 Hi everyone, it's Leah, your lead course instructor here at Advanced E-Clinical Training. And today's lesson is all about the pediatric assessment. Now the reason why we have a whole separate assessment for infants and children is because they are a whole sub-specialty of medicine that is kind of unrelated to adults. They have different norms, different ways that we assess things, different things that we look for. So that's why we wanted to just do a whole lesson just on the pediatric and infant assessment. Oh, right. So the pediatric assessment. So first, you want to start with a general observation of the child or the infant. You want to do a general appraisal of the child's appearance, their behavior, and you really want to look for any signs of abuse. So how does the child look? Are they in clean clothes or are they in dirty clothes? What is their state of hygiene? Is their hair brushed or are they cleaned themselves? And again, how are they dressed? Is it appropriate for the weather? If it's cold and snowing outside, do they have a coat? Do they have gloves? Things like that. So this is what you're going to look for in the general observation. Now just moving on to any signs of abuse. Now we're going to cover signs of abuse more in depth in another lesson coming up here very shortly, but just for right now, signs of abuse may be incompatibility of the story and the injury if there is an injury. So, you know, if the parent said that a child was jumping on the bed and fell off the bed and broke their arm, but the child is not old enough physically to be able to jump up and down on a bed or stand by themselves, we would know that would be incompatible. Inconsistent stories between the child and the caregiver. So the child is saying they were hurt one way and then the parent is saying they're hurt another way. Another sign of abuse could be injuries that are extremely unlikely given the children's development for their child's development. And then injuries that should have been avoided with basic parental supervision, such as a lot of times, you know, in the emergency room, we see things, children getting burnt with candles, hot wax. So, you know, generally you should not have candles burning. If you have a toddler or a child who's moving around in the hell because they're easily able to, you know, get up there and pull that down and burn themselves. So these are the general signs of abuse. But again, we're going to cover this more in depth in another lesson coming up very, very soon. So next, we move on with the pediatric assessment to their health history. So this is similar to a health history you would get from an adult. And you will obviously have this discussion with the parent or the caregiver or the adolescent, because a child of adolescent age, they are able to participate in their care and participate in their assessment as well. So during this general health history, please make sure to assess family history, medications, of course, if there are any allergies, you want to talk about the child's personal health history, if they have any chronic health conditions. Their birth history is something that is important to know as well, like whether the child was born premature or they spent any time in the NICU because this would be an indication that there were maybe a birth injury or if they were premature, their lungs didn't fully develop. And so this might predispose the child for some health conditions as they were growing. And then also you want to always ask about immunization. So are they up to date with, you know, are they up to date with all of their immunizations? And so here, if you just click on this link here, you can go over to the CDC. And this will give you a very nice overview of all the vaccines, vaccinations that children should have and at what age. All right. So moving on here. So during the health history or the assessment, we're going to be interviewing the child and adolescent as well as the parents. So but it's really important to understand that preschool children and other older children can be included in their interview. But it is important to understand that we must be age-appropriate. So, you know, if we're talking to a toddler, we're going to speak to an adolescent in a different way. So be age-appropriate. You might want to use age-appropriate toys and questions when interviewing the child or the adolescent. You definitely want to establish a rapport. So showing interest in the child and what the child has to say, both helps to make the child and the caregiver feel more comfortable during the assessment. And you also want to be honest when answering the child's questions, because this will help to build trust. Another thing you really want to do during your assessment is listen. So you want to listen to the child's comments and you want to listen to them attentively. And the child should be made to feel important in the interview as well. Now, with adolescents, it's a little bit different. They're older children, you know, mid-teen, teen age. And so they might feel more comfortable talking to you in private instead of in front of their parents. Now, this can be kind of a dicey situation. Sometimes we have to get the parent's permission to talk with the child. Alone and then, you know, at this point, the child or the adolescent, I should say, would feel more comfortable talking to you and maybe to divulge information to you that they would not have if their parent was sitting next to them or in the same room. All right. So of course, during any type of assessment here, we are going to have to do vital signs. Now, the order in which you do your vital signs is so, so, so important, especially with small children because they are going to get so easily upset when we try to do their vital signs. So first, you want to count the respirations before even touching the child because this is something that you can do and they don't even really know you're doing it. You're just counting their respirations so they should be calm while they are sitting next to their parents or their caregiver. And so that's a good time to then do the respirations. Of course, you don't want to count respirations when they're crying or they're heavily upset. So that's why we're going to do this first. Next, you want to measure their apical heart rate. So their apical heart rate is just under the left side of their breastbone and almost underneath the arm. So you want to count a full 60 seconds. If you can't get an apical heart rate, that's OK. You can always just try to feel their pulse and count their heart rate. And then next, you can take the child's blood pressure. Now, a BP is not always indicated for children. And so it is not always done on routine. So only do the blood pressure if it is necessary. And then lastly, you want to take the children's the child's temperature. Now, small children and infants will get very upset when you try to take their temperature. And then they may begin to cry. So that's why you want to do this vital sign last. Now, here's just a little chart on the vital signs. Normal vital signs by age for respiratory heart rate and blood pressure. Because, as I said, in the beginning of the lesson, it is different than a norm for an adult. And the norm changes from the time they are in infant and as they grow. So I'm not going to read all of these to you because you can read yourself. But these are the norms for children by their age for respiratory, their heart rate and by blood pressure. All right. So moving on to temperature. Again, the temperature is part of their vital signs. It should be either recorded in Celsius or Fahrenheit and that should be recorded just based upon whatever the policy is for your health care facility. You can do this orally, rectally or axillary. And again, a normal world temperature range is 36.4 to 37.4 Celsius, which is 97.6 to 99.3 Fahrenheit. Now, a rectal temperature is going to be slightly higher than an oral, but it also