Advanced Pediatric Assessment

| C h i o cca |
Advanced Pediatric Assessment

Advanced
Second Edition
| E l l e n M . C h i o cca | MSN, CPNP, APN, RNC-NIC
N
Pediatric

ow in its second edition, Advanced Pediatric Assessment is an in-depth, current guide to pediatric-focused assessment,
addressing the unique anatomic and physiological differences among infants, children, and adults as they bear upon pediatric
assessment. The second edition is updated to reflect recent advances in understanding of pediatric assessment for PNPs, FNPs,
and other practitioners, as well as students enrolled in these advance practice educational programs. This includes a new chapter
on the integration of pediatric health history and physical assessment, a Notable Clinical Findings section addressing abnormalities
Assessment
and their clinical significance at the end of each assessment chapter, updated clinical practice guidelines for common medical
conditions, updated screening and health promotion guidelines, and summaries in each chapter.
Based on a body-system framework, which highlights developmental and cultural considerations, the guide emphasizes the
physical and psychosocial principles of growth and development, with a focus on health promotion and wellness. Useful
features include a detailed chapter on appropriate communication techniques to be used when assessing children of different
ages and developmental levels and chapters on assessment of child abuse and neglect and cultural considerations during
assessment. The text presents nearly 300 photos and helpful tables and boxes depicting a variety of commonly encountered
pediatric physical findings, and sample medical record documentation in each chapter.
New t o t he S eco n d E ditio n :

| E l l e n M . C h i o cca |
A chapter on the integration of pediatric health history and physical assessment
Notable Clinical Findings addressing important abnormalities and their clinical significance in
each assessment chapter
Updated clinical practice guidelines for common medical conditions
Updated screening and health promotion guidelines
Accompanying student case study workbook (to be
purchased separately)
Also Available!
K e y F eat ure s :
Focuses exclusively on the health history and assessment Study Guide to Accompany
of infants, children, and adolescents Advanced Pediatric Assessment,
Provides the comprehensive and in-depth information Second Edition
needed by APN students and new practitioners
A Case Study and Critical Thinking Review
to assess children safely and accurately
ISBN: 978-0-8261-6177-2
Includes family, developmental, nutritional, and child
mistreatment assessment
Addresses cultural competency, including specific
information about the assessment of immigrant and Study Guide Set
and refugee children ISBN: 978-0-8261-2862-1
Fosters confidence in APNs new to primary care
with children
Second
Edition
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Advanced Pediatric
Assessment
Springer Publishing Company

Ellen M. Chiocca, MSN, CPNP, APN, RNC-NIC, is a clinical assistant professor in the School of Nursing at DePaul University.
She received a master of science degree in nursing and a postmaster nurse practitioner certificate from Loyola University, Chicago,
and a bachelor of science degree in nursing from St. Xavier University. Prior to joining the faculty at DePaul University, she taught
at Loyola University, Chicago, from 1991 to 2013. Ms. Chioccas clinical specialty is the nursing of children. Her research focuses
on how various forms of violence affect childrens health. She is certified in neonatal intensive care nursing and as a pediatric
nurse practitioner. In addition to teaching at DePaul, Ms. Chiocca also continues clinical practice as a pediatric nurse practitioner
at a community clinic in Chicago. Ms. Chiocca has published more than 25 journal articles and book chapters, and is also a peer
reviewer for the journal Neonatal Network. She is currently pursuing a PhD in nursing.

Advanced Pediatric
Assessment
Second Edition
Ellen M. Chiocca, MSN, CPNP, APN, RNC-NIC

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Chiocca, Ellen M., author.
Advanced pediatric assessment / Ellen M. Chiocca. Second edition.
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I. Title.
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To the two great loves of my life
My daughter, Isabella Grace Pan Di Chiocca, for bringing me such great joy,
and for being the brilliant, beautiful, wonderful person that you are.
My husband,
Ralph Zarumba, the great love of my life,
whose intelligence, unlimited kindness, generosity,
and patience never cease to amaze me.
And to my father
Frank Joseph Chiocca, Jr.
(19391987)
RIP


