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CHAPTER 9

CHAPTER 9. THE PEDIATRIC EXAMINATION. Introduction to the Pediatric Examination. Pediatrics deals with: Care and development of children Diagnosis and treatment of diseases in children Pediatrician: medical doctor who specializes in pediatrics. Well-child visit (health maintenance visit).

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CHAPTER 9

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  1. CHAPTER 9 THE PEDIATRIC EXAMINATION

  2. Introduction to the Pediatric Examination Pediatrics deals with: Care and development of children Diagnosis and treatment of diseases in children Pediatrician:medical doctor who specializes in pediatrics

  3. Well-child visit (health maintenance visit) Components Evaluation of growth and development of child Physical examination To detect any abnormal conditions associated with child's stage of development Anticipatory guidance Provides parents with information to prepare for anticipated developmental events Assists parents in promoting child's well being Immunizations

  4. Topics of a well-child Visit Topics included are: • safety • nutrition • sleep • play • exercise • development • discipline

  5. Typical schedule for well-child visits Typical schedule for well-child visits • 1 month • 2 months • 4 months • 6 months • 9 months • 15 months • 18 months • 24 months • Yearly thereafter

  6. Sick-child visit Sick-child visit: child exhibits signs and symptoms of disease • Physician evaluates patient's condition to arrive at a diagnosis and prescribe treatment Procedures performed by MA during pediatric office visits: • Vital signs • Weight • Visual acuity • Assisting with physical examination

  7. Developing a Rapport • Important to establish rapport with child • If trust and confidence gained: • Child more likely to cooperate during examination • Requires special techniques (based on age) • Explain procedure to children who are able to understand • Approach child at his/her level of understanding • Know what to expect from a child at a particular age • Realize that a child may regress when ill

  8. Developing a Rapport, cont. Toddlers: respond well to making a game of the procedure School-age children: explain purpose of an instrument

  9. Carrying the Infant Lift and carry infant in a manner that is safe and comfortable 1. Cradle position • Infant is cradled with his/her body resting against MA's chest

  10. Carrying the Infant, cont. 2. Upright position • Infant is held upright while resting against the MA's chest

  11. Growth Measurements • One of the best methods to evaluate progress of child • Measured at each office visit and plotted on growth chart: • Weight • Height (length) • Head circumference (up to 3 years)

  12. Measuring Weight Use: • Determine nutritional needs • Calculate proper med dosage Infants: measured in supine position Older children: measured in standing position

  13. Length Length and Height • 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

  14. Height b. Height (stature) • Older children: measured in standing position

  15. Head Circumference (HC) • Infancy: period of rapid brain growth • Important to measure HC in children under age 3 • Plot on a growth chart • Newborn HC range: 32 to 38 centimeters (12.5” to 15”) • 4-inch (10-cm) increase in HC occurs in first year of life • Important screening measure for: • Macroencephaly • Microencephaly

  16. Chest Circumference (CC) • At birth: HC is approximately 2 cm larger than CC • Chest grows at faster rate than cranium • Between 6 months and 2 years: measurements are about the same • After age 2: CC is greater than HC • CC not typically measured on routine basis • Only when heart or lung abnormality is suspected

  17. Growth Charts • Should be part of child's record • Developed to determine if child's growth is normal • Identifies children with growth or nutritional abnormalities • MA responsible for plotting child's measurements on growth chart

  18. Purpose of Growth Charts • 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 • Look at child's growth pattern (primary use) • Physician investigates significant changes in growth pattern: • Rapid rise or rapid drop

  19. Growth Chart

  20. Pediatric Blood Pressure Measurement • American Academy of Pediatrics recommends: • Children 3 years of age and older: measure blood pressure (BP) annually • Purpose • Identify children at risk for developing hypertension as adults • Identify children with kidney disease or heart disease • Once treated: BP usually returns to normal • Overweight children: usually have higher BP than those of normal weight • To reduce BP: Weight loss through a prescribed diet and physical activity

  21. Blood Pressure Cuff Size • Cuff too small: BP may be falsely high • Cuff too large: BP may be falsely low 3. Cuffs come in a variety of sizes • Measured in centimeters • Size of cuff: refers to inner inflatable bladder (not cloth cover) • Name of cuff (child, adult) • Does not necessarily imply that it's appropriate for that age

  22. Determining Proper Cuff Size • Assess child's arm circumference: midpoint between shoulder and elbow • Bladder of cuff should encircle 80% to 100% of arm

