Chapter 25 The Pediatric Patient

Competencies Differentiate the structural and physiological variations between pediatric patients and adults. Identify personal-social, language, and fine and gross motor findings when using the Denver II. (continues)

Competencies Elicit a complete health history from a patient or caregiver using standard components of a pediatric health history. (continues)

Competencies Identify various techniques of approaching patients at different developmental levels before initiating the physical examination. (continues)

Competencies Perform inspection, palpation, percussion, and auscultation in a head-to-toe examination of a pediatric patient.

Physical Growth Weight Length or height Head circumference (continues)

Physical Growth Average weight gain Rapid growth periods Infancy Adolescence

Allaying Childhood Fears During Physical Exam Infant Toddler Preschooler School age Adolescent

Anatomy and Physiology Vital signs Temperature regulation Variations by age Pulse Respirations Blood pressure (continues)

Anatomy and Physiology Skin and hair Lanugo Vernix caseosa Head Closure of fontanels (continues)

Anatomy and Physiology Eyes, ears, nose, mouth, and throat Visual acuity Variations in eustachian tube Development of sinuses Eruption of teeth (continues)

Anatomy and Physiology Breasts Breast tissue begins to develop at 8 to 10 years of age Thorax and lungs Infant Chest development Nose breathing Abdominal breathing (continues)

Anatomy and Physiology Heart and peripheral vasculature Placement Cardiac output Abdomen Musculoskeletal system Bone growth ends at 20 years of age (continues)

Anatomy and Physiology Neurological system Incomplete at birth Neurons become myelinated Urinary system Bladder location (continues)

Anatomy and Physiology Female genitalia Development of pubic hair Male genitalia Descent of the testes Onset of puberty

Health History Biographical data Name Contact information Source of data (continues)

Health History Chief complaint Infants, toddlers, young preschoolers are unable to describe their health concerns; caregiver will describe Older preschoolers, school-age children, and adolescents are able to describe their health concerns

Past Health History Birth history Medical history Prenatal Labor and delivery Postnatal Medical history Hospitalizations Emergency department visits (continues)

Past Health History Injuries and accidents Childhood illnesses Document exposure to measles, mumps, rubella, pertussis, chickenpox, RSV Immunizations (continues)

Past Health History Family health history SIDS ADHD Congenital disorders Mental retardation

Social History School or day care environment Home environment Academic performance (if applicable) Home environment Potential exposure to lead Gun safety (continues)

Social History Child’s personal habits Activities child enjoys How does child cope with stress? Domestic and intimate partner violence Adolescents may be at risk

Health Maintenance Activities Sleep Diet Safety Critical to assess childproofing the environment

Developmental Examination Denver II Personal-social Fine motor-adaptive Language Gross motor

Physical Examination Equipment Appropriate child-sized equipment Developmental examination tools Ophthalmoscope, otoscope (continues)

Physical Examination General approach Warm environment Methods to reduce anxiety and promote security Respect patient’s modesty (continues)

Physical Examination General approach (cont’d) Interview older children and adolescents separate from caregiver Perform uncomfortable procedures last

Examination Vital signs Blood pressure Heart rate Temperature Respiratory rate (continues)

Examination Physical growth Weight Height or length Head circumference Chest circumference Apgar score (continues)

Examination Skin Hair Inspect color, lesions Palpate texture (continues)

Examination Head Inspect for symmetry, shape, head control Palpate fontanels, suture lines, surface characteristics (continues)

Examination Eyes Assess eyes toward the end of the exam in children up to 10 years old Vision screening Tumbling E chart Allen test (continues)

Examination Eyes (cont’d) Strabismus screening Hirschberg test Cover-uncover test Color vision (continues)

Examination Eyes (cont’d) Inspect Eyelids Lacrimal apparatus Sclera Iris Pupils Lens (continues)

Examination Eyes (cont’d) Inspect Red reflex Retina Optic disc (continues)

Examination Ears Nose Auditory testing External ear Internal ear Inspect mucosa, nasal septum, presence of drainage (continues)

Examination Mouth and throat Inspect lips, buccal mucosa, teeth, hard palate, soft palate, oropharynx (continues)

Examination Neck Breasts Palpate thyroid and lymph nodes Inspection Assess sexual maturity rating (continues)

Examination Thorax and lungs Inspect shape of thorax, presence of retractions Palpate for tactile fremitus Percuss diaphragmatic excursion Auscultate breath sounds (continues)

Examination Heart and peripheral vasculature Usually performed at beginning of exam Inspect Apical impulse, precordium Palpate Thrill Peripheral pulses (continues)

Examination Heart and peripheral vasculature (cont’d) Auscultate Heart sounds Innocent murmurs (continues)

Examination Abdomen Calm child before proceeding Inspect Auscultate Contour Peristaltic wave Auscultate Bowel sounds Palpate (continues)

Examination Musculoskeletal system General approach Inspection Use of games to facilitate evaluation Inspection Muscles, joints, tibiofemoral bones Palpation Joints, feet, hip, femur

Neurological Examination General approach Infant Toddler (continues)

Neurological Examination Reflex mechanisms of the infant Rooting Sucking Palmar grasp Tonic neck Stepping Plantar grasp (continues)

Neurological Examination Reflex mechanisms of the infant (cont’d) Babinski Moro Galant Placing Landau (continues)

Neurological Examination Cranial nerve testing Infant Toddler School age Adolescent

Genitalia Examination Tanner sexual maturity rating Female Age-specific guidelines Inspect perineal area (continues)

Genitalia Examination Male Age-specific guidelines Inspect penis, scrotum Palpate scrotum Hernia

Anus Examination Performed if problem detected or abuse suspected Inspect for bleeding, fissures, prolapse, skin tags

Signs of Sexual Abuse in Children Strong fear of examination Presence of STD Absent or delayed anal reflex (continues)

Signs of Sexual Abuse in Children Anorectal tears, ecchymosis, pruritus, scarring, or bleeding Broken hymen, vaginal tears