First Nations and Inuit Health Branch (FNIHB) Pediatric Clinical Practice Guidelines for Nurses in Primary Care Show
The content of this chapter has been reviewed August 2009 On this page:The clinical assessment of infants and children differs in many ways from that for adults. Because children are growing and developing both physically and mentally, values for parameters such as dietary requirements and prevalence of disease, expected normal laboratory values and responses to drug therapy will be different from those observed in adults. Health Maintenance RequirementsHealthy children should have regular health maintenance visits, often done at well-baby clinics. Such visits customarily occur at 1 and 2 weeks of age, at 1, 2, 4, 6, 9, 12 and 18 months of age, and subsequently at 1- or 2-year intervals. At each visit, the child should undergo an appropriate history, physical examination and developmental assessment. Immunizations should also be given according to provincial guidelines. Anticipatory guidance should be provided about the following topics:
In addition, an assessment should be made of the quality of physical care, nurturing and stimulation that the child is receiving. The most important components that should be assessed at each health maintenance visit are shown in Table 1. Table 1: Components of Well-Child Assessments at Various Ages
* Formal developmental testing is done only if there is a concern on the part of the parents or caregiver or the health care professional. Refer to the appropriate primary health care provider (for example, speech-language pathologist, physician, psychologist) for assessment. The Rourke Baby Record (RBR), revised 2009, is an evidence-based health supervision guide for primary health care practitioners of children in the first 5 years of life. The forms are available from the Rourke Baby Record web site.
The Greig Health Record is an evidence-based child and adolescent health promotion guide for primary health care practitioners caring for children aged 6 to 17 years. Pediatric HistoryTips and TechniquesChildrenChildren who can communicate verbally should be included as historians, with additional details provided as necessary by parents or caregivers. Health care professionals should interact (for example, smile, coo) or play with children so as to not scare them or make them cry. Questions, explanations and discussions occurring with children present should take into account their level of understanding. Young children may be assisted in providing details of the history by such techniques as having them play roles or draw pictures. The interviewer should gain an understanding of the child's terminology for various body parts. AdolescentsAdolescents should be granted privacy and confidentiality.
Components of the Pediatric HistoryThe pediatric history includes many of the same components as the adult history, including:
In addition, the pediatric history should include the following information:
Physical Examination of the NewbornObserve the entire infant at the beginning of the examination, before the assessment of specific organ systems. It is important that the infant be completely undressed and in a warm environment with adequate illumination. General AppearanceAssess the following:
Vital SignsAverage values of vital signs for newborns:
Growth MeasurementsMeasure and record length, weight and head circumference. If the infant appears premature or is unusually large or small, assess gestational age (see Table 3, "Assessment of Gestational Age").
These parameters should be recorded on gender-appropriate growth curves, which should form part of the child's health record. Printable electronic versions of the growth charts are available at: Growth chart for boys : Growth chart for girls: For additional information about growth measurements, see "Growth Measurement" in the chapter, "Pediatric Prevention Activities and Health Maintenance." SkinColour
Lesions
Head and NeckHeadCheck for:
Measure head circumference. Eyes: Inspection
Ears: Inspection
Nose: Inspection
Palate: Inspection and Palpation
Mouth: Inspection
Tongue: Inspection
Teeth: Inspection
Chin: Inspection
Neck: Inspection
Neck: Palpation
Respiratory SystemVital Signs
See normal values in "Vital Signs," above. Inspection
Palpation
Auscultation
Percussion is of little clinical benefit and should be avoided, especially in low-birth-weight or preterm infants, as it may cause injury (for example, bruising, contusions) Cardiovascular SystemVital Signs
See normal values in "Vital Signs," above. Inspection
Palpation
Auscultation
AbdomenInspection
Auscultation
Palpation
Percussion usually omitted unless a problem such as abdominal distension is noted. Inspect the anal area for patency and for presence of fistulas or skin tags. GenitaliaThe genitalia should be carefully assessed, with particular attention to any malformation, abnormalities or sexual ambiguity. Male GenitaliaInspection
Female GenitaliaInspection
Musculoskeletal SystemInspection and PalpationSpine
Upper Extremities
Lower Extremities
Ortolani Maneuver
Barlow Maneuver
Central Nervous System
