NUR 6210 Exam 1 Study Guide: Pediatric Assessment and Health Promotion, Study Guides, Projects, Research of Nursing

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NUR 6210 Exam 1

Study Guide 2025/

William Paterson University

Administrator

NUR 6210 Exam 1 Study Guide Look at child, ABCs, Safety, Family present in room – survey the room – who is who?; caregivers mental state (alert, oriented, sleeping, sober); child’s mood

• before entering room: know your “norms”; remember your growth and development when approaching patient; ideal time to do exam: sleeping and not aware; assess a lot by just observing; make exam fun – blow out your penlight
• approaching pediatric patient – newborns/<6 months old = easiest to examine, no resistance; use pacifier, hold patient; warm hands, stethoscope; order of assessment varies depending on patient
  • infants >6 months = keep with parent due to separation anxiety; toys for distraction; start at feet but may need to vary assessment due to mood
  • toddlers = demonstrate instrument use on parent; parents hold patient if possible; don’t ask patient if you can do something: “NO” will be the answer; speak with confidence, explain each step
  • preschooler: allow them to touch/play with equipment; listen to stuff animals first; give positive feedback; use distraction to talk
  • school-age children: if older school age, ask if ok if parents are present; head to toe assessment; offer as many choices as possible; demonstrate how to use equipment and let them use it; teach about how body works
  • adolescent: cover body parts not being examined; offer privacy when changing – if safe!!; ask if ok with parents present during perineal/genital exam/care Vital signs:
  1. Respirations – observe/feel abdomen <6 years
  2. Pulse – auscultate apical pulse 1 full minute
  3. Blood pressure – appropriate cuff size; use same extremity (if possible) every time
  4. Temperature – oral: 1 minute, axillary: 3 minutes; < 7 years old axillary method preferred
  5. Height – rule of thumb: Average newborn length is 19.5- 20 inches; birth length increases 50% by end of 1 st^ year
  6. Weight – rule of thumb: Average newborn weight: 7 - 7.5 lbs; doubles by 6 months; triples by 1 year of age
  7. Head circumference – done until age 2; wraps around head at supraorbital prominence, above ears, and around occipital prominence
     • anterior fontanel – closes approximately 8 - 18 months; posterior fontanel closes approximately 1 - 2 months; assess through at least 2 years of age HEENT Assessment – head circumference, face symmetry, hair distribution, light reflex – pupils, eye size/spacing/color/drainage/discharge, nasal passage patent, ear placement, mouth (lips, teeth, gums, tongue, odor), trachea midline, lymph nodes,
  8. Respiratory assessment – observe/touch abdomen to obtain RR if <6 years old for 1 full minute; look for color, capillary refill, chest expansion/retractions, nasal flaring; check ease and depth: affected by emotion**; Respirations are irregular in infant/toddler – newborn: 30-50/minute; apnea in newborn (no breathing 20 seconds) is ABNORMAL
  9. Cardiovascular assessment – full minute (note activity); heart rate fluctuates with crying, eating, etc; check for tachycardia when sleeping; assess as much as quietly as possible before awakes; newborn 100-160/bpm; infants-2 years old 80-130/bpm; listen with bell and diaphragm; warm stethoscope!; listen recumbent & then sitting up
  10. Abdomen assessment – assess shape, assess abdominal movement – infants- 6 years old breathe with diaphragm ; auscultation with diaphragm x 4 quadrants; percussion (supine) – dullness over organs, tympany over stomach/intestines, resonance; palpation
  11. Genital/perineal assessment – PRIVACY; often deferred; explain what you’re going to do; assess: swelling, bruising, testicles – descended?, discharge, tanner stage
  12. Musculoskeletal assessment – assess upper/lower extremities for leg length discrepancies, skin fold asymmetry; ROM – active/passive; muscle strength – meeting developmental milestones good indication of muscle strength/tone
  13. Nervous system – behavior: calm, anxious, lack of interest; does it correlate with developmental milestones; communication: appropriate for age/developmental stage; balance; sensory function – numbness, tingling, altered sensation
  14. Skin Assessment – temperature, moisture, turgor, mottling, Mongolian spot, café au lait spot, moles/birth marks, acne, eczema, diaper rash, burns/bruises, thrush, stork bites, port wine stains Infant reflexes – all should be present at birth

