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UNIT 4 Assessment of Special Populations

A. The Pediatric Client

GENERAL ASSESSMENT GUIDELINES

Information from pediatric clients should be validated for reliability by an adult


informant.

Be gentle & genuine

Use simple straightforward questions in lay terms. Avoid words with double meanings.

Let client set the pace for conversations.

Use direct eye contact; sit at clients eye level.

Orient parents or caregiver

Use physical restraints for young children as needed. After restraining, let parents
comfort child.

Use distraction & play

Approach and techniques may be altered depending on development level of child

DEVELOPMENTAL APPROACHES TO ASSESSMENT

1. Infants [0 to 12 months old]

Provide a pacifier

Encourage parent or caregiver to ask questions during P.E.

Speak softly

Child may need to be placed on restraints

2. Toddlers [1 to 3 years old]

Allow toddler to sit on parents lap

Enlist parents aid

Use play

Focus on a favorite toy

or unique characteris-

tic about the child

Praise cooperation

3. Preschoolers [3 to 6 years old]

Use story telling

Use doll & puppet play

Give choices when able


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Allow child to manipulate equipment

4. Schoolagers [6 to 12 years old]

Maintain privacy

Use gown

Explain procedures & equipment

Teach about their bodies

PEDIATRIC HEALTH HISTORY

1. Biographical Data / Identifying Information

2. Chief Complaint & Hx of Present Illness

3. Past Hx (Prenatal Hx, Labor & Delivery, Birth Hx, Feeding Hx)

4. Health Hx

5. Family Hx

6. Personal / Social Hx

PHYSICAL ASSESSMENT

1. General Measurements

2. Physiologic Measurements

3. Head-to-Toe Assessment

4. Current Development Assessment

GENERAL MEASUREMENTS

HEIGHT (Length)

For < 2 years

Positioning:

- fully extend the body, holding head midline, & pushing knees downward to extend legs

For < 2 years

Technique: - Measure from vertex of head to heel of foot

Using a measuring board

For 2 years

Technique: - remove shoes - stand straight w/ head midline & vision parallel bet.
ceiling & floor back, buttocks, & back of heels against the wall

N Birth Length (BL): 45 - 55 cm

BL increases by 50% at 1 year.


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WEIGHT

For smaller child:

weigh naked, lying on a scale

For older child:

barefoot; in underpants or light gown

standing on platform scale

N Birth Weight (BW): 2.5 - 4 kg

Childs BW doubles at age 4 to 6 months and triples at 1 year.

HEAD CIRCUMFERENCE

only measured for children < 2 years

landmarks: slightly above eyebrows pinna of ears skull: occipital prominence

CHEST CIRCUMFERENCE

only measured for children < 2 years landmark: - nipple line

Normal Value

Head circumference (HC) = 33-35 cm

Chest circumference = HC 2 cm

ABDOMINAL GIRTH

landmark: - slightly above the umbilicus

MID-ARM CIRCUMFERENCE

landmark: - midway between shoulder & elbow

ANTERIOR FONTANELLE

C diamond-shaped; closes at 12 to 18 mos.

POSTERIOR FONTANELLE

C triangular; closes at 2 to 3 months.

IMPORTANT POINTS TO REMEMBER

Fontanelles normally bulge when child is crying.

Bulging fontanelles at rest is AbN; noted in infants with increased


intracranial pressure (ICP)

Depressed fontanelles noted in dehydration

PHYSIOLOGIC MEASUREMENTS

Temperature
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Axillary route
C Rectal route - lubricated thermometer inserted no more than 2 cm into rectum
Tympanic route
Oral route- - may be used in children > 4 yrs of age
Pulse

For < 2 years Measure apical pulse for 1 full minute


For 2 years Radial pulses may be taken

NORMAL VALUES [Pulse Rate]

1 mo.: 120 160 bpm

1 to 3 mos.: 100 150 bpm

3 mos. to 2 yrs.: 80 150 bpm

2 to 10 yrs: 70 110 bpm

10 yrs to adult: 60 100 bpm

Respiration

Children under 7 years old are abdominal breathers; observe abdominal movements Use
same technique as

adult if 7 years. Child should not be crying

NORMAL VALUES

[Respiratory Rate]

< 6 mos.: 30 60 cpm

6 mos. to 2 yrs.: 20 30 cpm

3 to 10 yrs: 20 28 cpm

10 yrs to adult: 12-20 cpm

BLOOD PRESSURE

Use appropriate cuff size Child shouldnt be crying as this BP.

