General Paediatric General Paediatric AssessmentAssessment

Robyn SmithRobyn SmithDepartment of PhysiotherapyDepartment of Physiotherapy

UFSUFS20122012

What is different about working What is different about working with children and adults?with children and adults?

Why do we find working with children and Why do we find working with children and babies so daunting??????babies so daunting??????

Infection control measuresInfection control measures

To prevent the spread of To prevent the spread of infection to already susceptible infection to already susceptible patients the following is to be patients the following is to be donedone::

Children are particularly Children are particularly susceptible to infectionsusceptible to infection

Wash your hands between Wash your hands between patients and spray with patients and spray with alcohol/ Hibitane spiritsalcohol/ Hibitane spirits

Remove your watch and ringsRemove your watch and rings Clean your stethoscope with Clean your stethoscope with

an alcohol swab between an alcohol swab between patientspatients

Where a mask and gown Where a mask and gown where indicatedwhere indicated

Subjective EvaluationSubjective Evaluation Interview mother/caregiver/childInterview mother/caregiver/child Use Use ‘tolk”‘tolk” where necessary where necessary If caregiver not available or If caregiver not available or

child is unable to communicate child is unable to communicate not possible rely on admission not possible rely on admission history available in the white history available in the white book in patient filebook in patient file

Interview Dr and other Interview Dr and other multidisciplinary team membersmultidisciplinary team members

NB: EssentialNB: Essential to get a to get a comprehensive patient history comprehensive patient history prior to observation physical prior to observation physical examination examination

Why is an effective history so Why is an effective history so important ???important ???

Interview: questions to ask the Interview: questions to ask the caregivercaregiver

Date of admission?Date of admission? Reason for admission?Reason for admission? How long was the child sick prior How long was the child sick prior

to admission, what signs and to admission, what signs and symptoms did she/he have?symptoms did she/he have?

Birth history relating to gestation, Birth history relating to gestation, birth weight, method of delivery, birth weight, method of delivery, Apgar scores?Apgar scores?

Any neonatal complications Any neonatal complications Child current developmental statusChild current developmental status Caregiver have any known Caregiver have any known

medical conditions, any TB medical conditions, any TB contacts at home?contacts at home?

Previous illness’ e.g. pneumonia, Previous illness’ e.g. pneumonia, bronchitis or TB resulting in bronchitis or TB resulting in previous admissions. Date of previous admissions. Date of admissions and duration?. Was admissions and duration?. Was TB treatment completed ? Health TB treatment completed ? Health after discharge?after discharge?

Previous surgical procedures? If Previous surgical procedures? If so what was done? Date?so what was done? Date?

Any familial history of Asthma, Any familial history of Asthma, haemophilia or other genetic haemophilia or other genetic conditionsconditions

Any known neurological Any known neurological conditions or problems?conditions or problems?

Any other children at home? What Any other children at home? What are their ages. Information on their are their ages. Information on their health developmental status?health developmental status?

Immunizations up to date?Immunizations up to date? Socio economic statuses e.g. Socio economic statuses e.g.

where are they residing, running where are they residing, running water and electricity? Are the water and electricity? Are the parent employed? parent employed?

Where applicable are they Where applicable are they receiving social grants?receiving social grants?

Medical history pertaining to current Medical history pertaining to current admissionadmission

Medical reason for current Medical reason for current admission?admission?

Does the child have a productive Does the child have a productive cough?cough?

When is the child coughing?When is the child coughing? Are there factors that exacerbate Are there factors that exacerbate

the coughing e.g. positioning?the coughing e.g. positioning? Paroxysmal coughing spells?Paroxysmal coughing spells? Coughing worse during a specific Coughing worse during a specific

time day?time day? If the child is productive, what is If the child is productive, what is

the appearance of the sputum in the appearance of the sputum in terms of colour, smell and terms of colour, smell and viscosity?viscosity?

Does the child have a tendency Does the child have a tendency towards recurrent upper towards recurrent upper respiratory tract infections? E.g. respiratory tract infections? E.g. croup and bronchiolitiscroup and bronchiolitis

Is the child dyspnoeic? Is the child dyspnoeic? Is there shortness of breath at rest Is there shortness of breath at rest

(grade 4), with activities of daily (grade 4), with activities of daily living (grade 3), with light exertion living (grade 3), with light exertion (grade 2) with activities e.g. (grade 2) with activities e.g. running (grade1) running (grade1) difference difference between dyspnoea and between dyspnoea and tachypnoeatachypnoea

Reasons for dyspnoeic episodes Reasons for dyspnoeic episodes e.g. exercise, emotional factors or e.g. exercise, emotional factors or stress related.stress related.

