Transcript 5 Respiratory assessment of a child

General Paediatric
Assessment
Robyn Smith
Department of Physiotherapy
UFS
2012
What is different about working
with children and adults?
Why do we find working with children and
babies so daunting??????
Infection control measures
To prevent the spread of
infection to already susceptible
patients the following is to be
done:
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Children are particularly
susceptible to infection
Wash your hands between
patients and spray with
alcohol/ Hibitane spirits
Remove your watch and rings
Clean your stethoscope with
an alcohol swab between
patients
Where a mask and gown
where indicated
Subjective Evaluation
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Interview
mother/caregiver/child
Use ‘tolk” where necessary
If caregiver not available or
child is unable to communicate
not possible rely on admission
history available in the white
book in patient file
Interview Dr and other
multidisciplinary team
members
NB: Essential to get a
comprehensive patient history
prior to observation physical
examination
Why is an effective history so
important ???
Interview: questions to ask the
caregiver
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Date of admission?
Reason for admission?
How long was the child sick prior
to admission, what signs and
symptoms did she/he have?
Birth history relating to gestation,
birth weight, method of delivery,
Apgar scores?
Any neonatal complications
Child current developmental
status
Caregiver have any known
medical conditions, any TB
contacts at home?
Previous illness’ e.g. pneumonia,
bronchitis or TB resulting in
previous admissions. Date of
admissions and duration?. Was
TB treatment completed ? Health
after discharge?
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Previous surgical procedures? If
so what was done? Date?
Any familial history of Asthma,
haemophilia or other genetic
conditions
Any known neurological
conditions or problems?
Any other children at home? What
are their ages. Information on their
health developmental status?
Immunizations up to date?
Socio economic statuses e.g.
where are they residing, running
water and electricity? Are the
parent employed?
Where applicable are they
receiving social grants?
Medical history pertaining to
current admission
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Medical reason for current
admission?
Does the child have a productive
cough?
When is the child coughing?
Are there factors that exacerbate
the coughing e.g. positioning?
Paroxysmal coughing spells?
Coughing worse during a specific
time day?
If the child is productive, what is
the appearance of the sputum in
terms of colour, smell and
viscosity?
Does the child have a tendency
towards recurrent upper
respiratory tract infections? E.g.
croup and bronchiolitis
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Is the child dyspnoeic?
 Is there shortness of breath at rest
(grade 4), with activities of daily
living (grade 3), with light exertion
(grade 2) with activities e.g.
running (grade1) difference
between dyspnoea and
tachypnoea
 Reasons for dyspnoeic episodes
e.g. exercise, emotional factors or
stress related.
 Is the child as active as other
children his age or as his other
siblings ?
Medication
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What medication taking
prior to admission?
Medication currently
being given? Available on
prescription chart in
patient file
List all the medications
currently being given and
the reason for their
administration e.g.
Panado (fever & pain)
Observation of vital signs
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Normal range is determined by age
Make use table available in notes
Make a copy and keep in clinical file
Get information from the vital sign sheet in file:
HR
BP
RR
SaO2
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Use mobile SaO2 monitor -give you HR and SaO2.. Make sure
values you use have been taken in the last 30 min.
WHY??? To ensure still relevant. Also look at vital sign trends over
48 hour period.
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NB If the child is on oxygen do not just stop the therapy or remove
the facemask/ nasal prongs. Without monitoring SaO2 !!!!!!!!
CXR
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Are any available? Hard copy
or comuterized
Date CXR was taken on?
AP/ lateral view
Evaluate and compare 2 latest
CXR’s. WHY? Monitor
changes –improvement or
deterioration
Any areas of abnormality or
pathology noted clearly
→ Reading and interpreting CXR
is a skill developed over time.If
you are unsure of what you are
seeing on the CXR ask the
doctor/ qualified to look at the
CXR’s with you.
Objective Evaluation
Once all the above information has been
collected then you may proceed with the
objective evaluation
General observations
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Weight is to be described us normal, underweight or overweight.
Percentiles may also be used.Possible reasons for the condition are
also to be given e.g. underweight due to chronic malnutrition etc.
Skin colour and condition is to be described.
Oedema. Generalized or area specific. Not reason for possible
oedema e.g. low albumin or cardiac failure in generalized oedema.
Cyanosis. Peripheral (fingers and toes) or central 9mucosa of the
mouth)
Clubbing of the fingers and toes (may be indicative of chronic heart ,
but particularly chronic lung conditions e.g. Bronchiectasis)
Indwelling devices e.g. IVI (note what is being administered IV),
catheter, ICD, central or arterial lines in PICU and Portovac drains in
surgical patients.
If ICD is present note how much fluid has drained, is
bubbling/swinging, type fluid e.g. clear/bloody
Note the wound location and condition in a surgical patient.