Reflexes,Reflexes are involuntary movements or actions that help to identify normal brain and nerve activity and development. Some are present at birth and serve a variety of purposes, others develop later. Abnormal reflexes - ones that persist after an age they should disappear, or are absent at birth when they should be present - can help identify neurological or motor disease early. See Table 7, "Newborn and Infant Reflexes." Deep Tendon ReflexesThese are not normally examined in the child under 5 years. Apgar StoreApgar scoring is done at 1 and 5 minutes after birth. If necessary, it is repeated at 10 minutes after birth. InterpretationAt 1 Minute< 7: depression of nervous system At 5 Minutes> 8: no asphyxia Table 2: Determination of Apgar Score*
* Sum the scores for each feature. Maximum score = 10; minimum score = 0. Assessment of Gestational AgeGestational age can be assessed on the basis of the newborn's external characteristics. Table 3: Assessment of Gestational Age
Screening TestsPhenylketonuriaAll newborns should be screened for phenylketonuria (PKU) by means of a capillary blood sample before discharge from the hospital. For any newborn who undergoes this type of screening at less than 24 hours of age, the screening test must be repeated between 2 and 7 days of age. For more information on PKU Congenital Hypothyroidism
Other Screening TestsFor more information, see specific procedures for hemoglobin screening, developmental screening, hearing screening and vision screening under "Screening Tests" in the chapter, "Pediatric Prevention Activities and Health Maintenance." Physical Examination of the Infant and Child , ,Clinicians should be aware of the different sizes of body parts in children relative to adults: the head is relatively larger, limbs relatively smaller and, in small children, the ratio of surface area to weight is relatively larger. TechniqueMuch information can be obtained by observing the child's spontaneous activities while the history is being conducted, without touching the child. For this purpose it is useful to have an age-appropriate toy available. Approach infants and young children slowly and start by playing with them to gain their trust. For a young child, do as much of the physical examination as possible with the child either being held by the parent or caregiver or supported on that person's lap. Generally, the least stressful parts of the exam should come first, with more intrusive or distressing parts later (for example, examination of the pharynx and/or ears with the child restrained). Allowing the child to play with the equipment can often decrease anxiety about certain parts of the exam. One must choose the quietest moment to do the respiratory and cardiac exam. This is usually at the beginning of the exam. The order of the examination must be varied to suit the situation. Care should be taken to select appropriate-sized equipment when examining a child (for example, blood pressure cuff width should be greater than two-thirds of the length of the upper arm). General AppearanceWithout touching the child, observe (if applicable):
Vital SignsAssess for:
Blood pressure measurements are influenced by sex, age and height. Therefore blood pressure charts should be used to interpret the values. See printable charts on the National Institutes of Health web site, http://www.cc.nih.gov/ccc/pedweb/pedsstaff/bp.html. Blood pressure should be recorded once in the healthy child under 2 years and then annually after that.1 Table 4: Normal Pediatric Heart Rate, Blood Pressure and Respiratory Rate By Age (adapted from Footnote 11 ,Footnote 12 ,Footnote 13)
Temperature Measurement in ChildrenProper temperature measurement is essential for clinical decision making in the pediatric population. Children should be unbundled for at least 15 minutes prior to taking their temperature. One needs to be aware of the normal temperature ranges for each measurement method and use recommended temperature measurement methods in children. See Table 5 and Table 6, below. Table 5: Normal Temperature Ranges Footnote 14
Table 6: Recommended Temperature Measurement Methods in Children Footnote 14
Tympanic temperature measurement is contraindicated in newborns due to the shape of the ear canal and the potential for vernix or amniotic fluid in the canal. Growth MeasurementsWeight should be done at each visit for any infant under 1, those presenting for a well-child visit, at least annually for older children, and for any infant or child who presents with vomiting, diarrhea, signs of shock, or in need of a medication where dosage is dependent on weight. Measurements of recumbent length (until 24 months old) or height, weight and head circumference (until 24 months old) should be part of every health maintenance visit. These parameters should be recorded on gender-appropriate growth curves, which should form part of the child's health record. The Canadian Paediatric SocietyFootnote 15 recommends using the WHO Growth Charts, specific to each sex. They can be found at: Growth charts for boys : Growth charts for girls: For additional information about growth measurements, see "Growth Measurement" in the chapter, "Pediatric Prevention and Health Maintenance." SkinNote colour, condition and lesions on all aspects of the body. Colour
Lesions
Head and NeckHead and Face
Eyes: InspectionTo open the infant's eyes, support their head and shoulders and gently lower the infant backward.