  23. Pediatric Blood Pressure Measurement, cont. • Make sure child is relaxed • Apprehension can cause BP to be falsely high • To reduce anxiety: • Explain procedure • Allow child to handle equipment (if appropriate) • Measure BP after child has been sitting quietly for 3 to 5 minutes

  24. Blood Pressure Classifications • Pediatric BP varies depending on: • Age • Height • Gender

  25. Blood Pressure Classifications, cont. • BP varies throughout the day due to normal fluctuations in: • Physical activity • Emotional stress • If child's BP elevated: • Two or more readings must be taken at different visits before diagnosis of hypertension can be made

  26. Collection of a Urine Specimen • Purpose • May be required as part of physical examination • To perform a urinalysis to screen for disease • Assist in diagnosis of pathologic condition • Evaluate effectiveness of therapy • Pediatric urine collector • Used for infants or young children who cannot urinate voluntarily • Consists of plastic disposable bag with adhesive around the opening

  27. Pediatric Urine Collector

  28. Pediatric Injections • Experience child has with early injections influences his or her attitude toward later ones • Explain procedure to children old enough • 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 • Another person should be present to: • Help position child or divert or restrain child, if needed • If child struggles/fights excessively: • Delay injection and consult physician

  29. Types of Needles • Intramuscular injection • Gauge and length of needle based on: • Consistency of med (Thick, oily medications = larger lumen) • Size of child (Needle must reach muscle tissue) • Length of needle range: ⅝ to 1 inch • Gauge range: 22 to 25 • Depends on viscosity of mediation • Subcutaneous injection • Length of needle range: ⅜ to ½ inch • Gauge range: 23 to 25

  30. Intramuscular Injection Sites • Site varies based on age of child • Injection site: indicated in package insert accompanying med • 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

  31. Dorsogluteal Site Courtesy Wyeth Laboratories, Philadelphia, Penn

  32. 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

  33. 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: • Compress the muscle tissue • Stabilize the extremity • Injection is administered into the compressed tissue

  34. Deltoid 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

  35. Immunizations • Immunity:resistance of the body to effects of harmful agents such as pathogenic microorganisms and their toxins • Active, artificial immunization:process of becoming immune through use of a vaccine or toxoid • Vaccine: A suspension of attenuated (weakened) or killed microorganisms administered to an individual • Toxoid: A toxin (poisonous substance produced by a bacterium) that has been treated by heat or chemicals to destroy its harmful properties

  36. Purpose of Childhood Immunizations • Build body's defenses • Protect from certain infectious diseases • Administered to infants and young children during well-child visits • American Academy of Pediatrics: • Publishes a recommended childhood immunization schedule annually (www.aap.org)

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

  38. Immunizations Be familiar with each immunization including: • Use • Common side effects • Route of administration • Dose • Method of storage

  39. Immunizations, cont. Package insert comes with each immunization: contains info about drug • Physician’s Desk Reference (PDR) can also be used to locate information

  40. Immunizations, cont. Immunizations administered to infants and children: • Hep B: Hepatitis B vaccine (IM) • DTaP: Diphtheria and tetanus toxoids and acellular pertussis vaccine (IM) • Hib:Haemophilus influenzae type b (IM) • IPV: Inactivated polio vaccine (IM or SC) • MMR: Measles, mumps, and rubella vaccine (SC) • Varicella: Chickenpox vaccine (SC) • PCV: Pneumococcal conjugate vaccine (IM)

  41. Immunizations, cont. Immunization record card provided to parents • Instruct parent to bring to well-child visits • Child's immunizations can be recorded • Instruct parents in: • Normal side effects of immunizations • What to do if side effects occur

  42. National Childhood Vaccine Injury Act (NCVIA) • Requires parents be provided with: • Information about benefits and risks of childhood immunization • CDC developed vaccine information statements (VIS) • Explains benefits and risks of immunizations in lay terms 3. Before a child receives an immunization: • Appropriate VIS must be given to child's parent or guardian • Parent must be given enough time to read VIS

  43. Vaccine Information Statement Courtesy Centers for Disease Control and Prevention, Atlanta, GA

  44. National Childhood Vaccine Injury Act (NCVIA), cont. • Information that must be charted in patient's medical record (required by NCVIA) • Name and publication date of each VIS given to parent • Date the VIS provided to parent • Date of administration of vaccine • Manufacturer and lot number of vaccine • Signature/title of health care provider who administered vaccine • Address of medical office where vaccine was administered

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