1. Moro/startle – any startling event causes arms to go straight out and hands wide open; disappears at 2 months
2. Palmer grasp – disappears at 5 - 6 months
3. Plantar reflex/babinski – lateral aspect of foot – big toe dorsiflexes, toes spread, and plantar flexion; disappears 9 - 12 months
4. Stepping reflex (until 2 months) – when held upright with feet on surface, appears to be taking steps or dancing; disappears 2 months
5. Tonic neck/fencing - when baby is lying down and head turned to one side, corresponding arm extends while other arm bends next to head – like fencing; disappears 5-7 months
6. Rooting reflex – prompts baby to turn head towards hand that strokes cheek or mouth – helps find nipple for feeding; disappears 4 months Health Promotion

• routine well visits – newborn (2- 3 days after discharge from hospital) then 2, 4, 6, 9, 12, 18, 24 months of age; then yearly from 3 years old
• immunization schedule https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html
• anticipatory guidance HEENT Assessment:
  1. Head assessment - visualization, head circumference measured at each well visit at each up to 36 months or until fontanelles closed, fontanelles (anterior and posterior fontanelles easily palpable during first several weeks of life), palpation is performed with patient in upright position – both are soft, relatively flat, visual pulsation of anterior fontanelle is normal especially in crying/agitating patient ; POUNDING pulsations, or persistent tenseness of fontanelle may indicate intracranial pressure;

a. Caput Succedaneum – diffuse swelling of soft tissue of newborn scalp; crosses suture line with possible bruising; due to compression/trauma to scalp from vaginal delivery; resolves in first few days of life; differential diagnosis – cephalohematoma, subgaleal hematoma b. Cephalohematoma – subperiosteal collection of blood bound by suture lines; usually due to trauma of vaginal delivery (large infant, prolonged labor, vaccum extraction, abnormal presentation); may prolong neonatal jaundice from reabsorption of hematoma; differential diagnosis – caput succedaneum; management – usually none needed, slow resolution over few weeks/months but observe from hyperbilirubinemia c. plagiocephaly: flattening of area due to repeated pressure on one part of head (positional plagiocephaly); babies develop from sleeping or being positioned in one position; treatment – vary sleep positions, exercises, corrective headband; can also see mild or moderate torticollis(twisting of neck) that can occur with this head issue also** - management: passive ROM exercises, if severe: refer for corrective headband but only if necessary and have to***differential diagnosis – craniosynotosis d. craniosynostosis – premature closure of one or more of cranial sutures; normally anterior suture line remains open until 2 years ; sign/symptoms – abnormal head shape; diagnostic testing: x-ray of skull; management – surgery to open suture – primarily done for cosmetic reasons, unless neurologic complication face – size of mouth, shape of lips, nose, distance between eyes, size shape and position of pinna; can be compatible due to syndrome, maternal drug ingestion or chromosomal abnormalities; periorbital or facial edema can be part of systemic allergic reaction or first indication of nephrotic syndrome; unilateral orbital or facial edema can be due to result of insect bite/cellulitis; unilateral or bilateral swelling not caused by edema may be secondary due infectious process or in the case of mumps (parotid gland swelling); lymphopathy and salivary gland pathology cause mandibular soft tissue swelling; unilateral facial paralysis secondary to a peripheral or central nerve defect may be attributable to traumatic injury, viral or bacterial infection or some other anomaly

