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Ch 31 Health Assessment of Children Approaching the Parent or Caregiver: -Greet parent by name -Remain approachable -Refer to child by name

and use correct gender when referring to child Approaching Child: -Colorful uniforms -Slow deliberate gestures -Young children will warm up when given time to be invisible in the room -Hiding behind a parent -Be at the same eye level as the child -Elicit cooperation by allowing child control over pace, order, anything else that the can control while still allowing you to obtain the information needed Communicating with the Child During History: -Given opportunities to participate in health history and assessment -Have child point to where it hurts -Validate info by asking parent -Obtain as much info from child as possible For teens: -Ask if they want to interview without parent present -Demonstrate interest by asking about school, work -Once trust is built, move on to more personal questions -If info indicates danger, must share info with parents Observing the Parent-Child Interaction: -Begins during focused assessment of interview and continues throughout exam -Behavior is crucial to proper assessment of familys needs -Infant will be relaxed and calm if needs are met -Crying may occur when baby is ill or frightened but can also indicate discomfort parent -Use high-pitched and soothing voices -Be aware of your reactions to the adolescents questions or behaviors, such as your nonverbal and facial expressions Determining the Type of History Needed: -If child is rarely seen by provider = complete history -Routine health care with mild illness = problem focused history -Critical situations = history taking delayed until childs condition is stabilized Components of Health Interview: -Initial visit = have family fill out questionnaire, but still get full interview Demographics: -Start with simple and nonintrusive questions -Once trust built, start with sensitive questions -ID who historian is, note how reliable you consider source of info to be Chief Complaints and History of Present Illness: -Ask about chief complaint -Response from child or parent may be a functional problem, a developmental disease Past Health History: -Any operations or hospitalizations -Document diet -Note allergies, and reaction to allergen -Immunization status

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Family History: -Key part of interview Developmental History: -Determine age by landmarks when gross/fine motor control achieved -Document speech problems such as stuttering or lisp -Assess feeding skills Functional History: -Safety measures -Routine health care -Nutrition -Physical activity -TV and computer habits -Sleep behavior -Elimination patterns -Hearing/vision problems -Relationships with other family members and friends -Religious involvement -Use of adaptive and assistive devices -Sexual practice Family Composition, Resources, and Home Environment: -Marital status of parents -Parents may not know routines if cared for by someone else -Family changes can affect the relationship Approaching the Child: Newborns and Infants: -Auscultate when child is asleep -Count HR before undressing child -Best to examine 1-2 hours before feeding -In head-to- toe manner -Delay moro reflex until end of exam Toddlers and Preschoolers: -Like to remove clothing one at a time -Replace item of clothing before moving on to next part of exam -Incorporate play into exam -Use little touch at beginning -Introduce equipment -Praise child for cooperation -If uncooperative, assess as thoroughly as possible and move on to next area -Fear body invasion and mutilation and will withdraw from any procedure or that is viewed as intrusive School Age Children: -Can be objective and realistic -Interested in how things work and why certain things need to be done and will be responsive to truthful and simple explanations -Respect desire to avoid pain and insult -Wear underpants for sense of security Adolescents: -Provide privacy while changing into gown -Attitude of respect -Head to toe manner -Allow time for questions from teen

