice of Therapeutic and Atraumatic Care
Patient and Family Advocacy
Caring, Supportive & Culturally Sensitive Interactions
Coordination and Collaboration
CRITICAL THINKING


Key elements.

Times:

Every month in the 1 st year.

Every 3 month of the 2 nd and 3 rd year.

Each 6 month of 4 th and 5 th year.

Yearly after the 6 th year.


Avoid touching painful areas until confidence has been gained.

Begin exam without instruments.

Allow child to determine order of exam if practical.

Use the same format as adult physical 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.


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.

Personal Hx., Life styles, Health Hx. (past and current), and Family Hx.
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Bio-graphic Demographic
Name, Date of Birth, Age
Parents & siblings info
Cultural practices
Religious practices
Parents’ occupations
Adolescent – work info
Past Medical History
•Allergies
•Past illness
•Trauma / hospitalizations
•Surgeries
•Birth history
•Developmental
•Family Medical/Genetics
Current Health Status
•Immunization Status
•Chronic illnesses or conditions
•What concerns do you have today?

EQUIPMENT

Stethoscope &
Sphygmomanometer

Pen Light

Otoscope /
Opthalmoscope

Scale


Ask questions about each system

Measurements: weight, height, head circumference, growth chart, BMI

Nutrition: breastfed, formula, favorite foods, beverages, eating habits

Growth and Development: Milestones for each age group


Inspection- eye only.

Palpation- tip of finger.

Percussion- use. . .

Dullness (solid organ), resonance (over solid organ or filled air), tympanic (hollow organ).

Auscultation- stethoscope.


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

Skin
HEENT
Neck
Chest & Lungs /
Respiratory
Heart &
Cardiovascular
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GI
GU & GYN
Musculoskeletal
& Extremities
Neuro
Endocrine


Sleep & Activity

Appetite

Bowel & Bladder

In a time crunch, these three questions should give you enough insight into the child’s general functioning –

Can get more detailed if any (+) responses


The approach is:



Orderly
Systematic
Head-to-toe



But FLEXIBILIY is essential
And be kind and gentle but firm, direct and honest

General Appearance & Behavior
 Facial expression
 Posture / movement
 Hygiene
 Behavior
 Developmental Status


Temperature: rectal only when absolutely necessary
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Pulse: apical on all children under 1 year

Respirations: infant use abdominal muscles
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Blood pressure: admission base line

And the “Fifth” Vital Sign is ____ ?

Toddler School-Age Adolescent

Infant
Heart Rate
80-150 70-110 60-110 60-100

Respiratory Rate
24-38 22-30

Systolic blood pressure
65-100 90-105

Diastolic blood pressure
45 - 65 55-70
14-22
90-120
60-75
12-22
110-125
65-85

 General
 Skin, hair, nails
 Head, neck, lymph nodes
 Eyes, ears, nose, throat
 Chest, Tanner Scale
 Heart
 Abdomen
 Genitalia, Tanner Scale,
 Rectal
 Musculoskeletal: feet, legs, back, gait


Use of your fingers and palms to determine:


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


Temperature
Hydration
Texture
Shape
Movement
Areas of
Tenderness
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
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Warm hands and short nails
Palpate areas of tenderness / pain last
Talk with the child during palpation to help him relax
Be observant of reactions to palpation
Move firmly without hesitation

H E E N T
Head
Eyes
Ears
Nose
Neck
Throat

HEAD & NECK, EYES, EARS, NOSE,
FACE, MOUTH & THROAT

Head: Symmetry of skull and face

Neck: Structure, movement, trachea, thyroid, vessels and lymph nodes
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Eyes: Vision, placement, external and internal fundoscopic exam

Ears: Hearing, external, ear canal and otoscopic exam of tympanic membrane
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Nose: Structure, exudate, sinuses

Mouth: Structures of mouth, teeth and pharynx



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Shape:
“N ormoCephalic –
ATraumatic ”
Lesions
? Edema

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Head Circumference (HC
Fontannels/sutures: Anterior closes at 10-18 months, posterior by 2 months
Symmetry & shape: Face & skull
Bruits: Temporal bruits may be significant after 5 yrs
Hair: Patterns, loss, hygiene, pediculosis in school aged child
Sinuses: Palpate for tenderness in older children
Facial expression: Sadness, signs of abuse, allergy, fatigue
Abnormal facies: “Diagnostic facies” of common syndromes or illnesses