2. Eye Assessment – examination, appearance, eyelids; start with least in your face assessments – such as corneal light reflex and ocular motility to most in your face to keep child cooperative*; best examined upright in caregiver’s arms with attention drawn to toy or bright object; infants are more easier to examine than uncooperative 18 month old to 3 year old ; by age 6 - 8 years , can sit alone facing examiner and able to follow directions; before using ophthalmoscope or touching child, examiner should note position facing of eyes/ width of palpebral fissures, eye color/appearance of sclera, conjunctiva; condition of eyelids, pupillary size/movement; asymmetry may be due to prominent epicanthus folds, difference in size or ptosis; widen or narrow palpebral fissures are the norm for some but can be a syndrome complex in others; examination of eyelids – lashes, color, presence of ptosis, skin defects a. Dacrostenosis – unilateral or bilateral obstruction of nasolacrimal duct; due to failure of duct canalization during gestation; 90% spontaneous resolve by 12 months; after this age, spontaneous resolution less likely; signs/symptoms – onset typically 1 - 2 weeks of age, continuous or intermittent tearing with crusting of lashes , conjunctiva clear, NO ERYTHEMA – no signs of infection because NO INFECTION PRESENT; differential diagnosis – opthalmia neonatorum, conjunctivitis, dacrocysitits, glaucoma, intraocular inflammation, external irritation; management = gentle massage with clean cotton ball lacrimal sac and nasolacrimal duct, for purulent drainage intermittent use of erythromycin ointment, refer to ophthalmologist by 6 to 12 months if not resolved (sooner if needed); purulent discharge can be from bacterial (gonorrhea or chlamydia) but most times caused by abundant tearing/blocked tear duct b. Strabismus – ocular misalignment; eyes may deviate outward (exotropia), inward (esotropia), downward (hypotropia) or upward (hypertrophia); affects approximately 4% of children younger than 6 years of age; intermittent exotropia is a normal variant in first 4 to 6 months because their eye muscles are immature at that stage; acquired strabismus occurring after 6 months of age usually from cataracts, retinoblastoma, anisometropia; diagnostic test – abnormal Hirschberg (unequal corneal light reflex) and cover-uncover test (abnormal movement of eye); management – refer to ophthalmologist, patching (unaffected eye) so affected eye develops and strengthens, surgery, corrective lenses
3. Ear examination – relationship of ear – shape and position of pinna – malformation in syndromes that affect mandibular facial shape structure such as Treacher Collins syndrome; protruding anteriorly placed pinna can be NORMAL variant; if external ear is displaced outward and anteriorly, consider mastoiditis or external otitis or cellulitis; ear skin tags can be associated with hearing loss but generally no clinical significance; ear pits involving pinna and preauriclar skin pits are associated with hearing loss with most instances; occasionally pit just in front of tragus may extend into subcutaneous cyst and become infected; palpation of tragus or pinna may cause significant pain with patient external canal irritation (Swimmer’s ear); canal can be red, swollen and painful due to external otitis or external object, external bite or furuncle; discomfort and swelling can distort tympanic membrane; otoscopic examination = normal tympanic membrane; acute otitis media has bulging tympanic membrane; clear canal prior to visualization; speculum is made to assist visualization, not to probe into ear canal; best with child sitting upright or lying supine with head tilted; hold patient head steady, take thumb/index finger of opposite hand of examiner and pull down pinna and back allowing maxima visualization of canal for infants; for >3 years, pull pinna up and back ; adult is helix up and back; can hold patient firmly on own lap to help examiner; smooth pink auditory canal is short and straight in infant and younger child and somewhat longer and more angulated in older child; tympanic membrane is usually translucent and allows visualization of middle ear structure; hearing = infant physical response to sound with startle response, eye blinking, turning toward sound are normal reactions; older child that is cooperative – testing can be done mouthing audible words into ear or whispering ears at a distance; in infant and young child – pull auricle inferiorly and posteriorly (down and back) and in middle school and adolescence – pull superiorly and posteriorly (up and back); or can pull tragus forward (anteriorly) with thumb in young children
4. Nose examination – patient head tilted back; clinicians sitting opposite; shape, position, inspection of nose structure using light; nasal speculum or for smaller child, use ear speculum in nose; to reduce discomfort and steady head, examiner should put outer ulnar aspect of hand not holding instrument against patient’s forehead; thumb of hand is used to elevate tip of nose; procedure allows optimal visualization of nose, nasal turbinates, mucosa, septum; mucosa is normally pink, vesticles are patent and easily visual to level of middle turbinance depending on age of child; cant see in young infant, but older child can see; septum is midline,

