Introduction to Pediatric Clinical Skills

Range of respiratory rates

-20-40 during early childhood -15-25 during late childhood, reaches adult levels at around 15 years of age

Where to record temperature in children

-auditory canal temperature recording are prefered

Why it is important to observe children play

-can detect behavioral, developmental and neurological abnormalities -

Visualizing tympanic membranes

-external auditory canal is directed upward and backward from the outside -pull auricle upward, outward and backward

When to measure head circumference

-measured until the child reaches 24 mo -after this measure if suspect genetic or CNS disorder

Testing visual fields in children

-one eye tested at a time (the other eye covered) -hold childs head at midline while bringing an object into the filed of vision from behind the child

Measuring heart rate

-over 60 second interval

Selecting a proper blood pressure cuff for childre

-should be wide enough to cover 2/3 of the upper arm or leg -narrow cuff will falsely elevate BP while wide cuff lowers it

Order in which to perform the examination

-start with least distressing procedure and keep most distressing for last (throat and ears) -begin with parts that can be done with the child sitting (examining eyes palpating the neck) -once a child is supine begin with the abdomen and save the throat, ears, and genitalia for last)

Getting information from both the child and the parent

-start with the child, use simple questions -parents can verify info, add details and context -discover the different gendas (even family members that are not there)

How to test visual acuity in young children

-where child cannot identify pictures on an eye chart -assess for fixation preference by covering one eye (if one eye has poor vision will object to having the good eye covered) -in visual acuity is important that both eyes show the same result

Average heart rate of children

1) 1-2 years (70-150) 2) 2-6 (68-138) 3) 6-10 years (65-125) Sinus bradycardia is a heart rate <100 beats/min in children< 3 years and < 60 beats/min in children 3-9 years

Ways of holding the otosope

1) Hold lateral aspect of you hand that has the otoscope against the head to provide buffer against sudden movements 2. Hold the head and pull up on the auricle with one hand, hold the otoscope with the other hand

Tips for examining a young child

1) Reassuring voice 2) Don't ask permission to examine a body part - ask which part of the body or which ear would like to examine first 3) Examine in parents lap. Let parent undress child 4) Make a game out of the examination "let's see how big your tongue is", "is Elmo in your ear" 5) Reassure parents if child misbehaving 6) First examine the child's toy 7) Let the child do some of the exam - then go back to get places missed 8) Give them tongue depressor puppets -if they are holding something they can resist

Vital signs to measure

1. Blood pressure 2. Pulse 3. Respiratory rate

Assessing a child's eyes

1. Determine whether the gaze is conjugate or symmetric 2. Test visual acuity of each eye

Things to note in the general survey

1. Height 2. Weight 3. Head circumference 4. BMI

Tips for examining the ear

1. Use largest possible speculum 2. Insert speculum 1/4 to 1/2 inch into the canal 3. First find landmarks (sometimes ear canal can resemble tympanic membrane) 4. Note whether tympanic membrane is abnormal

Assessing a childs head

1. observe the shape of the head, its symmetry and the presence of abnormal facies (can reflect chromosomal abnormalities, or other developmental problems such as fetal alcohol syndrome)

Tachypnea in children older than 1 year

>40 breaths per minute

Cover-uncover test

Have child watch your nose or tell if you are smiling or not while you cover ne of the childs eyes

Assessing a childs skin

Same as in Adults

Conjugate gaze

Test as did in adults -assessing the position and alignment of eyes and the function of extraocular muscles -corneal light reflex test -cover-uncover test

Interpreting BMI in children

Underweight < 5th percentile Healthy weight 5th-85th percentile Overweight 85-95th percentile Obese over 95th percentil