Clinical examination. The role of nurses in the clinical examination.

1. Clinical examination. The role of nurses in the clinical examination. Prepared by MD, Ass. Prof. Kovalchuk T.A. Department of Pediatrics # 2

2. Physical Growth

3. Physical Growth of Newborns • The average newborn weight 3200 to 3400 g. Admissible limits of the norm ranges from 2700 to 4000 g. Babies, which birth weight equals more than 4000 g, are called huge. • Birth length normal rate is 50 to 52 cm. Admissible limits of the norm ranges from 46 to 56 cm. • Head circumference is equal 34 to 36 cm. • Chest circumference equals 32 to 34 cm.

4. Weighing of children If the child is less than 2 years old, do tared weighing. • To turn on the scale, cover the solar panel for a second. When the number 0.0 appears, the scale is ready. • The mother will remove her shoes and step on the scale to be weighed first alone. Have someone else hold the undressed baby wrapped in a blanket. • Ask the mother to stand in the middle of the scale, feet slightly apart (on the footprints, if marked), and to remain still. The mother’s clothing must not cover the display or the solar panel. Remind her to stay on the scale even after her weight appears, until the baby has been weighed in her arms. • With the mother still on the scale and her weight displayed, tare the scale by covering the solar panel for a second. The scale is tared when it displays a figure of a mother and baby and the number 0.0. • Hand the undressed baby to the mother and ask her to remain still. • The baby’s weight will appear on the display (shown to the nearest 0.1 kg). Record this weight. Note: If a mother is very heavy (e.g. more than 100 kg) and the baby’s weight is relatively low (e.g. less than 2.5 kg), the baby’s weight may not register on the scale. In such cases, have a lighter person hold the baby on the scale.

5. Weighing of children If the child is 2 years or older and will stand still, weigh the child alone. If the child jumps on the scale or will not stand still, use the tared weighing procedure instead. Ask the mother to help the child remove shoes and outer clothing. Talk with the child about the need to stand still. • To turn on the scale, cover the solar panel for a second. When the number 0.0 appears, the scale is ready. • Ask the child to stand in the middle of the scale, feet slightly apart (on the footprints, if marked), and to remain still until the weight appears on the display. • Record the child’s weight to the nearest 0.1 kg.

6. Normal range of weight General Trends in Weight During Infancy

7. Normal range of weight Empirical formulas: 2 -10 years: W=10+2n; 10-16 years:W=30+4(n-10), where n - age of child in years

8. Measuring of length If a child is less than 2 years old, measure the child’s length lying down (recumbent) using a length board which should be placed on a flat, stable surface such as a table.

9. Rules of measuring length Speed is important. Standing on the side of the length board where you can see the measuring tape and move the footboard: • Check that the child lies straight along the board and does not change position. Shoulders should touch the board, and the spine should not be arched. Ask the mother to inform you if the child arches the back or moves out of position. • Hold down the child’s legs with one hand and move the footboard with the other. Apply gentle pressure to the knees to straighten the legs as far as they can go without causing injury. Note: it is not possible to straighten the knees of newborns to the same degree as older children. Their knees are fragile and could be injured easily, so apply minimum pressure. If a child is extremely agitated and both legs cannot be held in position, measure with one leg in position. • While holding the knees, pull the footboard against the child’s feet. The soles of the feet should be flat against the footboard, toes pointing upwards. If the child bends the toes and prevents the footboard from touching the soles, scratch the soles slightly and slide in the footboard quickly when the child straightens the toes. • Read the measurement and record the child’s length in centimetres to the last completed 0.1 cm in the Visit Notes of the Growth Record. This is the last line that you can actually see. (0.1 cm = 1 mm) • Remember: If the child whose length you measured is 2 years old or more, subtract 0.7 cm from the length and record the result as height in the Visit Notes.

10. Measuring of height If the child is aged 2 years or older, measure standing height unless the child is unable to stand. Use a heightboard mounted at a right angle between a level floor and against a straight, vertical surface such as a wall or pillar.

