General Paediatric Assessment

1. General Paediatric Assessment Robyn Smith Department of Physiotherapy UFS 2012

2. What is different about working with children and adults? Why do we find working with children and babies so daunting??????

3. Infection control measures To prevent the spread of infection to already susceptible patients the following is to be done: • Children are particularly susceptible to infection • Wash your hands between patients and spray with alcohol/ Hibitane spirits • Remove your watch and rings • Clean your stethoscope with an alcohol swab between patients • Where a mask and gown where indicated

4. Subjective Evaluation • Interview mother/caregiver/child • Use ‘tolk” where necessary • If caregiver not available or child is unable to communicate not possible rely on admission history available in the white book in patient file • Interview Dr and other multidisciplinary team members NB: Essential to get a comprehensive patient history prior to observation physical examination Why is an effective history so important ???

5. Date of admission? Reason for admission? How long was the child sick prior to admission, what signs and symptoms did she/he have? Birth history relating to gestation, birth weight, method of delivery, Apgar scores? Any neonatal complications Child current developmental status Caregiver have any known medical conditions, any TB contacts at home? Previous illness’ e.g. pneumonia, bronchitis or TB resulting in previous admissions. Date of admissions and duration?. Was TB treatment completed ? Health after discharge? Previous surgical procedures? If so what was done? Date? Any familial history of Asthma, haemophilia or other genetic conditions Any known neurological conditions or problems? Any other children at home? What are their ages. Information on their health developmental status? Immunizations up to date? Socio economic statuses e.g. where are they residing, running water and electricity? Are the parent employed? Where applicable are they receiving social grants? Interview: questions to ask the caregiver

6. Medical reason for current admission? Does the child have a productive cough? When is the child coughing? Are there factors that exacerbate the coughing e.g. positioning? Paroxysmal coughing spells? Coughing worse during a specific time day? If the child is productive, what is the appearance of the sputum in terms of colour, smell and viscosity? Does the child have a tendency towards recurrent upper respiratory tract infections? E.g. croup and bronchiolitis Is the child dyspnoeic? Is there shortness of breath at rest (grade 4), with activities of daily living (grade 3), with light exertion (grade 2) with activities e.g. running (grade1) difference between dyspnoea and tachypnoea Reasons for dyspnoeic episodes e.g. exercise, emotional factors or stress related. Is the child as active as other children his age or as his other siblings ? Medical history pertaining to current admission

7. Medication • What medication taking prior to admission? • Medication currently being given? Available on prescription chart in patient file List all the medications currently being given and the reason for their administration e.g. Panado (fever & pain)

8. Observation of vital signs • Normal range is determined by age • Make use table available in notes • Make a copy and keep in clinical file • Get information from the vital sign sheet in file: • HR • BP • RR • SaO2 • Use mobile SaO2 monitor -give you HR and SaO2.. Make sure values you use have been taken in the last 30 min. WHY??? To ensure still relevant. Also look at vital sign trends over 48 hour period. • NB If the child is on oxygen do not just stop the therapy or remove the facemask/ nasal prongs. Without monitoring SaO2 !!!!!!!!

9. CXR • Are any available? Hard copy or comuterized • Date CXR was taken on? • AP/ lateral view • Evaluate and compare 2 latest CXR’s. WHY? Monitor changes –improvement or deterioration • Any areas of abnormality or pathology noted clearly → Reading and interpreting CXR is a skill developed over time.If you are unsure of what you are seeing on the CXR ask the doctor/ qualified to look at the CXR’s with you.

10. Objective Evaluation Once all the above information has been collected then you may proceed with the objective evaluation

11. General observations • Weight is to be described us normal, underweight or overweight. Percentiles may also be used.Possible reasons for the condition are also to be given e.g. underweight due to chronic malnutrition etc. • Skin colour and condition is to be described. • Oedema. Generalized or area specific. Not reason for possible oedema e.g. low albumin or cardiac failure in generalized oedema. • Cyanosis. Peripheral (fingers and toes) or central 9mucosa of the mouth) • Clubbing of the fingers and toes (may be indicative of chronic heart , but particularly chronic lung conditions e.g. Bronchiectasis) • Indwelling devices e.g. IVI (note what is being administered IV), catheter, ICD, central or arterial lines in PICU and Portovac drains in surgical patients. • If ICD is present note how much fluid has drained, is bubbling/swinging, type fluid e.g. clear/bloody • Note the wound location and condition in a surgical patient.

