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


Clinical examination. The role of nurses in the clinical examination. Prepared by MD, Ass. Prof. Kovalchuk T.A. Department of Pediatrics # 2 Normal range of blood ... – PowerPoint PPT presentation

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

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

Physical Growth

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.

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
  • 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
  • Ask the mother to stand in the middle of the
    scale, feet slightly apart (on the footprints, if
    marked), and to remain still. The mothers
    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 babys weight will appear on the display
    (shown to the nearest 0.1 kg). Record this
  • Note If a mother is very heavy (e.g.
    more than 100 kg) and the babys weight is
    relatively low (e.g. less than 2.5 kg), the
    babys weight may not register on the scale. In
    such cases, have a lighter person hold the baby
    on the scale.

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
  • 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 childs weight to the nearest 0.1 kg.

Normal range of weight
General Trends in Weight During Infancy
Age in months Weight gain (grams) Weight gain (grams)
Age in months Monthly For the whole period
1. 600 600
2. 800 1400
3. 800 2200
4. 750 2950
5. 700 3650
6. 650 4300
7. 600 4900
8. 550 5450
9. 500 5950
10. 450 6400
11. 400 6800
12. 350 7150
Normal range of weight
  • Empirical formulas
  • 2 -10 years W102n
  • 10-16 years W304(n-10),
  • where n - age of child in years

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

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 childs 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 childs 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
  • Read the measurement and record the childs
    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.

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

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 childs 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 childs attention,
    soothe the child as needed, and inform you if the
    child moves out of position.
  • Position the childs 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
    childs 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 childs
    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.

Preparing to measure length or height
  • Be prepared to measure length/height
    immediately after weighing, while the childs
    clothes are off.
  • Before weighing
  • Remove the childs shoes and socks.
  • Undo braids and remove hair ornaments if they
    will interfere with the measurement of
  • 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.

Normal range of length/height
General Trends in Length During Infancy
Age in months Height gain (cm) Height gain (cm)
Age in months Monthly For the whole period
1. 3 3
2. 3 6
3. 3 9
4. 2.5 11.5
5. 2.5 14
6. 2.5 16.5
7. 2 18.5
8. 2 20.5
9. 2 22.5
10. 1-1.5 23.5-24
11. 1-1.5 24.5-25
12. 1-1.5 25.5-27
Normal range of length/height
  • Empirical formulas
  • 1-4 years H100-8(4-n)
  • 5-15 years H 1006(n-4),
  • where n - age of child in years

Measuring of head circumference
  • Head circumference is measured in all children
    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 the occipital
  • 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.

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

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

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

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.

  • There are four basic routes by which
    temperature can be measured
  • oral,
  • rectal,
  • axillary,
  • tympanic.
  • The oral route is usually reserved for
    children ages 56 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 is convenient,
    safe, and noninvasive yet, research is
    inconclusive as to the accuracy of reading and
    correlations with other body temperature

Normal range of body temperature according to age
Age Centigrade Fahrenheit
Newborn to 1 year 37.5-37.7 C 99.4-99.7
3 to 5 years 37.0-37.2 C 98.6-99.0
7 to 9 years 36.7-36.8 C 98.1-98.3
10 years and older 36.6 C 97.8
In norm oral temperature is 0.5 C higher than
axillary, rectal temperature is 0.5 - 1 C
higher than axillary.
Interpretation of body temperature
  • Normal body temperature (afebrile) varies
    with the age of the child. A temperature above
    38.5C or 101.5F is interpreted as 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, hypothermia is a body temperature below
    34.0C or 93.2F. A low body temperature can be
    related to sepsis, ambient cold exposure, or
    submersion cold injury.

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 child is
    crying, the measurement will not be accurate and
    should be retaken.

Normal range of respiratory rate
Age Resting respiratory rate
Newborn 30-50 per minute
1 year 20-40 per minute
3 years 20-30 per minute
6 years 16-22 per minute
10 years 16-20 per minute
14 years 14-20 per minute
18 years 16-20 per minute
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 as tachypnea.
    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.

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 the pulse, 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.

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.

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

Normal range of pulse and heart rate
Age Pulse/heart rate
Newborn 100-170 beats per minute
1 year 80-170 beats per minute
3 years 80-130 beats per minute
6 years 70-115 beats per minute
10 years 70-110 beats per minute
14 years 60-110 beats per minute
18 years 60-100 beats per minute
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.

Pulse rhythm

Blood pressure
Types of sphygmomanometer
Rules of the measuring blood pressure
  • Preparation give up physical activity for one
  • 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
  • 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
  • Methods of measuring blood pressure on
    lower extremities are the same but child lies on
    the stomach and bell is placed on the popliteal

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.

Thank you for attention!
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