slight deviation is normal; transient septum deformities due to utero positioning may be noted in newborn – differential diagnosis: infectious diseases (inhaled drugs) or traumatic injury; swelling, bleeding, abnormal lesions and types of secretions should also be noted; nasal discharge – thin, serous discharge may be seen in allergic rhinitis, upper respiratory infection; purulent nasal discharge – viral or bacterial infection involving nasopharynx or sinuses; impacted foreign body should be suspected with unilateral malodorous or purulent discharge noted; if in newborn , there happens to be

• Review of Systems – General health, growth, cardiovascular, respiratory, neurologic, hematologic, endocrine, infectious disease, immunologic, rheumatologic, gastrointestinal, genitourinary; date and length of hospitalization for any condition must be noted , poor weight gain, poor linear growth, impetigo can lead to rheumatic heart disease – having a cut can lead to impetigo risk; Kawasaki disease, petechiae of rheumatic heart disease,

sickle cell disease can lead to heart failure; lyme disease, h/o of untreated streptococcal infections; immunologic = low grade fever with or without rash; GI – do they need to take breaks when feeding? Gasp for air?; genitourinary issues can lead to hypertension

• pneumococcus – assess immunization; medications can affect heart = albuterol which can cause tachycardia; sycope
• Cardiovascular – Inspect, Auscultation, Palpation, Percussion when indicated
• History of present illness – inspect (general appearance, look at growth pattern, respiration, cyanosis/clubbing, edema of extremities, diaphoresis, chest deformity), palpation – precordial activity, apical maximal impulse; any thrills? Palpable delay in radial or brachial to femoral pulse – can be coarctation of aorta; ask young children and adolescents if they play sports = regular physical activity can be cause of slow resting heart rate; arrhythmia/syncope/sudden death of age 50 family history can be sign of long QT syndrome or cardiomyopathy (which can prevent them from playing sports); cocaine affects heart Auscultation – bell used to detect low frequency sounds while diaphragm picks up high frequency; entire precordium and supraclavicular sides and back included in exam; murmurs 50 - 80% detected during childhood especially during febrile cases – most cases innocent; murmurs vs **Stills murmurs (low pitched/musical sound, most common innocent or functional murmurs at 3 - 6 years of age– can disappear as patient moves into adolescent – best auscultated between left lower sternal border and apex, sounds like twang string or musical quality but not associated with thrill – listen with bell in supine – murmur can fade when child is upright or with Valsalva maneuver **); inspiration tends to intensify right sided lesions/mumur because increases venous return – murmur of pulmonary stenosis; inspiration also accentuates S3 of tricuspid regurgitation; expiration decreases venous return and can make ejection click of pulmonary stenosis louder; postural changes (squatting for 30 seconds to standing) decreases venous blood return to heart and systemic BP, can be used to intensify of murmurs left sided regions and mitral valve prolapse; Valsalva maneuver (decreases venous return) can prolong hypertrophic obstruction of cardiomyopathy