Respiratory Examination
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Chest shape:
Symmetrical or asymmetrical
Sternal recession sub and
intercostal costal recession
Is the chest shape normal or is
it deformed e.g. barrel shaped
Pectus carniatum or pectus
excavatum
Does the child have any signs
of respiratory distress e.g.
grunting, nasal flaring,
recession
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Breathing pattern:
Paradoxal breathing
Apical or diaphragmatic
breathing pattern
Any distress noted or is the
child breathing comfortably?
Respiratory rate ( described as
normal, bradypnoeic or
tachypnoeic relevant to the
age norm)
Does the child breathe through
his nose or mouth
Effect of positioning on
breathing pattern
Chest deformities
Signs of respiratory distress
Chest wall recession :
Respiratory Examination
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Cough:
Productive or unproductive?
Paroxysmal coughing spells?
Does the child have an
effective cough? Can he clear
his secretions successfully? If
not nasal suctioning will need
to be considered.
Does coughing result in
respiratory distress?
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Sputum:
Colour of secretions? e.g.
yellow indicative of a lung
infection, blood stained may be
indicative of haemoptysis.
Smell? foul smelling
secretions are often found in
cases of lung abscess’ or
severe infections
Viscosity? Loose or sticky
Amount? Give a measurable
indication e.g. tablespoon or ½
sputum mug per day.
Respiratory Examination
Auscultation:
 Auscultate accurately
over all the lung fields.
Compare the left and
right sides.
 Note the location of any
abnormal breath sounds
e.g. course crepitations
right basal lobe.
 Other abnormal breath
sounds e.g. transmitting
upper respiratory tract
sounds e.g. stridor or
snoring, amphoric
breathing, fluid etc
NB:
Always ask patient to
cough prior to
auscultation. Why?
To clear secretion in
upper respiratory
tract
Respiratory Examination
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Chest expansion:
In babies and smaller
children it is not
necessary to palpate, one
can simply observe the
chest expansion.
In older children chest
expansion may be
measured with a
measuring tape or
palpated.
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Posture:
Note any abnormalities
e.g. kyphosis or scoliosis
Shoulder girdle elevation
and tense shoulder girdle
musculature should also
be noted.
Positioning:
 In what position is the
patient sitting/lying in
his/her bed
Neurodevelopmental Assessment
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Where possible age appropriate
developmental milestones are to
be evaluated.
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everything appears normal not
necessary to do a full neurological
evaluation.
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Where one is suspicious of
neuroldevelopmental delay or
suspect neurological problems a
full neurological evaluation is to be
done.
In case of patients with multiple
system involvement may need
more than one session to
completely and comprehensively
assess patient.
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The following neurological
parameters also need to be
evaluated:
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Deep tendon reflexes e.g.
patella tendon, Ta, biceps and
Brachioradialis
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Active and passive muscle
tone
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Abnormal reflexes e.g.
Babinski and clonus
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Primitive reflexes e.g. ATNR,
rooting, startle, morro and
sucking reflex etc. Are normal
in a baby but should be
integrated by 6/12 months. If
these reflexes persist beyond
this period it is abnormal
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Functional abilities and
inabilities
Other systems
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Vision: focus and following
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Hearing a child should be able
to localize sound e.g. bell or
rattle from 4/12 months.
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Speech and language
development appropriate for
age
Feeding:
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Is the child feeding orally or via
NGT? If the child is fed via a
NGT does he have any
swallowing problems? e.g.
prevalent in CP children
Is the child where appropriate
eating normal table food? e.g.
abnormal that a 2 yr old is only
eating soft food.
If the child is failing to thrive
and undernourished is the
child being seen by the
dietician
Musculoskeletal system
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Can be observed
during active
movement and play
 Passive ROM and
muscle strength and
lengths can be
evaluated specifically
where one suspects a
particular problem
e.g. fracture, joint
bleed,hemiplegic arm
leg, GBS
Exercise tolerance
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Tested in children older than
two years, and where they are
well enough to do
cardiovascular activities.
The resting pulse is taken
The child is then allowed to do
some cardiovascular exercise
e.g. game, ball activities or
running until tired.
The pulse is then taken again.
The child is then allowed to
rest and the pulse is taken
again after 2 minutes.
If cannot measure exercise
tolerance specifically you may
still observe the child's pulse
after turning, sitting up over
side of be etc.
Also evaluate/ note:
 Respiratory rate
 Pulse rate and rhythm
 Use of accessory muscles of
respiration
 If there is an increase in the
frequency of coughing or the
severity of wheezing were
applicable
Function (ICF)
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Look at function relevant to age
 In older children you may ask him/her what they
would like to be able to do now, that they could
have done before. Or ask mother.
 When setting functional goals be realistic
 Make use of the diagnosis and prognosis to
determine whether your intervention is
preventative, promotive, curative or rehabilitative
References:
 Images
curtsey of GOOGLE
 Paediatric dictate UFS (2009)