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do not look upon them as 'cases' only. • Always believe what the mother tells, but try to be realistic about the importance the symptoms she is mentioning. • If he is not well nourished and not properly immunized, take the opportunity of a minor illness to prevent major diseases by advice and vaccination. • Use communication skill (APAC: Ask ,Praise, Advice and check ones understanding) 2.3 Physical Examination: A) Principles and techniques of physical examination: The principles and techniques of physical examinations in the case of a small children you should make it habit to undress the child and examine the whole child. To examine the whole body we start with the head and end at feet in older children and adults. In order not to frighten small children it is best to examine things that are uncomfortable or frightening to them last so as not to loose their cooperation. This means the last thing to do in a child is auscultation of the heart, inspection of the ears with an auriscope and inspection of the throat with a throat stick. We use our eyes, ears and hands in addition to a few special items of equipment to perform the physical examination. Pediatric Nursing and child health care 19 1. Chronological steps of physical examination: This consists of three parts: a. General appearance: This is what you observe while examing your patient The mental state of the patient • is he acting normally? • is he confused? • is he drowsy, stuporous or even comatose? etc. The general physical state of the patient • general state of health • weight and body build • colors • respiration • signs of dehydration • edema b. Vital signs:- These are: • Temperature • Pulse rate • Respiratory rate • Blood Pressure Pediatric Nursing and child health care 20 The temperature: All sick children should have their temperature measured (rectally, orally, and axially) The normal temperature is about 37• C. A temperature below 36• C is abnormally low and may be a sign of infection in a small baby. A temperature above 37.5• C is fever. When there is a fever it usually means an infection is present and you must try to locate the site of the infection and decide whether it needs treatment and with what. The pulse:- The pulse can be felt and count in children radically for fifteen seconds multiply by four. In the infant it is sometimes easiest to count the heart rate with the stethoscope apically. Normal pulse rate: • babies 100-140 beats per minute • children 80-100 beats per minute In fever the pulse rate generally rises. In dehydration the pulse rate may be very rapid and weak. The respiratory rate:- Normal respiratory rate: • < 2 month ,< 60 breath per minute • 2-12 months < 50 breath per minute • 12 month-5years< 40 breath per minute Pediatric Nursing and child health care 21 A rapid respiration of 60 or more in a small, feverish child is a very good indicator of pneumonia c. Anthropometric measurement: • Weight • Height/Length • head circumference • mid-arm circumference • Chest circumstances Weight: The best way to assess nutritional status is to take body weight. The weight should be charted on a weight chart. Most weight charts have three curves. The upper line shows the average weight of healthy well nourished children and this is an ideal growth curve. The middle shows the lowest weight that is still considered to be within limits of normal and the weights on this line are 80 % of the weights on the upper line. The lower curve shows 60 % of the ideal weight. According to Gomez classification any child whose weight is below this line is marasmic. Height: Height (length) is also used but more difficult to measure than weight especially in infants. It is a less sensitive measure than weight because it does not decrease during malnutrition, it only stops increasing. This means that height is Pediatric Nursing and child health care 22 not affected much for the first six months in malnutrition and is therefore more a measurement of longstanding malnutrition. d. Evaluation of various body system: For various body system evaluation we use our • eyes for inspection • hands for palpation • ears for auscultation • HEENT (hair color and texture, pallor, oral lesions, ear discharge, eye discharge, neck
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