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

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

• Prepared by MD,
• Ass. Prof. Kovalchuk T.A.
• Department of Pediatrics 2

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Physical Growth

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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.

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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 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
  weight.
• 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.

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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 childs weight to the nearest 0.1 kg.

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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
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Normal range of weight

• Empirical formulas
• 2 -10 years W102n
• 10-16 years W304(n-10),
• where n - age of child in years

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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.

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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
  toes.
• 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.

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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
  pillar.

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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.

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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
  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.

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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
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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

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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
  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.

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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

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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.

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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

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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.

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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 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
  measurements.

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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.
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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.

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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.

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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
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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.

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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.

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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.

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Places of pulse determination

• A. radialis
• A. temporalis
• A. carotis
• A. ulnaris
• A. femoralis
• A. poplitea
• A. tibialis posterior
• A. dorsalis pedis

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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
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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.

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Pulse rhythm

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Blood pressure
Types of sphygmomanometer
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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.

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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.

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Thank you for attention!