Is the child as active as other Is the child as active as other children his age or as his other children his age or as his other siblings ?siblings ?

MedicationMedication

What medication taking prior to admission?

Medication currently being given? Available on prescription chart in patient file

List all the medications List all the medications currently being given and currently being given and the reason for their the reason for their administration e.g. administration e.g. Panado (fever & pain)Panado (fever & pain)

Observation of vital signsObservation of vital signs Normal range is determined by ageNormal range is determined by age Make use table available in notesMake use table available in notes Make a copy and keep in clinical fileMake a copy and keep in clinical file

Get information from the vital sign sheet in file:Get information from the vital sign sheet in file: HRHR BPBP RRRR SaOSaO22

Use mobile SaOUse mobile SaO2 2 monitor -give you HR and SaOmonitor -give you HR and SaO2.2.. Make sure values you . Make sure values you use have been taken in the last 30 min. use have been taken in the last 30 min. WHY??? To ensure still relevant. Also look at vital sign trends over 48 hour WHY??? To ensure still relevant. Also look at vital sign trends over 48 hour period.period.

NB If the child is on oxygen do not just stop the therapy or remove the NB If the child is on oxygen do not just stop the therapy or remove the facemask/ nasal prongs. Without monitoring SaOfacemask/ nasal prongs. Without monitoring SaO2 2 !!!!!!!!!!!!!!!!

CXRCXR Are any available? Hard copy Are any available? Hard copy

or comuterizedor comuterized Date CXR was taken on?Date CXR was taken on? AP/ lateral viewAP/ lateral view Evaluate and compare 2 latest Evaluate and compare 2 latest

CXR’sCXR’s. WHY? Monitor . WHY? Monitor changes –improvement or changes –improvement or deterioration deterioration

Any areas of abnormality or Any areas of abnormality or pathology noted clearlypathology noted clearly

→ → Reading and interpreting Reading and interpreting CXR is a skill developed CXR is a skill developed over time.over time.If you are unsure If you are unsure of what you are seeing on of what you are seeing on the CXR ask the doctor/ the CXR ask the doctor/ qualified to look at the qualified to look at the CXR’s with you.CXR’s with you.

Objective EvaluationObjective Evaluation

Once all the above information has been Once all the above information has been collected then you may proceed with the collected then you may proceed with the objective evaluationobjective evaluation

General observationsGeneral observations WeightWeight is to be described us normal, underweight or overweight. is to be described us normal, underweight or overweight.

Percentiles may also be used.Possible reasons for the condition are Percentiles may also be used.Possible reasons for the condition are also to be given e.g. underweight due to chronic malnutrition etc.also to be given e.g. underweight due to chronic malnutrition etc.

Skin colourSkin colour and and conditioncondition is to be described. is to be described. OedemaOedema. Generalized or area specific. Not reason for possible . Generalized or area specific. Not reason for possible

oedema e.g. low albumin or cardiac failure in generalized oedema.oedema e.g. low albumin or cardiac failure in generalized oedema. CyanosisCyanosis. Peripheral (fingers and toes) or central 9mucosa of the . Peripheral (fingers and toes) or central 9mucosa of the

mouth)mouth) Clubbing of the fingers and toesClubbing of the fingers and toes (may be indicative of chronic heart , (may be indicative of chronic heart ,

but particularly chronic lung conditions e.g. Bronchiectasis)but particularly chronic lung conditions e.g. Bronchiectasis) Indwelling devicesIndwelling devices e.g. IVI (note what is being administered IV), e.g. IVI (note what is being administered IV),

catheter, ICD, central or arterial lines in PICU and Portovac drains in catheter, ICD, central or arterial lines in PICU and Portovac drains in surgical patients.surgical patients.

If ICD is present noteIf ICD is present note how much fluid has drained, is how much fluid has drained, is bubbling/swinging, type fluid e.g. clear/bloodybubbling/swinging, type fluid e.g. clear/bloody

Note the Note the wound locationwound location and and conditioncondition in a surgical patient. in a surgical patient.