• lungs and liver assessed for signs of congestion – tachypnea in presence of arousal or wheezes may indicate pulmonary congestion; presence of hepatomegaly is sign of elevated central venous pressure; liver more than 2 sonometers below the right costal margin is abnormal and consistent with congestive heart failure
• Mitral valve – 5 th^ intercostal space – midclavicular line (apex beat)
• Tricuspid valve – 4 th^ or 5 th^ intercostal space – lower left sternal edge
• Pulmonary valve – 2 nd^ intercostal space – left sternal edge
• aortic valve – 2 nd^ intercostal space – right sternal edge
• listen over each area with both the BELL (for low pitched sounds-gallops and split S2) and the DIAPHRAGM (high pitched sounds – pericardial rubs, S1/S2 and most murmurs)
• tip: complex cardiac anomalies may cause you to hear multiple dynamic murmurs (Tetralogy of Fallot)
• common diagnostic studies – ECG, laboratory test, CXR (xray) – generally abnormal only when congenital heart disease is significant enough to cause hemodynamic changes* Innocent murmurs – always asymptomatic; early ejection systolic; short, soft, vibrating, musical, does not radiate (vary with posture and position) Pathologic murmurs – symptomatic; diastolic; long, loud, high pitched, harsh, radiate – infants: poor feeding (fatigue), failure to thrive, wheezing/dyspnea, cyanosis
• older child: exercise intolerance, chest pain/exertional dyspnea, syncope
• down syndrome – atrio-ventricular canal defect
• Marfan syndrome – mitral regurgitation, mitral valve prolapse
• respiratory distress: tachypnea, wheezing, clubbing nails usually takes 1 - 2 years to develop, nasal flaring, tripod position, retraction of muscles Respiratory Assessment – prenatal, perinatal, postnatal important – maternal prenatal substance abuse (cocaine) can cause fetal hypoxia or uterine contractions causing premature deliveries/respiratory complications; birth- 3 years: note APGAR score – anything lower than 7 can be indicative of respiratory distress at birth and perinatal asphyxia; meconium aspiration important; bronchopulmonary dysplasia * = note gestational age at birth, weight of premature infants (vulnerable to get BPD and need oxygen therapy) and any complications Review of Systems – skin, ear, cardiovascular, respiratory, immunity, immunization, allergies, hospitalizations, injuries, surgical history, current meds (for allergies/asthma), family/social history (eczema, snoring, upper respiratory infection, cystic fibrosis, air pollution, allergens), history or present illness; more than 6 - 10 respiratory tract infections must be noted, number of acute external media otitis and cough should also be noted; assess immune system for allergic rhinitis or allergic angioedema; chest trauma can cause respiratory issue/pneumothorax; important to note if in daycare* onset of respiratory symptoms and presence of cough and fever
• physical exam, vital signs, current growth parameters (lack of growth can be chronic hypoxemia; new onset of drop in weight or height indicates an acute problem), auscultation (can be challenging in toddler – ausculate before palpate/percussion – maximum safety and prevent stranger anxiety, have patient facing parent to feel secure – use pediatric stethoscope for 1 full minute in each field – can be loud/harsher and difficult to localize due to thin chest wall;
• listen to the apex/apices (above clavicles) and under axilla; crying can mimic or exacerbate retractions
• croup – tightening of upper airway