is the most accurate. So keep that in mind. Now, the pain assessment, of course, we're always going to assess pain on any assessment, whether it's an adult or a child. In the adult pain assessment, we ask the patients, you know, are you having any pain today? Could you please rate your pain level on a scale of zero to 10, zero being no pain at all, 10 being the worst pain that you've ever had. But children and infants, they can't do this, obviously. They can't describe their pain that way. So there are several different pain charts that have been modified to help so we could help quantify what a child's pain level is. We can see that right here. These are different pediatric pain scales. We have the cries pain scale. Because obviously babies cry, this is the quickest and the easiest way to assess potential causes of their crying. So cries is an acronym and crying requires O2, increased vital signs, expression, sleeplessness. So each of these is a variable scale of zero to two. So if the baby is crying, it's zero. And you can see here, inconsolable is the two. They're highly pitched crying, it's a one. And if they're not crying, it's a zero. I don't see this one used very often. I have to say actually, we don't, I've never really actually even used this one, but I just thought I would let you know that it's here, you might see it in your practice. We have the flack pain scale and this is for children ages two to seven years old. Again, flack is a mnemonic, I'm sorry, an afterman and it stands for face, legs, activity, cry, and consolidability. Like the cries pain scale, this set of variables is scored on a scale of zero to two. Next, we have the faces pain scale and this is the most popular one. And the faces scale is the most common for children three and older and it uses six drawings of faces to help the patient break their pain on a scale of zero to five. So basically you will, if you are using this pain scale and the facility that you're working in, they'll give you a chart, you have a chart that'll have faces on it that you will then show to the child and ask them, what kind of pain are you having? And they will be able to point to one of those faces. And then there's the outer pain scale and this is for children three to 13. It's kind of like the faces scale but uses photographs to help them break their pain again from zero to 10. But like I said, the faces pain scale is the most popular and the one that I've seen most often. All right. So moving on to their physical growth and development. Now, when assessing a child's physical growth and development, there are several measurements that we need to take, including length and height. Now, the difference between length and height is it's referred to length when the child cannot stand upright, but once the child can stand upright, we refer to that as their height, weight. We always wanna weigh the child. So an infant can be weighed nude so you wanna make sure all their clothes are off, their diaper is off and they're lying nude on an infant scale. When the baby is old enough to sit, the child then can be weighed while sitting and then again, once the child is able to stand, they can stand on a scale. Head circumference. This is a good one as well. So this measurement is completed in younger children to ensure proper development. So a paper or a plastic tape measure is placed around the largest part of the head just above the eyebrows and around the most prominent part of the back of the head. And when collecting these measurements, we want to make sure to plot them on a proper growth chart so we can see how the child is growing and how they compare to other children of the same age. So these, if you go to the CDC here again, using this link right there, you can see the growth charts that we should be using and plotting on. Right, so I just wanted to touch a little bit on length and height again. As I said, length is measured when the child cannot stand and so you wanna measure the child in a recombinant position, meaning lying down on their back. And this is the correct measurement to use for infants younger than 24 months of age or children aged 24 to 36 months who cannot stand unassisted. So a baby's length is measured from the top of their head to the bottom of their heels. And a lot of times this takes two people to do this, to do this measurement. An accurate length measurement also requires a calibrated length board with certain features for measuring length in this type of position. So the child should be placed on their back in the center of this length board so the child is lying straight with their shoulders and their buttocks flat against the measuring surface and both legs should be fully extended and the feet should be flat against the foot piece. So as you could see even with this description, it probably will take two people to do this measurement. Here's a YouTube video that you could check out. If you click on this link, it'll take you there and just show you a nice video on how that should be done to do the length and the height. Now, of course, as I said, the standing height of a child is measured with the height board or for the most accurate height measurements, the board should be placed on a flat smooth floor. So very similar to like when you've gone to the doctor and they do your annual physical and you get your weight and your height. So doing a height there for an adult is very similar to doing the height for a child. And again, you can click on this link and I'll show you a nice little video on how to do that. All right, so weighing. As I said before, an infant is weighed nude, lying on an infant scale. When the child is old enough to sit, the child can be weighed sitting on the scale but fibers and clothes have to be removed. Head circumference, as I said, this measurement is obtained in younger children to ensure proper development. This is how we place the plastic tape or the measurement around the largest part of the head, just above the eyebrows and around the most prominent part of the back of the head. Next, we wanna move on to cognitive development. Now, cognitive development is something that will be assessed during a pediatric assessment. So cognitive milestones represent very important steps forward in a child's development. And so this is where you assess your patient's ability to communicate. Their vocabulary, their gestures. You also wanna take note of how they think or how they're problem solving. And again, here is a nice little link that you can click on and you can see all of the cognitive developmental milestones that are considered norms for a growing child. Psychosocial development. So we also want to assess the child's communication skills, how they play, what their temperament is like. Now, Eric Erickson was an ego psychologist and he developed one of the most important and influential theories of psychosocial development. And this theory is based on biological, psychological and social factors that a person may encounter during their life. And so here are Eric Erickson's stages of psychosocial development. Stage one, trust versus mistrust. Stage two is autonomy versus shame and doubt. Three is initiative versus guilt. Stage four is industry versus inferiority. And then identity versus confusion from the teen years to 18 years old. And so stage one through stage five is most appropriate for the pediatric assessment of course, stage six, seven and eight. So happen, but we're not assessing that because we're generally, we're not gonna see pediatric patients after they turn 18. And here is a link for you to see more about Eric Erickson's stages of psychosocial development a little bit more in depth. And so that concludes it here for our pediatric assessment. If again, you know, you always know if you have any questions, if you have any concerns, if you need to clarify anything, you know, you can always email me schedule office hours with me as well. And thanks so much for coming and listening.