11. Rules of measuring height Working with the mother, and kneeling in order to get down to the level of the child: • Help the child to stand on the baseboard with feet slightly apart. The back of the head, shoulder blades, buttocks, calves, and heels should all touch the vertical board. • Ask the mother to hold the child’s knees and ankles to help keep the legs straight and feet flat, with heels and calves touching the vertical board. Ask her to focus the child’s attention, soothe the child as needed, and inform you if the child moves out of position. • Position the child’s head so that a horizontal line from the ear canal to the lower border of the eye socket runs parallel to the base board. To keep the head in this position, hold the bridge between your thumb and forefinger over the child’s chin. • If necessary, push gently on the tummy to help the child stand to full height. • Still keeping the head in position, use your other hand to pull down the headboard to rest firmly on top of the head and compress the hair. • Read the measurement and record the child’s height in centimetres to the last completed 0.1 cm in the Visit Notes of the Growth Record. This is the last line that you can actually see. (0.1 cm = 1mm) • Remember: If the child whose height you measured is less than 2 years old, add 0.7 cm to the height and record the result as length in the Visit Notes.

12. Preparing to measure length or height Be prepared to measure length/height immediately after weighing, while the child’s clothes are off. Before weighing: • Remove the child’s shoes and socks. • Undo braids and remove hair ornaments if they will interfere with the measurement of length/height. If a baby is weighed naked, a dry diaper can be put back on to avoid getting wet while measuring length. If the room is cool and there is any delay, keep the child warm in a blanket until length/height can be measured. Explain all procedures to the mother and enlist her help.

13. Normal range of length/height General Trends in Length During Infancy

14. Normal range of length/height Empirical formulas: 1-4 years: H=100-8(4-n); 5-15 years: H= 100+6(n-4), where n - age of child in years

15. Measuring of head circumference • Head circumferenceis measured in allchildren less than 2 years of age or in children with known or suspected hydrocephalus. Place the child in a sitting or supine position. Using a tape measure, measure anterior from just above the eyebrows and around posterior to theoccipital protuberance. • Microcephaly, a anomaly characterized by a small brain with a resultant small and a mental deficit, is an abnormal finding. Another, hydrocephalus, is an enlargement of the head without enlargement of the facial structures.

16. Normal range of head circumference Infants • Birth-6 months - monthly gain: 1.5 cm • 6-12 months - monthly gain: 0.5 cm Children • 1-5 years - yearly gain: 1 cm • 6-15 years - yearly gain: 0.6 cm

17. Measuring of chest circumference • Chest circumference is measured up to 1 year of age. It is a measurement that, by itself, provides little information but is compared to head circumference to evaluate the child's overall growth. Measure the chest circumference by placing the tape measure around the chest at the nipple line. Measure at the end of exhalation. From birth to about 1 year, the head circumference is greater than the chest circumference. After age 1, the chest circumference is greater than the head circumference. A measured chest circumference below normal limits is abnormal. A below normal chest circumference for age can be attributed to prematurity.

18. Normal range of chest circumference Infants • Birth - 6 months - monthly gain: 2 cm • 6-12 months - monthly gain: 0.5 cm Children • 1 - 10 years - yearly gain: 1.5 cm • 11-15 years - yearly gain: 3 cm

19. Assessment of physical development Percentile chart: 25th - 75th percentiles - normal data. 10th - 25th percentiles - less than average data 75th - 90th percentiles – bigger than average data. These measurements may or may not be normal, depending on previous and subsequent measurements and on genetic and environmental factors. 10th - 5th percentiles – low data, 90th - 95th percentiles - high data, which require further examination. Below the 3rd and above the 97th percentiles are extremely low and extremely high and reflect pathological deviations of physical development.

20. Thermometry There are four basic routes by which temperature can be measured: • oral, • rectal, • axillary, • tympanic. The oral route is usually reserved for children ages 5—6 years and older. A rectal temperature is considered the most accurate and can be taken in children of all ages. However, it is not appropriate in all instances, for example, in the child who presents with a history of diarrhea. A tympanic temperature isconvenient, safe, and noninvasive; yet, research is inconclu­sive as to the accuracy of reading and correlations with other body temperature measurements.

21. Normal range of body temperature according to age In norm oral temperature is 0.5° C higher than axillary, rectal temperature is 0.5 - 1° C higher than axillary.

