Peds Physical Assessment

How should providers give anticipatory guidance?

give current information and anything relevant that could come up before next visit (next milestones, etc)

What are the elements of H&P history?

height, weight, head circumference (until 36mo)

Components of health supervision

H&P, developmental and behevioral-social-emotional screening, vision/hearing screening, population/risk-based-screening, immunization, injury prevention, parent/child interaction, identify at risk children

What is the goal for number of visits from birth to 21yo?

32 visits (newborn, 1 week, 11 between 1mo and 36mo, yearly after 36mo) Positive corellation between

How can you minimize anxiety/threats with children?

go from least to most invasive, allow child to maintain eye contact with parents (adolescent privacy), encourage caregiver participation (hug and love, not restrain), maintain privacy, allow child to touch equipment (toddler touch, tell then do. older demonstrate them more time to process)

Principles of physical assessment

allow choices when possible, assess readiness, adapt to child, position of comfort (sitting, lying is vulnerable), organized sequence (limited time, do all stethoscope at once, do things when quiet), patient but firm, praise

Guidelines for communication

AITED + promise: introduce self and role, acknowledge child first (build trust w parents so kid is more trusting, tell family what you’re doing = less hovering), at childs eye level, age-appropriate language, be positive and honest (yes it might hutst, heres two ways we can make it better)

Approach and sequence in assessment

older kids: head to toe. infants/toddlers: chest to toe, then face. least to most invasive/traumatic, private areas last (ATI: head to toe, most invasive last)

How should you approach an infant?

use quiet calm tone and respond to babies social cues, limit body heat loss, assess between eating/sleeping cycles (1hr after food), 4-6mo in crib, older child can stay on parents lap, assess alertness, observe for symmetry coordination and strength (too young for commands). play is assessment!

Sequence of assessment in infant?

first observe RR, quiet= ascultate, palpate, percuss, proceed chest to toe, traumatic procedures last (eye, ear, mouth)

How should you approach a toddler?

cautiously, anticipate short attention span, keep hands busy/distract, sit in parents lap, praise cooperative behavior, introduce equipment gradually and let them touch it, inspect through play, dont ask yes/no questions

What is the sequence of assessment in a toddler?

keep hands busy, minimize physical activity initially, ascultate/percuss/palpate whenever quiet, poor body boundaries so perform traumatic procedures last (eyes, ears, mouth)

How should you approach a preschooler?

incorporate play, imagination, focus explanations on sensory experience (magical thinking), like to explore environment, use playful techniques, simple/direct language, child is literal (cat scan is scary), give choices but dont ask if “ok”. Show equipment/demo on you or stuffed animals, egocentric, animisms, say no = do something and go back to it, they can’t tell time

What is the sequence of assessment in toddler?

If cooperative, head to toe. If not, proceed like toddler

How should you approach a school aged child?

might prefer privacy, prefer to sit but cooperate, head to toe approach, written and visual information, explain use of equipment and reason for assessment, elicit specific questions/concerns, ask/answer Qs

How to approach adolescents for assessment?

privacy is important, concerned with body image, reassure that changes are normal. expect that they may be more tired in AM, less chatty

What sequence should you use for physical assessment?

head to toe with private areas last

What is therapeutic play?

kids want to be normal, effective technique in relating to child, reduces trauma of illness, prepares child for procedures, work through autonomy vs shame and doubt, match piaget and erikson stages, worth through a process or emotion

Techniques/ order of assessment

inspect, palpate, percussion, ascultation. exception of abdomen, ascultate before palpating or percussing

What elements of general appearance are we assessing?

alertness, muscle tone, work of breathing, presenting appearance, body development and nutritional status, activity level, cooperativeness. if show signs of distress, stop and intervene

What history should you obtain?

chief complain and present illness, review symptoms including pain, birth history (impacts kid for a long time), immunizations, growth and development, functional and dietary hx

What are some history red flags in infants?

feeding difficulties (ex falling asleep during), diaphoresis (babies never sweat), poor weight gain, decreased wet diapers (signs of cardiac dysfunction)

What are some history red flags in older children?

exercise tolerance/activity level, dyspnea on exertion, fainting spells (signs of cardiac dysfunction)

Elements of pediatric assessment

physical and developmental assessment (ages and stages questionnaire), vitals, pain, weight (naked if infant), height/length, head circumference under 36mo. Months are critical in children!

What tool do you use for the first 2-3 years to get a baby’s length?

