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CHAPTER 9
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
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Well-child visit
(health maintenance visit)
1. Components
a. 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
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Topics of a well-child Visit
Topics included are:
1)
2)
3)
4)
safety
nutrition
sleep
play
5) exercise
6) development
7) discipline
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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
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Sick-child visit
Sick-child visit: child exhibits signs and symptoms
of disease
a. Physician evaluates patient's condition to arrive at
a diagnosis and prescribe treatment
Procedures performed by MA during pediatric
office visits:
a. Vital signs
b. Weight
c. Visual acuity
d. Assisting with physical examination
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Developing 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
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Developing a Rapport, cont.
a. Toddlers: respond well
to making a game of the
procedure
b. School-age children:
explain purpose of an
instrument
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Carrying the Infant
Lift and carry infant in a manner
that is safe and comfortable
1. Cradle position
a. Infant is cradled with his/her
body resting against MA's
chest
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Carrying the Infant, cont.
2. Upright position
a. Infant is held upright
while resting against the
MA's chest
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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. Weight
b. Height (length)
c. Head circumference (up to 3 years)
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Measuring Weight
Use:
•
Determine
nutritional needs
•
Calculate proper
med dosage
Infants: measured in
supine position
Older children:
measured in
standing position
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Length
Length and Height
a. 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
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Height
b. Height (stature)
•
Older children: measured
in standing position
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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
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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
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Growth 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
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Purpose 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
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Growth Chart
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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
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Blood 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
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Determining 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
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Pediatric Blood Pressure
Measurement, cont.
1. Make sure child is relaxed
a. 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
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Blood Pressure Classifications
1. Pediatric BP varies depending on:
a. Age
b. Height
c. Gender
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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
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Collection of a Urine Specimen
1. Purpose
a. 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 collector
a. Used for infants or young children who cannot
urinate voluntarily
b. Consists of plastic disposable bag with adhesive
around the opening
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Pediatric Urine Collector
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Pediatric Injections
1. Experience child has with early injections
influences his or her attitude toward later ones
2. Explain procedure to children old enough
a. 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
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Types of Needles
1. 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 inch
c. Gauge range: 22 to 25
•
Depends on viscosity of mediation
2. Subcutaneous injection
a. Length of needle range: ⅜ to ½ inch
b. Gauge range: 23 to 25
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Intramuscular Injection Sites
1. Site varies based on age of child
2. Injection site: indicated in package insert
accompanying med
a. 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
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Dorsogluteal Site
Courtesy Wyeth Laboratories, Philadelphia, Penn
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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
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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
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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
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Immunizations
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
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Purpose of Childhood
Immunizations
a. Build body's defenses
b. Protect from certain
infectious diseases
c. Administered to infants and
young children during wellchild visits
•
American Academy of
Pediatrics:
–
Publishes a recommended
childhood immunization
schedule annually
(www.aap.org)
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Immunization Schedule
From Department of Health and Human Services, Centers for Disease Control and Prevention, United States, 2007
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Immunizations
Be familiar with each immunization
including:
a. Use
b. Common side effects
c. Route of administration
d. Dose
e. Method of storage
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Immunizations, cont.
Package insert comes with each
immunization: contains info about drug
a. Physician’s Desk Reference (PDR) can also
be used to locate information
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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)
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Immunizations, cont.
Immunization record card
provided to parents
a. 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
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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:
a. Appropriate VIS must be given to child's parent or
guardian
b. Parent must be given enough time to read VIS
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Vaccine Information Statement
Courtesy Centers for Disease Control and Prevention, Atlanta, GA
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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
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