Use a Doppler stethoscope for children < 3 yrs.

NORMAL VALUES [Blood Pressure]

Systolic:

1-7 years = age in years + 90

8-18 years = (2 x age in years) + 90

Diastolic:

1-5 years = 56

6-18 years = (age in years) + 52

HEAD TO TOE ASSESMENT

Normal Variation:
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1. Acrocyanosis- Cyanosis of the extremities only; normal within 12H after birth

- When the newborns body temperature drops, the hands and/or feet may
appear blue

(acrocyanosis)

2. VERNIX CASEOSA- Cheesy, white substance found on the skin and skin folds of newborns

3. DESQUAMATION- Cracking or wrinkling of skin; seen in post-term newborns

4. PHYSIOLOGIC JAUNDICE- Only normal if > 24 H after birth occurring

5..LANUGO - Fine, downy hair covering the body of newborns; abundant in pre-term infants

- The fine, downy hairs called lanugo, which appear on the newborns body, shoulders,
and/or back at birth, develop in the fetus at 3 months gestation and disappear within the first
2 weeks of life.

6. MILIA Small, white papules on the nose, forehead or chin of newborns; resolve within a
few weeks

7. ERYTHEMA TOXICUM- Cause unknown; disappears w/in a week from birth

8. TELANGIECTATIC NEVI (Stork Bites)- Due to stretching of certain blood vessels; most often
temporary

9. MONGOLIAN SPOTS- Bluish pigmented areas noted on the sacral areas of Asian and black
infants; disappears over time

10. HARLEQUIN SIGN- One side of the body turns red; the other side is pale; cause unknown.

11. HEMANGIOMA - Caused by increased amount of blood vessels in the dermis. Fades with
time

12. PORT-WINE STAIN Dark-red or bluish birth mark; darkens with exertion or temperature;
doesnt fade with time

13. CAF AU LAIT SPOT - A light brown, round or oval patch

Abnormal Variation

1. Central Cyanosis- Indicates poor oxygenation; medical emergency.

2. PATHOLOGIC JAUNDICE- If occurring within 24 H after birth

3. CAF AU LAIT SPOTS - ABNORMAL if there are more than six, separate, large patches (may
have neurofibromas)

4. CHILD ABUSE- Bruises or ecchymoses in various areas or in unusual locations Circular


burn areas

HEAD AND NECK

NORMA VARIATION

1. MOLDING - Oddly-shaped head due to overriding of sutures in newborns


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2. CAPUT SUCCEDANEUM - Swelling of the newborns scalp from vaginal birth; heals
spontaneously after a few days

3.

ABNORMAL VARIATION

1. CEPHALHEMATOMA - Birth injury with bleeding into the periosteal space

2. HYDROCEPHALUS- Very large head due to excessive accumulation of CSF

3. MICROCEPHALY

4. DOWN SYNDROME- Third fontanelle between anterior & posterior fontanelles; unusual
facial proportions; short, webbed neck; wide, flat, philtrum

5. TORTICOLLIS (Wry Neck)- infant should have head control by 4 months

EYES

LEA SYMBOL CHART

Used on children 4 to 6 yrs old; esp. those who are illiterate or preliterate

If child cant recognize the symbols, a response card is used (child points symbol on the card
based on what he sees on the chart)

HOTV CHART-

Can also be used on children ages 4 to 6 yrs old

For those who dont know the alphabet, also use a response card

Snellen E Chart (for children)

Can be used for illiterate children aged 4 to 6 years old; although not commonly used
anymore.

Blackbird Preschool Vision Screening Test

Can be used on children as young as age 3.

Uses a modified E that resembles a bird and a story to engage childrens attention.

The child "flies with Blackbird" showing with their arms which way it is flying.