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Performing a Physical Exam: General Apperance: -Observe childs state of alertness and response to stress of situation -Newborns posture is flexed, arms and legs tucked in -Older infant has better head and neck control -Toddler lordosis, bowlegs, large head -Preschooler is more slender and upright -School-age and adolescent are upright, well-balanced -Initial observation reveals lots of information -Delay interpretation until you have further info Vital Signs: -Greater fluctuation in what is considered normal in children compared to adults Temperature: -Many routes to taking temps. -Method depends on childs age and condition -By age 4, child can hold oral thermometer -Axilla temp. is good for uncooperative, neurologically impaired, immunosuppressed or have injuries or surgery to the oral cavity -Rectal is invasive Pulse: -Assess rate while sleeping or resting -Rate is much faster than in adults -As child grows, rate slows and the range of normal values narows -PMI: point of maximal impulse -Point on chest wall where heartbeat is heard most distinctly -Third or fourth intercostal space -Moves more medial and slightly lower until age 7 (apical) -Take apical if irregular rate or congenital heart defect Respiratory rate: -Count for a full minute -Infants respirations are primarily diaphragmatic, count ab movements -After age 1, count thoracic movements Pulse Ox: -Included in vitals -Pulse rate can coincide with apical pulse rate to ensure the oxygen saturation reading is accurate -Potential errors include abnormal hemoglobin value, hypotension, hypothermia, ambient light interference, motion artifact, skin breakdown -Falsely low readings may be associated with nonsecure connection, cold extremities/hypothermia, hypovolemia -Falsely high readings may be associated with carbon monoxide poisoning and anemia Blood pressure:
-Should be taken in same limb, at same place, same position with each subsequent measurement to ensure consistency in tracking BP -Systolic pressure in children is at the moment the first Korotkoff sound is heard as the manometer pressure is lowered -Point at which the sound disappears is the diastolic pressure -In children older than 1 year, systolic pressure in the thigh tends to be 10-40 mmHg higher than in the arm, diastolic remains the same

-Systolic pressure increases if child is crying or anxious, so measure the blood BP wit child quiet and relaxed

Weight: Weight for length: -For children between the ages of newborn and 36 months, plot weight on a growth chart in comparison to the childs length -Children placing less than that 5th percentile on the weight-forlength chart are considered underweight -Those placing greater than 95th percentile are considered to be overweight BMI: -Body fat is determined by comparing the childs height and weight -<5% = underweight, between 85- 95% = overweight Head Circumference: -Measured until the third birthday Monitoring Equipment: -Apnea monitor measures abnormal or irregular breathing in infants -Cardiopulmonary monitor generally measures HR and RR Skin: Inspection: -Blueness of the hands and feet, known as acrocyanosis (normal bc of immature circulatory system) -Cooling or warming the newborn and young infant may produce a vasomotor response causing mottling of skin over trunk and extremities -Babies of darker skin, will be paler than their prents -Dark skinned, commonly have hyperpigmented areolas, genitals, linea negra -Inspect for lanugo (soft, downy hair on body, particularly the face and back) Palpation: -Palpate for skin temp, moisture, texture, turgor, edema Hair and nails: -Note presence of a greasy, scaly plaque on scalp of infants (seborrheic dermatitis) benign and usually treated -Dry, brittle nails may indicate a nutritional deficiency -Inspect skin around nails to ensure that it is intact and without signs of infection Head: Inspection: -May be temporarily misshapen from uterine positioning or a long vaginal delivery -Observe by looking down on it from above -After 4 mts of age, the infant should have achieved enough head control to hold the head erect and in midline when placed in a vertical position Palpation: -Anterior fontanel is about the size of a quarter at birth and slowly gets smaller until it can no longer be felt when it is closed by the age of 9- 18 mts -Posterior fontanel is much smaller and may close at any time between shortly after birth and apporoximately 2 month of age