13. Chest shape: Symmetrical or asymmetrical Sternal recession sub and intercostal costal recession Is the chest shape normal or is it deformed e.g. barrel shaped Pectus carniatum or pectus excavatum Does the child have any signs of respiratory distress e.g. grunting, nasal flaring, recession Breathing pattern: Paradoxal breathing Apical or diaphragmatic breathing pattern Any distress noted or is the child breathing comfortably? Respiratory rate ( described as normal, bradypnoeic or tachypnoeic relevant to the age norm) Does the child breathe through his nose or mouth Effect of positioning on breathing pattern Respiratory Examination

14. Chest deformities

15. Signs of respiratory distress

16. Chest wall recession :

17. Cough: Productive or unproductive? Paroxysmal coughing spells? Does the child have an effective cough? Can he clear his secretions successfully? If not nasal suctioning will need to be considered. Does coughing result in respiratory distress? Sputum: Colour of secretions? e.g. yellow indicative of a lung infection, blood stained may be indicative of haemoptysis. Smell? foul smelling secretions are often found in cases of lung abscess’ or severe infections Viscosity? Loose or sticky Amount? Give a measurable indication e.g. tablespoon or ½ sputum mug per day. Respiratory Examination

18. Auscultation: Auscultate accurately over all the lung fields. Compare the left and right sides. Note the location of any abnormal breath sounds e.g. course crepitations right basal lobe. Other abnormal breath sounds e.g. transmitting upper respiratory tract sounds e.g. stridor or snoring, amphoric breathing, fluid etc NB: Always ask patient to cough prior to auscultation. Why? To clear secretion in upper respiratory tract Respiratory Examination

19. Chest expansion: In babies and smaller children it is not necessary to palpate, one can simply observe the chest expansion. In older children chest expansion may be measured with a measuring tape or palpated. Posture: Note any abnormalities e.g. kyphosis or scoliosis Shoulder girdle elevation and tense shoulder girdle musculature should also be noted. Positioning: In what position is the patient sitting/lying in his/her bed Respiratory Examination

20. Where possible age appropriate developmental milestones are to be evaluated. If milestones on par age and everything appears normal not necessary to do a full neurological evaluation. Where one is suspicious of neuroldevelopmental delay or suspect neurological problems a full neurological evaluation is to be done. In case of patients with multiple system involvement may need more than one session to completely and comprehensively assess patient. The following neurological parameters also need to be evaluated: Deep tendon reflexes e.g. patella tendon, Ta, biceps and Brachioradialis Active and passive muscle tone Abnormal reflexes e.g. Babinski and clonus Primitive reflexes e.g. ATNR, rooting, startle, morro and sucking reflex etc. Are normal in a baby but should be integrated by 6/12 months. If these reflexes persist beyond this period it is abnormal Functional abilities and inabilities Neurodevelopmental Assessment

21. Vision: focus and following Hearing a child should be able to localize sound e.g. bell or rattle from 4/12 months. Speech and language development appropriate for age Feeding: Is the child feeding orally or via NGT? If the child is fed via a NGT does he have any swallowing problems? e.g. prevalent in CP children Is the child where appropriate eating normal table food? e.g. abnormal that a 2 yr old is only eating soft food. If the child is failing to thrive and undernourished is the child being seen by the dietician Other systems

22. Musculoskeletal system • Can be observed during active movement and play • Passive ROM and muscle strength and lengths can be evaluated specifically where one suspects a particular problem e.g. fracture, joint bleed,hemiplegic arm leg, GBS

23. Tested in children older than two years, and where they are well enough to do cardiovascular activities. The resting pulse is taken The child is then allowed to do some cardiovascular exercise e.g. game, ball activities or running until tired. The pulse is then taken again. The child is then allowed to rest and the pulse is taken again after 2 minutes. If cannot measure exercise tolerance specifically you may still observe the child's pulse after turning, sitting up over side of be etc. Also evaluate/ note: Respiratory rate Pulse rate and rhythm Use of accessory muscles of respiration If there is an increase in the frequency of coughing or the severity of wheezing were applicable Exercise tolerance

24. Function (ICF) • Look at function relevant to age • In older children you may ask him/her what they would like to be able to do now, that they could have done before. Or ask mother. • When setting functional goals be realistic • Make use of the diagnosis and prognosis to determine whether your intervention is preventative, promotive, curative or rehabilitative

25. References: • Images curtsey of GOOGLE • Paediatric dictate UFS (2009)