NEURO ASSESSMENT

LOC / Glasgow coma scale

Pupil size

Vital Signs

Pain

Seizure Activity

Focal Deficits

BACTERIAL MENINGITIS
Clinical Manifestations in an Older Child


High fever
Headache






LOC Changes / GCS
Nuchal rigidity / stiff neck
+ Kernigs = inability to extend legs
+ Brudzinski sign = flexion of hips when neck is flexed
Purple rash (check for blanching)
“Looks Sick”

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

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PERRR
Red Reflex
Corneal Light Reflex
Strabismus:


Alignment of eye important due to correlation with brain development
May need to corrected surgically
Preschoolers should have vision screening

Refer to ophthalmologist is there are concerns o

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Vision: Red reflex & blink in neonate
Examine external structure of the:
1- Conjunctiva- glassy
2- Sclera- clear
3- Cornea- cover the iris and pupil
4- pupils- compare for size, shape, test for reaction.
5- Iris- color, size and clarity. 6-12 M.
Snellen chart for older children
Irritations & infections
PERRL
Amblyopia (lazy eye): Corneal light reflex, binocular vision, cover-uncover test


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Ask about hearing concerns


Inquire about infant’s response to
Observe an older infant’s/toddlers speech pattern
Inspect the ears
•Assess the shape of the ears
Determine if both ears are well formed
•Assess
External shape and size.
Pinna: line, low set ear (retardation).
Internal structure.

Pinna is pulled down and back to straighten ear canal in children under 3 years.

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




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.

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Exudate
Pharynx
Tonsils
Signs & Symptoms of Allerg

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Assess for symmetry, deformity, skin lesion.


 Palpate for septal deviation.
Smooth and moist, with pinkish color.
ic Rhinitis
Palate
Gums
Swallow
Oral Hygiene
Condition of teeth
Missing teeth
Orthodontic
Appliances


Exam nose & mouth after ears

Observe shape & structural deviations

Nares: (check patency, mucous membranes, discharge, turbinates, bleeding)

Septum: (check for deviation)

Infants are obligate nose breathers

Nasal flaring is associated with respiratory distress


Fever

Purulent rhinorrhea

Facial Pain – cheeks, forehead

Breath odor

Chronic cough – could be day and night

(+) Post-nasal drip

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Lips: color, symmetry, moisture, swelling, sores, fissures
Buccal mucosa, gingivae, tongue & palate for moisture, color, intactness, bleeding, lesions.
Tongue & frenulum - movement, size & texture
Teeth - caries, malocclusion and loose teeth.
Uvula: symmetrical movement or bifid uvula
Voice quality, Speech
Breath - halitosis

Is it strept or is it viral or could it be mono?
Lymph nodes
& ROM

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√ position, lymph nodes, masses, fistulas, clefts
Range of Motion (ROM)
Check clavicle in newborn
Head control in infant
Trachea & thyroid in midline
Carotid arteries (bruits)
Meningeal irritation

• How does the child look?
• Color
• Work of Breathing: Effort used to breathe

All 4 quadrants

Front and back

Take the time to listen

Be sure about “lungs CTAB”
(clear to auscultation bilaterally)


Anatomy.

Inspection: symmetry, movement of chest wall.

Breathing pattern- abdominal breathing.

Palpation:

1- light palpation: in light circular motion to detect lesion and masses

2- deep palpation: palpate for internal organ like liver and spleen.


Clubbing

Snoring (expiratory): upper airway obstruction, allergy,

Dullness to percussion: fluid or mass
Increased or Decreased Respirations
Stridor
Wheezing




Auscultation
Wheezing
Retractions


Subcostal
Intercostal


Sub-sternal
Supra-clavicular
Red Flags:
 grunting

 nasal flaring stridor

Think:

Infection


Foreign body aspiration
Anaphylaxis

Insect bites/stings, medications, food allergies

AND ALL ASTHMA
DOESN’T ALWAYS WHEEZE!