Respiratory ExaminationRespiratory Examination

Chest shape:Chest shape: SymmetricalSymmetrical or asymmetrical or asymmetrical Sternal Sternal recession recession sub and sub and

intercostal costal recession intercostal costal recession Is the chest shape normal or is Is the chest shape normal or is

it deformed e.g. barrel shapedit deformed e.g. barrel shaped Pectus carniatumPectus carniatum or or pectus pectus

excavatumexcavatum Does the child have any signs Does the child have any signs

of of respiratory distressrespiratory distress e.g. e.g. grunting, nasal flaring, grunting, nasal flaring, recessionrecession

Breathing pattern:Breathing pattern: Paradoxal Paradoxal breathing breathing Apical or diaphragmatic Apical or diaphragmatic

breathing patternbreathing pattern Any distress noted or is the Any distress noted or is the

child breathing comfortably?child breathing comfortably? Respiratory rate ( described as Respiratory rate ( described as

normal, bradypnoeic or normal, bradypnoeic or tachypnoeic relevant to the tachypnoeic relevant to the age norm)age norm)

Does the child breathe through Does the child breathe through his nose or mouthhis nose or mouth

Effect of positioning on Effect of positioning on breathing patternbreathing pattern

Chest deformitiesChest deformities

Signs of respiratory distressSigns of respiratory distress

Chest wall recession :Chest wall recession :

Respiratory ExaminationRespiratory Examination

Cough:Cough: Productive or unproductive?Productive or unproductive? Paroxysmal coughing spells?Paroxysmal coughing spells? Does the child have an Does the child have an

effective cough? Can he clear effective cough? Can he clear his secretions successfully? If his secretions successfully? If not nasal suctioning will need not nasal suctioning will need to be considered.to be considered.

Does coughing result in Does coughing result in respiratory distress?respiratory distress?

Sputum:Sputum: Colour of secretions? e.g. Colour of secretions? e.g.

yellow indicative of a lung yellow indicative of a lung infection, blood stained may be infection, blood stained may be indicative of haemoptysis.indicative of haemoptysis.

Smell? foul smelling Smell? foul smelling secretions are often found in secretions are often found in cases of lung abscess’ or cases of lung abscess’ or severe infectionssevere infections

Viscosity? Loose or stickyViscosity? Loose or sticky Amount? Give a measurable Amount? Give a measurable

indication e.g. tablespoon or ½ indication e.g. tablespoon or ½ sputum mug per day.sputum mug per day.

Respiratory ExaminationRespiratory Examination

Auscultation:Auscultation: Auscultate accurately Auscultate accurately

over all the lung fields. over all the lung fields. Compare the left and Compare the left and right sides.right sides.

Note the location of any Note the location of any abnormal breath sounds abnormal breath sounds e.g. course crepitations e.g. course crepitations right basal lobe. right basal lobe.

Other abnormal breath Other abnormal breath sounds e.g. transmitting sounds e.g. transmitting upper respiratory tract upper respiratory tract sounds e.g. stridor or sounds e.g. stridor or snoring, amphoric snoring, amphoric breathing, fluid etcbreathing, fluid etc

NB: NB: Always ask patient Always ask patient to to cough prior to cough prior to

auscultation. Why? auscultation. Why? To clear secretion To clear secretion

in in upper respiratory upper respiratory tracttract

Respiratory ExaminationRespiratory Examination

Chest expansion:Chest expansion: In babies and smaller In babies and smaller

children it is not children it is not necessary to palpate, one necessary to palpate, one can simply observe the can simply observe the chest expansion.chest expansion.

In older children chest In older children chest expansion may be expansion may be measured with a measured with a measuring tape or measuring tape or palpated.palpated.

Posture:Posture: Note any abnormalities Note any abnormalities

e.g. kyphosis or scoliosise.g. kyphosis or scoliosis Shoulder girdle elevation Shoulder girdle elevation

and tense shoulder girdle and tense shoulder girdle musculature should also musculature should also be noted. be noted.

Positioning:Positioning: In what position is the In what position is the

patient sitting/lying in patient sitting/lying in his/her bedhis/her bed

Neurodevelopmental AssessmentNeurodevelopmental Assessment

Where possible age appropriate Where possible age appropriate developmental milestonesdevelopmental milestones are to are to be evaluated.be evaluated.

If milestones on par age and If milestones on par age and everything appears normal not everything appears normal not necessary to do a full neurological necessary to do a full neurological evaluation.evaluation.