Normal visual acuity:

1 year : 20/200

2 years : 20/70

5 years : 20/30

6 years : 20/20
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Age 5 = children should be able to differentiate colors

ABNORMAL

1. Down Syndrome- Wide-set position, upward slant, and thick epicanthal folds

2. BRUSHFIELDS SPOTS - Also often seen in children with Down syndrome; are small white
or grayish spots in the periphery of the iris

3. SUN-SETTING Appearance Suggests hydrocephalus

EARS

The ears and kidneys develop at the same time in utero; so malformed ears may be
accompanied by renal problems

MOUTH & THROAT

NORMAL VARIATION

1. NATAL TEETH- Teeth present at the time of birth; usually removed by physician

2. EPSTEINS PEARLS Small yellow-white cysts on the hard palate & gums of newborns;
disappears after 1 week

ABNORMAL VARIATION

1. CLEFT LIP & CLEFT PALATE

IMPORTANT POINTS

Deciduous Teeth:

Lower central incisors first to erupt between 4 to 6 months

All twenty (20) deciduous teeth erupt by 36 months

Permanent Teeth:

6 years = permanent tooth eruption begins and progresses until all 32 have erupted

Tonsils:

6 years : reach adult size

10 to 12 yrs. : twice the adult size

end of adolescence : atrophy, same as adult

CHEST

NORMAL VARIATION

1. WITCHS MILK- Enlarged, engorged breasts sometimes with a white liquid discharge in
newborns; results from the influence of maternal hormones; resolves within days

LUNGS

NORMAL
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Hyperresonance = normal percussion tone elicited in infants because of thinness of the chest
wall

5 to 6 years old = AP to transverse thoracic diameter (1:1 in young children) reaches adult 1:2
ratio

HEART

Location of Apical Pulse:

1 to 4 yrs old: left 4th ICS, to the left of midclavicular line (MCL)

4 to 6 yrs old: left 4th ICS, left MCL

7 yrs old & above: left 5th ICS, left MCL

Sinus arrhythmia is NORMAL in young children.

ABDOMEN

Umbilical cord of newborns:

Should demonstrate two (2) arteries & one (1) vein

Remnant of cord should appear dried 24 to 48 hours after birth

4 years old & below: abdomen is prominent in standing & supine positions

ABNORMAL FINDING

1. UMBILICAL HERNIA- Common in African American children; usually disappear at the age of
1 year

GENITALIA

NORMAL VARIATION

1. PSEUDOMENSTRUATION- Scant vaginal bleeding in newborns; due to influence of maternal


hormones; resolves spontaneously

ABNORMAL VARIATION

1. Phimosis- An unretractable foreskin in a child older than 3 months suggests phimosis

2. Paraphimosis is indicated when the foreskin is tightened around the glans penis in a
retracted position

3. Hypospadias (urinary meatus on the ventral surface of glans) and epispadias (urinary
meatus on dorsal surface of glans) are congenital disorders

4. Epispadia- urinay meatus on top of the glans pennis dorsal surface

5. Hydroceles are common in infants. They are a collection of fluid along the spermatic cord
within the scrotum that can be transilluminated

6. AMBIGUOUS GENITALIA - Enlarged clitoris with fusion of the posterior labia majora
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ANUS

The newborn should pass meconium, the first stool, within 24 to 48 H from birth

Imperforate anus (no anal opening) should be referred. Pustules may indicate secondary
infection of diaper rash. No passage of meconium stool could indicate no patency of anus or
cystic fibrosis.

BACK & EXTREMITIES

NORMAL VARIAITON

1. GENU VARUM - Bow-legged; common in toddlers who have a wide-based gait

2. GENU VALGUM- Knock-kneed; also common in those aged 2 to 7

ABNORMAL VARIATION

1. PALMAR SIMIAN CREASE- Suggests Down syndrome

2. POLYDACTYLY- extra digits

3. SYNDACTYLY- webbing of the digits

4. TALIPES EQUINOVARUS Clubfoot; there is adduction of forefoot, inversion of entire foot


and entire foot points downward

5. CONGENITAL HIP DYSPLASIA For infants < 1 year old, positive (+) Ortolanis & Barlows
sign [a click is heard]

- For infants there is limited hip abduction and difference in limb length (leg on affected hip
is longer)

Ortolanis maneuver - Flex knees, abduct thigh and move knees outward and down toward
table

Barlows maneuver - Flex knees, adduct thigh and legs until thumbs touch

6. SPINA BIFIDA- Outpouching of the spinal cavity due to incomplete closure of vertebrae;
the sac may rupture

NEUROLOGIC ASSESSMENT:
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