See also vision screening procedures under "Screening Tests" in the chapter, "Pediatric Prevention and Health Maintenance" for more details. Ears
See also hearing screening procedures under "Screening Tests" in the chapter, "Pediatric Prevention Activities and Health Maintenance" for more details. Nose: Inspection
Mouth
Neck: Inspection
Neck: Palpation
Respiratory SystemInspection
Palpation
Auscultation
Percussion as indicated. Cardiovascular SystemInspection
Palpation
Auscultation
AbdomenInspection
Auscultation
Percussion
Palpation
GenitaliaInspect the external genitalia and note stage of sexual maturity. Male GenitaliaInspection
Female GenitaliaInspection
Musculoskeletal SystemInspection and PalpationSpine
Upper Extremities
Lower Extremities
Ortolani Maneuver
Barlow Maneuver
Central Nervous System
Reflexes ,Reflexes are involuntary movements or actions that help to identify normal brain and nerve activity and development. Some are present at birth and serve a variety of purposes, others develop later. Abnormal reflexes - ones that persist after an age they should disappear, or are absent at birth when they should be present - can help identify neurological or motor disease early. The following are some of the reflexes that should be tested in newborns and infants up to 2 years of age. Table 7: Newborn and Infant Reflexes (adapted fromFootnote 18 ,Footnote 19 ,Footnote 20)
Deep Tendon ReflexesDeep tendon reflexes are not usually tested in children under 5 years of age. In older children, deep tendon reflexes may be tested. Reflexes must be symmetric. The child must be relaxed and comfortable. The reflexes include the biceps, brachioradialis, triceps, patellar and achilles. Cranial Nerve AssessmentAfter 2 years of age, cranial nerves can be tested with some modifications according to the developmental stage of the child. See Table 8, "Cranial Nerve Assessment in Children." Table 8: Cranial Nerve Assessment in Children (adapted from Footnote 21)
ScreeningDevelopmental Milestones ,Assessment of developmental progress should be part of each complete health assessment (well-child visit) and take place at all visits for children who do not present regularly for well-child care. Developmental assessment is done by making inquiries of the parents or caregiver and by clinical observation of the child's achievement of major age-appropriate milestones. These are in areas of gross and fine motor, speech and language, and personal and social development. Developmental milestones are achieved at different ages in different children. See the Rourke Baby Record or Table 9, "Developmental Milestones by Age and Type" for the ages by which certain developmental milestones should occur. Table 9: Developmental Milestones by Age and Type (should be present by this age) (adapted fromFootnote 24 ,Footnote 25 ,Footnote 26)
A developmental screening tool should be used to look at more specific developmental milestones at each well-child visit. Screening tools are not diagnostic, but help to determine when further assessment is needed. There are two broad categories of screening tools: those that rely on information from the parent or caregiver and those that rely on eliciting skills directly from the infant or child. Nurses are encouraged to use the same developmental screening tool that the majority of nurses are using in their province and/or their region and for which they have training. Some developmental screening tools that are appropriate for First Nations and Inuit children areFootnote 27: All of these tools rely on information from parents or caregivers. Some of the tools are also a teaching tool for parents about their child's development. More detailed assessments are indicated when it appears, or concerns are raised by the parents, caregiver or health professional, that a child is not progressing normally, according to the above measures. Any child with suspected delay(s) should be referred promptly to the appropriate primary health care provider (for example, speech-language