Infantometer. One person hold head (parent), provider extend knees and flex feet

How to you obtain height in kids over 3?

standing w/ stadiometer

How do you obtain head circumference/OFC

OFC above eyebrows and ears, abuse can cause brain bleeds and increase head percentile (first warning sign if jump more than 2 percentilesO

What indicates measuring an abdominal circumference?

if child has hx of abdominal issue

What growth raises concern?

Jumping up or down 2+ percentiles on growth charts, not following known family Hx

What is measured using growth charts?

height, weight, head circumference

What percentiles ranges need further investigation?

under 5% and over 95%, look at family hx!

What vital sign leads to adverse most events?

tachycardia

What are are influencing factors of vital signs?

fever (tachy), crying/anxiety/fear/pain (tachy, htn, rr high), hypoxia (first indicator of shock, BP late), movmement/activity, meds

How to measure vitals in infant/toddler?

assess comfort, RR first, apical HR second, then BP (annually in kids over 3, all inpatient kids), measure temp last (can go earlier if better tolerated)

Where do you measure temperature on a neonate?

axillary

How to measure temp on infant?

rectal or axillary (temporal of over 3mo)

How old does a kid need to be to measure temperature temporally?

3 mo w/o fever risk

What are contraindications for a rectal temperature?

MAIN: neonates and immunosuppressed. other: anal fissure, imperforate anus, rectal bleed, abscess, surgery, diarrhea, neutropenia, anemia, neonates in critical care

What is considered a true fever?

38C/100.4F, cultures sent at 38.5. do not treat first fever to see how high it will climb

How do you take a rectal temperature?

child side lying with leg flexed. insert lubricated probe ½ inch for infant, 1in for child

Why does hypothermia cause risk?

indication of infection, neonates and infants at particular risk. Under 36.5, if under 36 trigger sepsis alert

How to you obtain HR?

listen to apical for 1min, may feel brachial pulses to confirm. hypothetically over 2yo can use radial. (infant/young: 4th intercostal, medial to left midclavicular. Older: 5th intercostal)

What is the normal HR for birth-4 weeks?

110-160

What is the normal HR for infants?

90-160

What is the normal HR for 1-2yrs?

80-140

What is the normal HR for 3-5?

70-120

What is the normal HR for 6-12?

60-110

What is the normal HR for 13-18?

50-110

Where do you watch for breathing in kids under 7?

abdominal, diaphragmatic breathers

What kind of RR do infants have?

periodic breathing, count for 1 full min

What is an early indicator of respiratory distress?

tachypnea

What is apnea?

no breathing for 20 sec

What is a normal RR for birth- 4 weeks?

30-60

What is a normal RR for 1mo-2yr?

25-30

What is a normal RR for 3-12 years?

20-25

What is a normal RR for 13-18?

16-20

How do you pick correct size of BP cuff?

width 40% of arm circumference, length 80% circumference

Where should you take BP for infants and toddlers?

calf

How do pediatric blood pressures compare to that of adults?

much lower

What are general differences of child vs adult?

head proportionally larger, higher metabolic rate, greater insensible losses, poor temp reg, immature immune sys and organs, cannot verbalize symptoms

Skin differences in children

thinner, lower concentration of fat (mottling/patchy, resolve 6-12mo), prone to diaper rash (dermatitis), greater risk for skin breakdown, seborrheic dermatitis (cradle cap), assess symmetry of skin folds!

What are some normal skin marks?

cafe au lait, hyper pigmented nevi, pigmented nevi, and vascular lesions (salmon nevi, strawbery nevi, nevus flammeus)

how to assess male genitalia?

presence/distribution of hair, foreskin if non circumsised (philamosis = cannot retract, paraphimosis = stuck in retraction and cut off blood flow), undescended tested, swelling in scrotum, testicular enlargement

how to assess female genitalia?

limited to observation of external structures,

How to assess head and neck?

symmetry, shape, flattening, palpable ridge, balding, fontanels. Short neck, poor head control, range of motion

How to assess eyes?

upper lid falls near iris, round, permanent color 6-12 mo, extra ocular movements (asymmetric in newborns), squinting, red reflex

What can issues with the ears be a warning sign for?

kidneys, they develop at the same time. Low set = cognitive issues

What should the height of the ears be?

top of eat level with outer eye

Which way do you pull ears to examine them?

under/= 3 downs and back, over 3 up and back

What is nasal flaring a sign of?

respiratory distress

How to inspect mouth?

look for teeth, dental decay, palate intact, oral candidiasis (thrush)

how old must a child be to self report pain?

4