3. Chest wall configuration/deformities: a. barrel shaped chest = chronic respiratory destruction or poorly controlled asthma; b. pectus excavatum (hollow chest; moderate or severe can compress chest or lungs and needs to be referred*); c. pectus carinatum [pigeon’s chest – protrustion = indicative of Marfans or Noonan syndrome = genetic disorder that prevents various parts of body from normal development); asymmetry of chest wall and movement can be pneumothorax or consolidation of pneumonia Challenging pediatric patients – in any system assessment; some may be uncooperative and resistant – developmentally appropriate in infants, toddlers and young children; if child is uncooperative, provider should explore possible reasons: parents teach children not to let strangers touch them, parent should talk to child before visit to make them feel safe; fear is another factor – can be age appropriate – allow them to express fear and have caregiver or examiner explain in easy terms what the exam is about; never lie about health care visit and what may or may not be done at visit Eyes – use dolls and assess their eyes first to make child less scared

• assess alignment – strabismus use pen light; use toy to assess eye movement – allow them to move head with eyes
• red reflex symmetrically present; leukocoria “white pupil” first sign of retinoblastoma*
• infant visual acuity – fix and follow; preschool – pictures or letter cards; 6+ years = sloan letters (normal eye exam) Ears – hold otoscope like a pen – delicate, not like a hammer; straighten ear canal by pulling ear and up and head to side; brace hand at cheek to prevent sticking in ear jerk Newborn physical exam – goal: make sure patient is adequately warm; be quick – if unexposed temperature gets cold; skin mottle – sign of getting cold; can do exam under warmer; auscultation may be difficult because they may cry – can return when they’re sleeping for rest of exam
• height,weight, head circumference on every exam for infant
• HR – 90 - 160 bpm; RR 30 - 60; BP is not usually measured unless infant is critically ill
• *pulse ox is abnormal in first 10 minutes of life (60-90%) and can take the rest of day to go up to 100%; second day of life pulse ox should be normal to r/o congenital heart disease
• normal growth averages at 6 months of age: height/length 0.5-1inch/month, weight 3 - 4 ounces/week (double birth weight by 6 months and triple by 1 year), Head circumference 0.25’/month (0.8cm/month) – if not as expected, have infant return for two week f/u or sooner if concerned
• newborns can lose up to 10% of their birth weight but want to see they gained back to their birth weight by 2 weeks of age – continue breast feeding and follow up in 2 days for weight check if under – newborn at the time must gain at least 1-2 oz and is still feeding well. Then must f/u in 7-10 days to make sure they gained birth weight – if not enough lbs, need to add formula supplement with feedings
• formula fed babies don’t usually need vit D supplement**
• head to toe – feel sutures (slightly overriding and elevated but should stabilize quickly), should feel anterior fontanelle and small posterior – any asymmetries can be partial craniosyntosis
• eyes – red reflex (can be absent in patient with retinoblastoma) – useful but can also assess for slipped lenses; look at irises (coloboma is present may mean charged syndrome)
• ears – as you draw line backward from eye it should intersect the top third of that ear; look for any abnormalities in placement - r/o syndromes or renal abnormalities with ear
• mouth – put finger in and palpate top of mouth – if there’s abnormalities cleft palate – inspection and palate is high arched or may be abnormal with lack of patency inside**; check babies sucking while in mouth
• nose – suck out both nares, check for patency; if tube goes in but cant get through that patient may have coanal atresia which can cause respiratory distress
• neck
• palpate clavicles for fractures – that can happen during delivery in large bodies or bad shoulder dystocia
• heart/lungs – half of normal newborns will have a mumur in first day of life*
• **liver – normal to feel in baby – should be palpable up to 3 cm below costal margin ; normal to palpate kidneys/spleen too
• check for patent rectum = first newborn exam; can be surgical emergency if not
• inspect genitalia
• extremities – check stability of hips, inspect spine for sacral dimples/tufts
• acrocyanosis is normal and common – blue of extremities
• look at all fingers and toes; single palmar crease = down syndrome
• neurologic – infants like to be tight, not open extremities and relaxed; high flexor tone, clenched hands; look for asymmetry of reflexes***; deep tendon reflexes in knees and heel 2 - month-old check – naked with just diaper; check length, head circumference, weight; plot on chart

1. assess skin for lesions, temperature, color; 2. Back of head – round? Fontanelle – anterior is still open, posterior fontanelle is starting to close or will be closed (by three months); 3. Otoscope to assess for red reflex present to r/o retinoblastoma if not present; 4. Social smile and track object past midline – if not, referral, follows faces; 4. Check ears, otoscope pull ear up and back*; if baby gets annoyed, stop and do something else – do things that bother them the most at the end; assess mouth;
2. can they turn head side to side easily? r/o Torticollis
3. assess for heart murmurs and lungs then move down to abdomen for bowel sounds; feel for soft, nondistended abdomen;
4. assess hips for Barlow maneuver – legs out and bring together; Ortalani’s legs 90 degrees and move outward = no clicks, femoral pulses are bilateral
5. assess circulation and strength of extremities; are their movements starting to get symmetrical? And moving?
6. Anticipatory guidance to parents: does patient have social smile? Normal. Do they coo? (normal) And show pleasure or displeasure? Can you differentiate their cries? Emotional health of parents and how they are coping is also worth asking; how is

head control? Can baby hold head steady without support? When on tummy, can they lift head up? Encourage tummy time; fine motor development – cant hold objects but can open and close hands and can bring hands together (normal); feedings? Poops/pees? Car seat – rear facing*; is baby sleeping alone? Bassinett? Swaddle – if baby shows signs of rolling over, avoid swaddles or take arms out of swaddle; do not take eyes off when bathing in tub

limit adverse effects of toxic stress on brain development – chronic conditions in adulthood stem from childhood and increase over time

