CHAPTER 9

CHAPTER 9THE PEDIATRIC EXAMINATION

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

Introduction to the Pediatric Examination

1. Pediatrics deals with:a. Care and development of childrenb. Diagnosis and treatment of diseases in children

2. Pediatrician: medical doctor who specializes in pediatrics


Well-child visit (health maintenance visit)

1. Componentsa. Evaluation of growth and development of childb. 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 Visit

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

5) exercise6) development7) discipline


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


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 treatmentProcedures performed by MA during pediatric

office visits:b. Vital signsc. Weightd. Visual acuitye. Assisting with physical examination


Developing a Rapport

1. Important to establish rapport with child2. If trust and confidence gained:

a. Child more likely to cooperate during examination3. Requires special techniques (based on age)4. Explain procedure to children who are able to

understand5. Approach child at his/her level of understanding

a. Know what to expect from a child at a particular age6. Realize that a child may regress when ill


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 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.

2. Upright positiona. Infant is held upright

while resting against the MA's chest


Growth Measurements

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

2. Measured at each office visit and plotted on growth chart:a. Weightb. Height (length)c. Head circumference (up to 3 years)


Measuring Weight

Use:• Determine

nutritional needs• Calculate proper

med dosageInfants: measured in

supine positionOlder children:

measured in standing position


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

b. Height (stature)• Older children: measured

in standing position


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) 1. At birth: HC is approximately 2

cm larger than CC2. Chest grows at faster rate than

craniumb. Between 6 months and 2

years: measurements are about the same• After age 2: CC is greater

than HC3. CC not typically measured on

routine basisa. Only when heart or lung

abnormality is suspected


Growth Charts

1. Should be part of child's record2. Developed to determine if child's

growth is normal3. Identifies children with growth or

nutritional abnormalities4. MA responsible for plotting child's

measurements on growth chart


Purpose of Growth Chartsa. 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 Chart


Pediatric Blood Pressure Measurement

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

pressure (BP) annually2. 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 weighta. To reduce BP: Weight loss through a prescribed diet

and physical activity


Blood Pressure Cuff Size1. Cuff too small: BP may be falsely

high2. Cuff too large: BP may be falsely

low3. Cuffs come in a variety of sizes

a. Measured in centimetersb. 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 Sizea. Assess child's arm circumference: midpoint

between shoulder and elbowb. Bladder of cuff should encircle 80% to 100% of

arm


Pediatric Blood Pressure Measurement, cont.

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

to be falsely high2. To reduce anxiety:

a. Explain procedureb. Allow child to handle

equipment (if appropriate)3. Measure BP after child has

been sitting quietly for 3 to 5 minutes


Blood Pressure Classifications

1. Pediatric BP varies depending on:a. Ageb. Heightc. Gender


Blood Pressure Classifications, cont.

• BP varies throughout the day due to normal fluctuations in:a. Physical activityb. 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 Specimen1. Purpose

a. May be required as part of physical examination• To perform a urinalysis to screen for disease

b. Assist in diagnosis of pathologic conditionc. Evaluate effectiveness of therapy

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

urinate voluntarilyb. Consists of plastic disposable bag with adhesive

around the opening


Pediatric Urine Collector


Pediatric Injections1. 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

needed4. If child struggles/fights excessively:

a. Delay injection and consult physician


Types of Needles1. Intramuscular injection

a. 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 inchc. Gauge range: 22 to 25

• Depends on viscosity of mediation

2. Subcutaneous injectiona. Length of needle range: ⅜ to ½ inchb. Gauge range: 23 to 25


Intramuscular Injection Sites1. Site varies based on age of child2. 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 Site

Courtesy Wyeth Laboratories, Philadelphia, Penn


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.

• 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 tissue2) Stabilize the extremity

– Injection is administered into the compressed tissue


Deltoid SiteDeltoid 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


Immunizations1. 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 toxoida. 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

a. Build body's defensesb. Protect from certain

infectious diseasesc. 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 Schedule

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


Immunizations

Be familiar with each immunization including:a. Useb. Common side effectsc. Route of administrationd. Dosee. Method of storage


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 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. Immunization record

card provided to parentsa. Instruct parent to

bring to well-child visits• Child's immunizations

can be recordedb. Instruct parents in:

• Normal side effects of immunizations

• What to do if side effects occur


National Childhood Vaccine Injury Act (NCVIA)

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

immunization2. CDC developed vaccine information

statements (VIS)a. Explains benefits and risks of immunizations in

lay terms3. 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 Statement

Courtesy Centers for Disease Control and Prevention, Atlanta, GA


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

parentb. Date the VIS provided to parentc. Date of administration of vaccined. Manufacturer and lot number of vaccinee. Signature/title of health care provider who

administered vaccinef. Address of medical office where vaccine was

administered

CHAPTER 9

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