An Approach to Assessing Children Flashcards
do children see the world differentyl?
yes
Think back…
- As a child what made you happy?
- Triggered your imagination?
- What was fun? (also what was not fun?)
- Favourite toys?
- Best things to play with?
An Approach to general paediatrics:
•Holistic multi-system approach essential - why?
More than one problem may exist
More than one system may be involved
An Approach to general paediatrics:
•Start with the age - why?
Guides approach to history taking and examination
Common pathologies differ
Conditions manifest differently at different ages
Consider common _________ for the presenting problem
differential
Anticipate what is different:
what is different in paediatrics?
- Parent(s) will be there - Astute observers, Resident carers
- Play is essential and clinically helpful (Play helpful for understanding pathologies and facilitates aspects of clinical examination)
- Specialised nursing staff - Different ratios, Understandably protective, Experienced at recognising sick children
- Treatments differ by weight and age
How can you Prepare for your encounter with a child?
- Why have they come to see you or been referred to the hospital or clinic?
- Do you know the child’s name age and sex?
- Do you have an opportunity to observe the child before “starting” your assessment?
- What is the likely differential diagnosis?
- What conditions do you need to rule out?
- What information have the nurses gathered?
Take a good history - how is it done and why is it important:
- Key step to making the _______
- Gather important __________
- Potentially rule out significant _________
- Helps examination be more ________
- Be calm and ________
- Show _______ in what the parents are saying
- Facilitates dealing with concerns and ________
diagnosis
information
pathology
targeted
empathetic
interest
anxieties
Age appropriate approach - how is it done?
- Consider the age and developmental stage
- Consider language and intellectual skills
- Typically most questions directed to parents
- Some questions are appropriate for a child
- Different perspectives may be gathered from both parents or from parent and child
- Pre-verbal children communicate! (eye contact etc)
- Older children can be quiet
History Taking Key Stages:
how is the introduction done?
Introduce yourself, identify the patient and who is with them (parents/ carers/ others)
Generate rapport with the child
Note your “examination” observations
History Taking Key Stages:
whats after the introduction?
Presenting complaint (what’s already known?)
History Taking Key Stages:
whats involved in the history of presenting complaint?
Onset, progress, variation, effects, observations
Chronological stages (Including GP/ A+E/ Ward)
General/systems enquiry may be appropriate here
Know your units….. (Weight)
what are they?
- What units do we measure a child’s weight in?
- What units do parents want the weight in?
- What is a pound?
- What is an ounce?
- What is a stone? - 14 pounds (6.35kg)
- How much weight should a baby gain?
- ~150(100)- 200g/ week 1st 6 months
- = 20-30g per day (need to average time intervals)
- Up to 10% loss in first few days is common
•I once saw….
- “Birth weight: 98.5”
- “Birth weight: 2 pounds 7 ounces” (Term, 0NNU)
Know your units… (Feeding)
•How much feed should a baby take? - Probably 140-180 ml/kg/day (100ml/kg/day if ill)
- Baby 1 (3m, Vomiting and unsettled): - “He weighs 11lbs, he usually takes a 7oz feed 6 times per day, he always seems hungry and unsettled after his feed. What should we do?”
- Baby 2 (6m Bronchiolitis and feeding concerns): - “She weighs 151/2lbs, she usually takes a 10oz feed 5 times per day, she just been taking 4oz every 3 hours. What should we do?”
Be prepared to ask about pooh…
what things should you ask?
- Children in nappies vs. independent toileting (parents less involved)
- Frequency (per day, week or even month)
- Size, shape, appearance and consistency
- Difficulties passing
- Pain on passing
- Blood or mucus seen
- Parents are sometimes surprised!
HIstory taking key stages:
what information do you want in regards to Birth History?
Detail depends on age and presentation
Some features may be very relevant years later
HIstory taking key stages:
what comes after birth history?
- Past Medical History (Admissions/ Similar Problems)
- Immunisations (Missed?/ Additional?)
HIstory taking key stages:
what do you want to know about development?
What can they do? Any concerns?
Basic enquiry essential (Walking, Words, Support)
What age where they when they first walked, talked etc
HIstory taking key stages:
what infromation do you need in regards to drugs and allergies?
This illness/Regular/Previous
May need to ask specifically about inhaler as people may not see that as drugs
Family and Social History - what do you want to know?
•Key stage in assessing patients:
- Recent and related health issues
- Parents/siblings (age and health)
- Relationship dynamics
•School and nursery:
- Common source of infective contacts
- Can give insight into developmental progress
•Parental social history impacts on child’s health
- Smoking/alcohol/ drugs/occupation/stress
Addressing concerns and closure - how should this be done?
- What made them come to see you today?
- What concerns do they have?
- What were they looking to understand?
- Discuss above questions (appropriate for stage)
- Summarise key features
- Check understanding and safety net
- Document history and discussions
- Note date, time, who was present/ gave history
Examination:
- Key step in working towards a _______
- Already _______ during history taking
- ___ appropriate techniques used
- Be sensitive to what _______ children
diagnosis
started
Age
upsets
What you are trying to examine?
- ABCDE and baseline observations/ vital signs
- General condition and peripheries
- Respiratory system
- Cardiovascular system
- Alimentary system
- Neurological and musculoskeletal systems
- ENT and skin
- Developmental skills
- Measurements and centile
what are some Tips on getting started your examination?
- Observe first (Watch at start so you can get to know what is happening with the child)
- Be friendly and smile (Child will respond to a positive smiley face)
- Speak to the child (even if they are weeks old)
- Get down to their level (crouch down so not looking down onto them, to their eye level)
- Be careful moving them- keep parents close (don’t want to upset them)
- Gentle handling and gradual exposure
- Show interest in their toys + play
What is the method of examination?
- It can be different every time!
- Always start with good observation - Pre-assessment, During history
- Think of each system
- Think of each area (of the body)
- Think of the method for that age
- Rapport is essential - Key step is to get that good rapport to be able to keep the child distracted and keep the child and parent on side with you and can extent your examination time