22. Interpretation of body temperature Normal body temperature (afebrile) varies with the age of the child. A temperature above 38.5°C or 101.5°F is interpretedas hyperthermia. An elevated body temperature can be related to severe illnesses such as meningitis, or common childhood illnesses such as otitis media and streptococcus pharyngitis, or heat exposure. In contrast, hypothermiais a body temperature below 34.0°C or 93.2°F. A low body temperature can be related to sepsis, ambient cold exposure, or submersion cold injury.

23. Respiratory Rate Respiratory rate per minute can be determined by such methods: • To count the frequency of contraction of the thorax visually. • To count the frequency of inhalations holding the stethoscope at the nostril of the child. • To count the frequency of inhalations during the auscultation of the lungs. • To count the breathing rate movements placing the hand on the thorax. Try to obtain the respiratory rate early in the assessment, when the child is most cooperative and not crying. If the childis crying, the measurement will not be accurate and should be retaken.

24. Normal range of respiratory rate

25. Interpretation of respiratory rate Diseases of the respiratory system is usually characterized by the increase in the frequency by more than 10 % and is defined astachypnea. Besides, the rise in body temperature by every degree more than 37º C results in the increase of the respiratory rate up to 10 respiratory movements. The reduction of the respiratory rate by 10 %and more is called bradypnea – which indicates lesion in the respiratory center.

26. Pulse determination An apical pulse (heart rate) should be taken on neonates, infants, and young children (under 2 years of age) and on all children with cardiac problems or on digitalis preparations. To determine thepulse, place your stethoscope over the child's precordium, which is the part of the front of the chest wall that overlays the heart, great vessels, pericardium, and some pulmonary tissue. Pulse rate is determined by palpating peripheral big vessels in children over 2 years of age.

27. Rules for determination of pulse rate • The most accurate data can be obtained in the morning right after sleep, on an empty stomach. • A child should be calm, as excitation and physical exercises may result in increase of heart rate. • A child sits or lies down. • At first, the pulse is palpated on both hands by the second and third fingers on radial artery in the area of radiocarpal joint. • Pulse can be read during 15 or 20 seconds, and than the figure obtained should be multiplied by 4 or 3 respectively.

28. Places of pulse determination • A. radialis • A. temporalis • A. carotis • A. ulnaris • A. femoralis • A. poplitea • A. tibialis posterior • A. dorsalis pedis

29. Normal range of pulse and heart rate

30. Interpretation of pulse rate • Increase in pulse rate by 10 % and more than the norm indicates tachycardia, which is one of the first indications of intoxication, cardiovascular diseases and also such endocrinal (hyperthyroidism) and blood (anemia) pathology. Increase in temperature for every degree above 37º C accelerates pulse rate by ten-fifteen beats per minute. Decrease in pulse rate by 10 % and more than the norm indicates braducardia – happens in myocarditis, neglected hypotrophy, hypertensions and while recovering after scarlet fever and other infectious diseases.

31. Pulse rhythm

32. Blood pressure Types of sphygmomanometer

33. Rules of the measuring blood pressure • Preparation: give up physical activity for one hour. • In sitting or lying position. • The device is placed on the table or bad in such a way that the heart of a child, arm, zero point of scale and the cuff are on the same horizontal level. • Air should be completely removed from the cuff, which is tied around the arm 2 cm above the cubital fossa so that it would be possible to put 1-2 fingers under it. • Hand of the child is placed on the table with its palm upwards, muscles relaxed. • Localization of brachial artery in the cubital fossa is determined by palpation. • The bell of the stethoscope is placed on the place where brachial artery is located and air is pumped into the cuff till it reaches 40-50 mmHg above the level where pulsation of artery stops. • After that the pressure in the cuff is slowly reduced, - the moment of occurrence and termination of loud and strong tones are registered on a mercury column by auscultation and visually (systolic and diastolic pressures respectively. Methods of measuring blood pressure on lower extremities are the same but child lies on the stomach and bell is placed on the popliteal artery.

34. Normal range of blood pressure • Newborns: 70/35 mmHg on the upper and lower extremities. • 12 months: 90/60 mmHg on the upper extremities. • 1-15 years: systolic blood pressure = 90 + 2n diastolic blood pressure = 60 + n, n – age of child in years. In children below 9 months blood pressure becomes higher than blood pressure on the upper extremities – by 5-20 mmHg.

35. Thank you for attention!