Where one is suspicious of Where one is suspicious of neuroldevelopmental delay or neuroldevelopmental delay or suspect neurological problems a suspect neurological problems a full full neurological evaluationneurological evaluation is to be is to be done. done.

In case of patients with multiple In case of patients with multiple system involvement may need system involvement may need more than one session to more than one session to completely and comprehensively completely and comprehensively assess patient.assess patient.

The following neurological The following neurological parameters also need to be parameters also need to be evaluated:evaluated:

Deep Deep tendon reflexestendon reflexes e.g. e.g. patella tendon, Ta, biceps and patella tendon, Ta, biceps and BrachioradialisBrachioradialis

Active and passive Active and passive muscle muscle tonetone

Abnormal reflexesAbnormal reflexes e.g. e.g. Babinski and clonusBabinski and clonus

Primitive reflexesPrimitive reflexes e.g. ATNR, e.g. ATNR, rooting, startle, morro and rooting, startle, morro and sucking reflex etc. Are normal sucking reflex etc. Are normal in a baby but should be in a baby but should be integrated by 6/12 months. If integrated by 6/12 months. If these reflexes persist beyond these reflexes persist beyond this period it is abnormalthis period it is abnormal

Functional abilitiesFunctional abilities and and inabilitiesinabilities

Other systemsOther systems VisionVision: focus and following: focus and following

Hearing Hearing a child should be able a child should be able to localize sound e.g. bell or to localize sound e.g. bell or rattle from 4/12 months.rattle from 4/12 months.

Speech and languageSpeech and language development appropriate for development appropriate for ageage

FeedingFeeding: :

Is the child feeding orally or via Is the child feeding orally or via NGT? If the child is fed via a NGT? If the child is fed via a NGT does he have any NGT does he have any swallowing problems? e.g. swallowing problems? e.g. prevalent in CP childrenprevalent in CP children

Is the child where appropriate Is the child where appropriate eating normal table food? e.g. eating normal table food? e.g. abnormal that a 2 yr old is only abnormal that a 2 yr old is only

eating soft food. eating soft food. If the child is failing to thrive If the child is failing to thrive

and undernourished is the and undernourished is the child being seen by the child being seen by the dieticiandietician

Musculoskeletal systemMusculoskeletal system

Can be observed during Can be observed during active movement and active movement and playplay

Passive ROM and Passive ROM and muscle strength and muscle strength and lengths can be evaluated lengths can be evaluated specifically where one specifically where one suspects a particular suspects a particular problem e.g. fracture, problem e.g. fracture, joint bleed,hemiplegic joint bleed,hemiplegic arm leg, GBSarm leg, GBS

Exercise tolerance Exercise tolerance Tested in children older than two Tested in children older than two

years, and where they are well years, and where they are well enough to do cardiovascular enough to do cardiovascular activities.activities.

The resting pulse is takenThe resting pulse is taken The child is then allowed to do The child is then allowed to do

some cardiovascular exercise e.g. some cardiovascular exercise e.g. game, ball activities or running game, ball activities or running until tired.until tired.

The pulse is then taken again.The pulse is then taken again. The child is then allowed to rest The child is then allowed to rest

and the pulse is taken again after and the pulse is taken again after 2 minutes.2 minutes.

If cannot measure exercise If cannot measure exercise tolerance specifically you may still tolerance specifically you may still observe the child's pulse after observe the child's pulse after turning, sitting up over side of be turning, sitting up over side of be etc. etc.

Also evaluate/ note:Also evaluate/ note: Respiratory rateRespiratory rate Pulse rate and rhythm Pulse rate and rhythm Use of accessory muscles of Use of accessory muscles of

respirationrespiration If there is an increase in the If there is an increase in the

frequency of coughing or the frequency of coughing or the severity of wheezing were severity of wheezing were applicableapplicable

Function (ICF)Function (ICF)

Look at Look at function relevant to agefunction relevant to age In older children you may ask him/her In older children you may ask him/her what they what they

would like to be able to do now, that they could would like to be able to do now, that they could have done beforehave done before. Or ask mother.. Or ask mother.

When setting functional goals be realisticWhen setting functional goals be realistic Make use of the Make use of the diagnosis and prognosisdiagnosis and prognosis to to

determine whether your intervention is determine whether your intervention is preventative, promotive, curative or rehabilitativepreventative, promotive, curative or rehabilitative

References:References:

Images curtsey of GOOGLEImages curtsey of GOOGLE Paediatric dictate UFS (2009)Paediatric dictate UFS (2009)