Dry, non-productive

Mucousy – productive

Croupy

Acute – less than 2-3 weeks

Chronic – more than 2-3 weeks

Associating Symptoms

•AUSCULTATING HEART SOUNDS
The Auscultation Assistant – Hear Heart Murmurs, Heart Sounds, and Breath Sounds. http://www.wilkes.med.ucla.edu/inex.htm
Pillitter
•Perfusion – capillary refill
• “Warm to touch”

Pillitteri


Use supine position with pillow under the head and knee flexed.

Divide abd. to 4 Quadrant, and examine from button to top.

Examination of the abdomen involve the inspection, auscultation, palpation and percussion.









Contour
Bowel Sounds & Peristalsis
Skin: color, veins
Umbilicus
Assess for Tenderness, Ridigity, Tympany, Dullness
Hernias: umbilical, inguinal, femoral
Masses - size, shape, dullness, position, mobility
Liver, Spleen, Kidneys, Bladder

Abdominal girth should be measured over the umbilicus
Whenever possible.


Normal: every 10 to 30 seconds.

Listen in each quadrant long enough to hear at least one bowel sound.

Absent

Hypoactive; peritonitis, paralytic illeus

Normoactive

Hyperactive, GE, Intestestinal obs.


Excessive gas

Chronic constipation

Lactose intolerance

Viral gastroenteritis

Irritable bowel syndrome

Heartburn or indigestion

GERD

Food allergy

Parasite infections
(Giardia)
What are we most concerned about?


Appendicitis

Bowel obstruction --
Cholecystitis with or without gallstones

Food poisoning
(salmonella, shigella)

Inflammatory Bowel
Disease –

Ulcerative colitis

Hernia

Intussusception

Kidney stones

Pancreatitis

Sickle cell crisis

Ulcers

Urinary tract infections









Appearance –color, facial, ROM, gait, position
Pain – get your pain scales out
Nausea
Vomiting
Diarrhea
Bloating
Vomiting
Inability to pass gas or stool









FROM, MAE - neck, shoulder, elbow, wrist, hip, knee, ankle, foot, digits
Alignment, contour, strength, weakness & symmetry
Limb, joint mobility: stiffness, contractures
Gait – observe child walking without shoes
Spinal alignment - Scoliosis
Muscle Strength & Tone
Hips – O & B
Reflexes


Bone, joints-cartilages, ligaments and muscles.

Inspect the joint for flexion and extension, abduction, adduction, rotation.

Inspect the symmetry and observe the edema.

Lateral curvature of spine
Key Points:
• Barefoot
• Feet Together
• Bend Over –”Diving Of a Diving Board”
• Check Hips
Medline.com


The Five P’s:

Pain

Paresthesia

Passive stretch

Pressure

Pulse-less-ness









Rashes
Lesions
Lacerations
Lumps
Bumps
Bruises
Bites
Infections










Macule
Papule
Vesicle, bulla
Pustule
Cyst
Patch
Plaque
Wheal
Striae








Scale
Crust
Keloid
Fissure
Ulcer
Petechiae
Purpura
Ecchymosis

Capillary bleeding: Petichiae and purpura usually indicate serious conditions


Bacterial infections

Abscess formation

Severity varies with skin integrity, immune and cellular defenses

Examples:
 impetigo
 cellulitis


Privacy and modesty.

Explain procedures and equipment.

Interact with child during exam.





Privacy issues – first consideration
HEADS: home life, education, alcohol, drugs, sexual activity
/ suicide
GAPS Guidelines for
Adolescent
Preventive Services
Bright Futures

HEADS
 H ome life


E motions /
Depression or
E ducation
A ctivities


D rugs / Alcohol /
Substance
Abuse
S exuality activity or
S uicide
SHADESS
•S chool
•H ome
•A ctivities
•D rugs / Substance
Abuse
•E motions /
Depression
•S exuality
•S afety

COMMON SCHOOL HEALTH
FOCUSED ASSESSMENTS




The “I don’t feel good”
– where do I begin?
Behavioral / Mental
Health Concerns
Chronic Conditions &
Special Needs
What Else?

THE








Never doubt how vitally important you are; never doubt how important your work is – and never expect anyone to acknowledge it before you do.
Every moment, in everything you do, you are making a difference.
In fact, you are in the business of making a difference in other people’s lives.
In that difference lies their healing and your power.
Never forget it.
Leah L. Curtin, RN, MS, MA, DSC, FAAN