• establish caring relationship – children’s wellbeing greatly depends on the care received from their family and environment in which they live.
• care is best provided in a patient-centered medical or health care home that promotes holistic care of the child and family by partnering with primary pediatric health care provider – allows provider to create trusting partnership to limit effects of psychosocial adversity in childhood and improve quality of care provided over time by same provider
• caring relationship includes patient-provider relationship without bias in regard to racial, ethnic or socioeconomic differences;
• one of most important aspects of health interview is observing interaction between parent and child – analyze verbal responses and interactions to see how parent fosters child development and self-esteem and a window into child’s world; nonverbal cues provide most revealing picture of child’s demeanor and of parent-child relationship - a child who is withdrawn, refuses to make eye contact or consistently stressed when communicating exhibits signs of strain in environment – alert PCP to communicate concern to family and provide support, referral – children often mirror emotions of adults around them
• children and media – parents should monitor social media, gaming, cell phone activity for potential impact on emotional health - too much can cause developmental delay or speech expressive delay in infant; heavy parental use of mobile device is associated with fewer verbal and nonverbal interactions between parent and child
• promote opportunities for children and adolescents to contribute to health care decisions creates child-centered approach to care that empowers and enables child within family – a mode proposes: irrespective of age, the child is listened to; child is supported in expressing views; child’s views are taken into account, child is involved in decision making process, child can share power and responsibility in decision making
• cultural humility – a change in overall perspective around diversity and increasing awareness of power imbalances in provider-patient relationship – recognize language barriers and effectively use interpreters, explore parental beliefs and their impact on child, build on family strengths, recognize and explore use of cultural beliefs/alternative therapies; as PCP, understand how your personal values and beliefs influence care, alter practices to eliminate cultural disparities
• effective communication – learn to make eye contact when child is interested and avoid eye contact when child is fearful – direct your attention to parent to allow child to adjust to environment; explaining exactly what you are going to assess during exam will decrease anxiety and build trust – “talk through” assessment and findings and reassure
• children 6 to 11 years of age can be directly interviewed and participate in care; adolescents should always be interviewed separately from parent Interviewing: 1. Question indirectly to encourage children/adolescents who are reluctant to discuss feelings; engage young child “ I am going to tell you a story …”; 2. Pose scenarios for young child, “what would you do if…” for older school age child/adolescent “How would you feel if?”; 3. Begin with less threatening topics and move slowly to more sensitive topics “tell me how things are going at school” vs “has anyone hurt you?”’ 4. State your expectations clearly – “ I need you to be very quiet so I can listen to…” to child…. To adolescent say “ to take care of you, I need you to tell me..”; 5. Do not offer a choice to child or adolescent when in reality there is no choice; 6. Use “I” when speaking “I need to ask you this question because I want to help you” vs “you must tell me what is going on” – avoid using YOU which creates defensive atmosphere;

7. Ask young child to draw picture of family – reveals feelings/captures child’s attention Quiet to active approach to Physical examination – begin with parts of exam that require child to be quiet or silent “pulse and respiratory rate, auscultation of heart sounds, respiratory sounds and abdomen”; assess genitalia and cranial nerves before more invasive exam of ears and mouths and before measuring height, weight, temp, blood pressure.