-Dehydration = sunken fontanel -Increased intracranial pressure/overhydration = bulging fontanel Neck: -Webbing of neck skin folds may be associated with Turner syndrome -Lax neck skin may occur with Down Syndrome -Pain or resistance to ROM may indicate meningeal irritation -Dont assess neck in a trauma victim -Enlarged cervical lymph nodes frequently occur in association with upper respiratory infections and otitis media Eyes: -Epicanthal folds can be present in children of Asian descent, children with genetic abnormalities, or those with fetal alcohol spectrum disorder -PERRLA Ears: -Pinna should deviate no more than 10 degrees -Low set ears may be associated with genetic abnormalities or syndromes -Tympanic membrane should be pearly pink or gray, translucent, allowing visualization of the bony landmarks Nose and Sinuses: -Nose can be displaced temporarily by birth trauma in newborns Mouth and Throat: -Salivation in infants begins at about 3 months, drooling occurs bc the infant doesnt learn to swallow saliva for several months -Tongue extrusion reflex is normal in infants up until the age of 6 mts. And allows the infant to suckle easily from birth -When teeth begin to erupt, happens symmetrically for about a month, toddlers have 20 teeth by 30 mts of age -Tonsils usually cant be seen in the infant -Child becomes toddler, tonsils become dramatically larger and then begin to decrease in size again by the ninth year Thorax and lungs: -Children often have respiratory infections and disorders and may exhibit alterations in resp. effort and breath sounds -Cyanosis indicates hypoxia -Newborns chest should be smooth and round, with transverse diameter equal to anterior-posterior diameter -Pectus excavatum (depressed sternum) -Pectus carinatum (protruberent sternum) -Newborns and young children demonstrate an irregular respiratory pattern -Nasal flaring = labored breathing -Typical locations for retraction include the intercostal, subcostal, substernal, suprasternal, clavicular regions -Pay attention to position child naturally assumes to breathe comfortably -Resp distress often sit forward and are uncomfortable lying down or talking -Hypperresonance in lungs can mean asthma -Have loud breath sounds -Resp distress may exhibit diminished breath sounds, most often in lung bases -Infants and children with secretions in the nasopharyngeal area may have those sounds transmitted over the lung fields -Both genders have swollen nipples from maternal estrogen -Occasionally gynecomastia is caused by marijuana use, anabolic steroids, or hormone dysfunction

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-A tender nodule palpated just under the nipple confirms pubertal changes Heart and peripheral perfusion: -Radial pulse is very difficult to palpate in children less than 2 -Auscultate heart with the child in upright and reclined positions -Be sure to listen for 1-3 minutes bc of irregularity of rhythyms in some children -Innocent murmurs occur frequently in children bc of the childs more dynamic circulation, thin chest wall, angulated vessels Abdomen: -Visible peristaltic waves are abnormal and should be reported immediately -Not uncommon to see umbilical hernia protrude through and become larger when the infant or toddler strains or cries -This is benign finding and will usually disappear as the abdomen becomes stronger -Full bladder may yield dullness and percussion -Kidneys are rarely palpable -Palpate inguinal areas for presence of hernia or enlarged lymph nodes Genitalia and Anus: -Foreskin cannot be retracted in a boy ocer 3 years may indicate phimosis -Scrotum is ordinarily more deeply pigmented than the rest of the skin -Newborn/s labia minora are swollen from the effects of maternal estrogen but will decrease in size and be hidden by the labia majora within the weeks of life -Small amounts of blood-tinged discharge may be present in first few wks from maternal hormone exposure Musculoskeletal: -Newborn, tenderness or crepitus reveals a fracture sustained at birth -A bump indicates callus formation with clavicle fracture -Newborns spine has a C-shaped curve and remains round for first 3 mts -Cervical spine begins to develop around 3-4 mts of age as baby gains head control -By 12-18 mts of age, lumbar curve develops, which corresponds to the onset walking -Infants feet and legs appear bowed secondary to in utero positioning but can straightened through passive ROM -Bowing of lower legs lessens as the toddler begins to bear weight and usually resolves in the second or third year of life -Genu varun (bow legs) -Genu valgum (knock knee) -Normal to have flat feet in toddler and young child -Inability to straighten the foot midline may indicate clubfoot Neurologic: -Reflexes: -Primitive= Moro, root, suck, asymmetric tonic neck, plantar/palmar grasp, step, and babinski -Protective = righting and parachute reactions -Newborns deep tendon reflexes are normally brisk (3+) -They decrease to average (2+) USUALLY BY 4 MTS

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