2Introduction to the Pediatric Examination Pediatrics deals with:Care and development of childrenDiagnosis and treatment of diseases in childrenPediatrician: medical doctor who specializes in pediatrics
3Well-child visit (health maintenance visit) ComponentsEvaluation of growth and development of childPhysical examinationTo detect any abnormal conditions associated with child's stage of developmentAnticipatory guidanceProvides parents with information to prepare for anticipated developmental eventsAssists parents in promoting child's well beingImmunizationsWhat should we say to the parent about the importance of a well-child visit?
4Topics of a well-child Visit Topics included are:safetynutritionsleepplayexercisedevelopmentdisciplineWhat are some safety tips to give to parents?
5Typical schedule for well-child visits 1 month2 months4 months6 months9 months15 months18 months24 monthsYearly thereafterIt is important for parents to stay with this schedule because immunizations are given to the child.
6Sick-child visitSick-child visit: child exhibits signs and symptoms of diseasePhysician evaluates patient's condition to arrive at a diagnosis and prescribe treatmentProcedures performed by MA during pediatric office visits:Vital signsWeightVisual acuityAssisting with physical examinationGive some examples of acute illnesses a child may have.6
7Developing a Rapport Important to establish rapport with child If trust and confidence gained:Child more likely to cooperate during examinationRequires special techniques (based on age)Explain procedure to children who are able to understandApproach child at his/her level of understandingKnow what to expect from a child at a particular ageRealize that a child may regress when illHow can you communicate to the child?7
8Developing a Rapport, cont. Toddlers: respond well to making a game of the procedureSchool-age children: explain purpose of an instrument
9Carrying the InfantLift and carry infant in a manner that is safe and comfortable1. Cradle positionInfant is cradled with his/her body resting against MA's chestPatient teaching may be required for the family.9
10Carrying the Infant, cont. 2. Upright positionInfant is held upright while resting against the MA's chestCradling the head provides safety to the head and neck.
11Growth MeasurementsOne of the best methods to evaluate progress of childMeasured at each office visit and plotted on growth chart:WeightHeight (length)Head circumference (up to 3 years)The head circumference may be measured longer if disease is present.11
12Measuring Weight Use: Infants: measured in supine position Determine nutritional needsCalculate proper med dosageInfants: measured in supine positionOlder children: measured in standing positionWhat is the recumbent position?12
13Length Length and Height Length Measured in children younger than 24 monthsMeasured from vertex of head to heel in supine positionTwo people are needed to accurately determine lengthWhat is the vertex of the head?Why are two people needed to determine length?13
14Height b. Height (stature) Older children: measured in standing positionThe extremities grow at a faster rate than the trunk.
15Head Circumference (HC) Infancy: period of rapid brain growthImportant to measure HC in children under age 3Plot on a growth chartNewborn HC range: 32 to 38 centimeters (12.5” to 15”)4-inch (10-cm) increase in HC occurs in first year of lifeImportant screening measure for:MacroencephalyMicroencephalyHow would you plot the head circumference?15
16Chest Circumference (CC) At birth: HC is approximately 2 cm larger than CCChest grows at faster rate than craniumBetween 6 months and 2 years: measurements are about the sameAfter age 2: CC is greater than HCCC not typically measured on routine basisOnly when heart or lung abnormality is suspectedThe circumference is taken at the nipple line.
17Growth Charts Should be part of child's record Developed to determine if child's growth is normalIdentifies children with growth or nutritional abnormalitiesMA responsible for plotting child's measurements on growth chartWhat is NCHS?17
18Purpose of Growth Charts Compares child's weight and length (or height) with other children of same ageExample: 18-month-old boy: Weight: 25th percentile; Height: 80th percentileInterpretation75% of 18-month-old boys weigh more; 25% weigh less20% of 18-month-old boys are taller; 80% are shorterLook at child's growth pattern (primary use)Physician investigates significant changes in growth pattern:Rapid rise or rapid drop18
20Pediatric Blood Pressure Measurement American Academy of Pediatrics recommends:Children 3 years of age and older: measure blood pressure (BP) annuallyPurposeIdentify children at risk for developing hypertension as adultsIdentify children with kidney disease or heart diseaseOnce treated: BP usually returns to normalOverweight children: usually have higher BP than those of normal weightTo reduce BP: Weight loss through a prescribed diet and physical activityThe patient should be relaxed and not anxious during the taking of a BP.20
21Blood Pressure Cuff Size Cuff too small: BP may be falsely highCuff too large: BP may be falsely low3. Cuffs come in a variety of sizesMeasured in centimetersSize 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 age21
22Determining Proper Cuff Size Assess child's arm circumference: midpoint between shoulder and elbowBladder of cuff should encircle 80% to 100% of arm22
23Pediatric Blood Pressure Measurement, cont. Make sure child is relaxedApprehension can cause BP to be falsely highTo reduce anxiety:Explain procedureAllow child to handle equipment (if appropriate)Measure BP after child has been sitting quietly for 3 to 5 minutesWhat are some ways the MA could calm the child?