• preterm and newborns: begin with infant swaddled on exam table or parent’s arms to maintain body temperature; can auscultate cardiac/respiratory sounds before disturbing infant – then have patient on table and remove everything but diaper – observe symmetry, strength, coordination, overall appearance, skin color, breathing pattern, degree of alertness
• infants and up to 6 months of age: until 6 months of age, infants are effectively assessed on exam table to provide stable surface; calm, gentle approach to avoid frightening child
• children 6 months to 2 years: with infants 7-9months of age, PROGRESSIVE approach to eye contact is required due to stranger anxiety; offer puppets or toys to child to demonstrate parts of physical exam; once infant can sit normally around 6 - 8 months of age, exam can be in parent’s lap to decrease fear and stranger anxiety – clothing should be removed gradually from “quiet” to active; can keep in parent’s lap whole time if needed
• young children: by three years of age, most children still apprehensive but can make eye contact and separate briefly from parent; observe their ability to be comforted, evaluate their response to environment and level of social interaction and relationship with parent; young children respond best to slow, even, steady voice; give child time to warm up to situation before undressing them = modesty; age 3 - 5, give clear directions allow them to respond; enjoy games, drawing, role playing the physical exam with dolls or stuffed animals
• children 6 - 11 years: benefit most from talk through approach; interested in learning about their bodies/health and form a body image of themselves, becoming more independent; allow child to participate and respect modesty; a “head to toe” assessment with child on exam table is most effective during middle childhood**
• adolescent: approach used should be based on child’s developmental stage rather than age* because develop during early, middle, late adolescent proceeds unevenly and vary among 11 to 18 year olds; respect and confidentiality needed to develop trusting relationship; parental input is important but adolescent should be interviewed and examined separately from parent Chapter 2 Assessment Parameters
• growth is most dynamic aspect of childhood; in early years, height and weight measurements are key indicators of health; abnormal progression of weight gain and height parameters is often first indicator of abnormalities in growth and maturation patterns; growth normally proceeds in a predictable pattern during childhood from “cephalocaudal (head to tail)” and “proximodistal (near to far)”; plotting serial measurements regularly on standardized growth curve for age and gender is reliable method of monitoring growth and essential for comprehensive well-child care
• accurate assessment of gestational age in newborn begins with prenatal and birth history; infants can be classified by gestational age as “term infant, preterm infant and postterm infant”
• head circumference: routine part of growth assessment in first 2 years of life – taken with measurement tape at point of greatest

• height: most stable measurement of growth and maturation; linear growth is genetically predetermined and therefore adult height generally occurs within predictable range; linear growth often occurs in spurts followed by long quiescent periods in which no growth occurs; increase in appetite and sleep sometimes before growth spurt; infant/toddler, place on flat surface/exam table with measuring device Immunization chart Birth – 1 st^ dose of Hep B 1 month – 2 nd^ dose of Hep B 2 months – 2 nd^ dose of Hep B, 1 st^ dose of rotavirus, 1 st^ dose of DTaP (diphtheria, tetanus, & acellular pertussis), 1 st^ dose of Hib (haemophilius influenza type b), 1st^ dose of PCV13 (pneumococcal conjugate), 1st^ dose of IP (inactivated poliovirus) 4 months – 2 nd^ dose of rotavirus, 2 nd^ DTap, 2 nd^ Hib, 2 nd^ PCV13, 2 nd^ IPV 6 months – 3 rd^ dose of hep b, can get RotaTeq (3rd^ dose series of rotavirus vs Rotarix which is only 2 doses at 2 and 4 months), 3 rd^ dose DTaP, 3 rd dose PCV13, 3rd^ dose IPV, annual vaccination of influenza, 3rd^ dose Hib, Hep B – birth, 1 - 2 months and 6 months- 18 months Rotavirus – 2 months, 4 month, 6 month DTaP – 2 months, 4 months, 6 months, 15 - 18 months, 4 - 6 years Hib – 2 months, 4 months, 6 months, 12 - 18 months PCV13 – 2 months, 4 months, 6 months, 12 - 15 months IPV – 2 months, 4 months, 6- 18 month, 4 - 6 years Influenza (yearly) 6 months – 2 doses given at least 4 weeks apart recommended for children 6 months- 8 years for the first time getting flu vaccine MMR (mumps measles rubella) – 12 - 15 months, 4-6 year Varicella – 12 - 15 months, 4 - 6 years Hep – A - 12 - 23 months (2 doses needed for lasting protection, 1 st^ dose.. then second dose given 6 months after first dose