pathologist, physician, psychologist) for assessment. As part of each complete health assessment, attempts should also be made to assess responses to sound and ability to see. For more information, see "Hearing Screening" and "Vision Screening" in the chapter, "Pediatric Prevention and Health Maintenance." Other Screening TestsRoutine screening should be done in infants and children for hemoglobin, development, hearing and vision. See specific procedures for hemoglobin screening, developmental screening, hearing screening and vision screening under "Screening Tests" in the chapter, Pediatric Prevention Activities and Health Maintenance." SourcesAll internet addresses are valid as of June 2010. Books and MonographsBehrman RE, Kliegman R, Jenson HB. Nelson's essentials of pediatrics. 16th ed. Philadelphia, PA: W.B. Saunders; 1999. Berkowitz CD. Berkowitz's pediatrics: A primary care approach. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2008. Bickley LS. Bates' guide to physical examination and history taking. 7th ed. Baltimore, MD: Lippincott Williams & Wilkins; 1999. Burns CE, Dunn AM, Brady MA, Starr NB, Blosser CG. Pediatric primary care. 4th ed. St. Louis, MO: Saunders Elsevier; 2009. Cheng A, et al. The Hospital for Sick Children handbook of pediatrics. 10th ed. Toronto, ON: Elsevier; 2003. Frankenburg WK, Dodds JD, Fandal AW. Denver Developmental Screening Test: Manual/workbook for nursing and paramedical personnel. Boulder, CO: University of Colorado Medical Centre; 1986. Hockenberry MJ. Wong's nursing care of infants and children. St. Louis. MO: Mosby; 2003. Mandleco BL. Growth & development handbook: Newborn through adolescent. Clifton Park, NY: Thomson Delmar Learning; 2004. Morris A, Mellis C, Moyer VA, Elliott EJ, editors. Evidence-based pediatrics and child health. London, England: BMJ Books; 2004. p. 206-14. Rudolph CD, et al. Rudolph's pediatrics. 21st ed. New York, NY: McGraw-Hill; 2003. Ryan-Wenger NA, editor. Core curriculum for primary care pediatric nurse practitioners. St. Louis, MO: Mosby Elsevier; 2007. Internet GuidelinesCanadian Pediatric Society. (2010, March). Greig Health Record. Canadian Task Force on Preventive Health Care. (1994). Well baby care in the first 2 years of life. Gesell Institute of Human Development. (n. d.). Gesell developmental observation. Paul H. Brookes Publishing. (2009). Ages and stages questionnaires. Which developmental milestone would the nurse anticipate for a 15The nurse would anticipate that a 24-month-old toddler can use a straw to drink liquids. The 15-month-old toddler is expected to drink well from a cup. Beginning to use a fork by holding it in the fist and spilling small amounts of food when using a spoon are expectations for a 36-month-old toddler.
Which client would the nurse conduct a developmental surveillance on during a scheduled health maintenance visit quizlet?The nurse would conduct a developmental screening for the 9-month-old infant during a scheduled health maintenance visit. The 2-week-old newborn, the 15-month-old toddler, and the 4-year-old preschooler would all require developmental surveillance during a health maintenance visit.
Which forms of conservation would the nurse include in the developmental assessment process for a 6 year old client?The 6-year-old school-age client is expected to understand and apply conservation related to mass, length, and number; therefore, the nurse should include these in the developmental assessment process. Understanding of conservation of area and weight are not expected until 9 to 10 years of age.
For which clients should the nurse measure head circumference during the growth and development assessment select all that apply quizlet?The nurse measures head circumference during the growth and development assessment until 36-months of age. The 2-month-old infant, the 3-year-old preschooler, and the 18-month-old toddler would all require as head circumference to assess growth.
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