24Blood Pressure Classifications Pediatric BP varies depending on:AgeHeightGenderThe stethoscope should not touch the cuff.24
25Blood Pressure Classifications, cont. BP varies throughout the day due to normal fluctuations in:Physical activityEmotional stressIf child's BP elevated:Two or more readings must be taken at different visits before diagnosis of hypertension can be madeHow long should you wait before taking a BP if the patient has been exercising?25
26Collection of a Urine Specimen PurposeMay be required as part of physical examinationTo perform a urinalysis to screen for diseaseAssist in diagnosis of pathologic conditionEvaluate effectiveness of therapyPediatric urine collectorUsed for infants or young children who cannot urinate voluntarilyConsists of plastic disposable bag with adhesive around the openingWhat conditions may warrant a necessity for a urine specimen?26
27Pediatric Urine Collector On a male, the penis and scrotum should be placed through the opening of the collection bag.
28Pediatric InjectionsExperience child has with early injections influences his or her attitude toward later onesExplain procedure to children old enoughBe honest and attempt to gain trust and cooperationTell child it will hurt, but only for a short timeExplain that the med will help child get betterAnother person should be present to:Help position child or divert or restrain child, if neededIf child struggles/fights excessively:Delay injection and consult physicianParents may also need support during this procedure.28
29Types of Needles Intramuscular injection Subcutaneous 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 inchGauge range: 22 to 25Depends on viscosity of mediationSubcutaneous injectionLength of needle range: ⅜ to ½ inchGauge range: 23 to 25Check the package insert of the immunization for injection site.29
30Intramuscular Injection Sites Site varies based on age of childInjection site: indicated in package insert accompanying medDorsogluteal siteUntil child is walking, gluteus muscle is:Small and not well-developedCovered with a thick layer of fatInjection may come close to sciatic nerveDanger increased: if child squirming or fightingDo not use gluteal site until child has been walking for at least 1 yearThis site is used frequently in adults.30
31Courtesy Wyeth Laboratories, Philadelphia, Penn Dorsogluteal SiteCourtesy Wyeth Laboratories, Philadelphia, Penn
32Vastus Lateralis Site Vastus lateralis Recommended for infants and young childrenLocated on anterior surface of midlateral thighAway from major nerves and blood vesselsMuscle is large enough to accommodate the medThe child should be restrained during injections.32
33Vastus Lateralis Site, cont. Length of needle: depends on size of thigh1 inch used most oftenTo administer injection:Infant is placed on backThigh is grasped in order to:Compress the muscle tissueStabilize the extremityInjection is administered into the compressed tissueMost immunizations are given in this site.33
34Deltoid Site Deltoid muscle is shallow: To administer injection: Can accommodate only very small amount of medTo administer injection:Muscle is grasped between thumb and fingersNeedle inserted pointing slightly upward toward shoulderThe deltoid site is not used until a child is older and the deltoid muscle is better formed.34
35ImmunizationsImmunity: resistance of the body to effects of harmful agents such as pathogenic microorganisms and their toxinsActive, artificial immunization: process of becoming immune through use of a vaccine or toxoidVaccine: A suspension of attenuated (weakened) or killed microorganisms administered to an individualToxoid: A toxin (poisonous substance produced by a bacterium) that has been treated by heat or chemicals to destroy its harmful propertiesGive an example of a vaccine.35
36Purpose of Childhood Immunizations Build body's defensesProtect from certain infectious diseasesAdministered to infants and young children during well-child visitsAmerican Academy of Pediatrics:Publishes a recommended childhood immunization schedule annually (www.aap.org)How would you explain to a parent the importance of immunizations?36
37Immunization Schedule From Department of Health and Human Services, Centers for Disease Control and Prevention, United States, 2007
38Immunizations Be familiar with each immunization including: Use Common side effectsRoute of administrationDoseMethod of storageWhat are some common side effects of immunizations?38
39Immunizations, cont.Package insert comes with each immunization: contains info about drugPhysician’s Desk Reference (PDR) can also be used to locate informationThe MA should always refer to the PI (package insert) before administering an immunization.39
40Immunizations, 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)The polio vaccine was once given orally.Another name for pertussis is whooping cough.40
41Immunizations, cont. Immunization record card provided to parents Instruct parent to bring to well-child visitsChild's immunizations can be recordedInstruct parents in:Normal side effects of immunizationsWhat to do if side effects occurWhat should the MA do if the parent loses the immunization card?41
42National Childhood Vaccine Injury Act (NCVIA) Requires parents be provided with:Information about benefits and risks of childhood immunizationCDC developed vaccine information statements (VIS)Explains benefits and risks of immunizations in lay terms3. Before a child receives an immunization:Appropriate VIS must be given to child's parent or guardianParent must be given enough time to read VISWhat does CDC stand for?These forms can be printed from the internet.42
43Vaccine Information Statement Courtesy Centers for Disease Control and Prevention, Atlanta, GA
44National 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 parentDate the VIS provided to parentDate of administration of vaccineManufacturer and lot number of vaccineSignature/title of health care provider who administered vaccineAddress of medical office where vaccine was administeredWhere do you locate the name and publication date on the VIS form?44