Contents
Prefaceix 14. Assessment of the Ears291

Acknowledgmentsxi 15. Assessment of the Eyes317
16. Assessment of the Face, Nose, and Oral
UNIT I: THE FOUNDATIONS OF CHILD HEALTH
Cavity341
ASSESSMENT
17. Assessment of the Thorax, Lungs, and
1. Child Health Assessment: An Overview3
Regional Lymphatics365
2. Assessment of Child Development and 18. Assessment of the Cardiovascular
Behavior19 System383
3. Communicating With Children and 19. Assessment of the Abdomen and Regional
Families47 Lymphatics407
4. Assessment of the Family61 20. Assessment of the Reproductive and
5. Cultural Assessment of Children and Genitourinary Systems429
Families73 21. Assessment of the Musculoskeletal
UNIT II: THE PEDIATRIC HISTORY AND PHYSICAL System451
EXAMINATION 22. Assessment of the Neurologic System473
Section 1: Gathering Subjective Data UNIT III: ASSESSMENT OF CHILD MENTAL HEALTH AND
6. Obtaining the Pediatric Health History97 WELFARE
7. Assessing Safety and Injury Risk in 23. Assessment of Mental Disorders in Children
Children119 and Adolescents509
Ellen M. Chiocca and Claire Sorenson 24. Assessment of Child Abuse and
Neglect523
Section 2: Gathering Objective Data
8. The Pediatric Physical Examination151 UNIT IV: SYNTHESIZING THE COMPONENTS OF THE
9. The Health Supervision Visit: Wellness PEDIATRIC HEALTH ASSESSMENT
Examinations in Children175 25. The Complete History and Physical
10. Assessment of Nutritional Status193 Examination: From Start to Finish545
11. Assessment of the Neonate209
Appendix A N
ormal Vital Signs in Infants,
12. Assessment of the Integumentary
Children, and Adolescents 555
System243
Appendix B CDC Growth Charts 561
13. Assessment of the Head, Neck, and Regional Index573
Lymphatics271


Preface
Pediatric health care experts agree that the health adolescents, and continues with a brief survey of
care needs of children are vastly different from growth and development, a discussion of the com-
those of adults. From infancy through adoles- munication skills required to work with children,
cence, a child experiences many dramatic physi- a focus on the parentchild relationship, and gen-
ologic, psychosocial, developmental, and cognitive eral strategies for obtaining the child health his-
changes. Thus, it is critical for the pediatric health tory and performing the physical examination.
care provider to possess specialized knowledge and Chapter 2 provides a detailed overview of the
skills to accurately assess children during health general principles of growth and development,
and illness. Concepts related to the health assess- including a discussion of selected developmental
ment and physical examination of adults cannot be theorists. Both physical and psychosocial growth
universally applied to the care of children; children and development are discussed, including gross
are not simply little adults. and fine motor, language, psychosocial, and cog-
The goal of the second edition of Advanced nitive development. Detailed tables list normal
Pediatric Assessment mirrors that of the first: to growth and developmental milestones from birth
emphasize the uniqueness of children when con- through adolescence, as well as developmental
ducting a health assessment and to show that, red flags and selected developmental screening
depending on the childs age and developmental tools. Chapters 3, 4, and 5, which are devoted to
stage, the approach to obtaining the history and communication with children, family assessment,
physical assessment can vary dramatically. Because and cultural assessment of children and families,
this book focuses only on infants, children, and complete the unit.
adolescents, the physical, psychosocial, develop- Unit II, The Pediatric History and Physical
mental, and cultural aspects of child assessment Examination, focuses on obtaining subjective
can be addressed in greater detail than is possible and objective data specific to the child health
in across-the-life-span textbooks. Consequently, examination. Chapter 6 is devoted to the pedi-
this book has a dual focus: to serve not only as a atric health history and Chapter 7 to assessing
course textbook in advanced practice nursing pro- the safety of the childs environment. Chapter
grams, but also as a reference for practicing pediat- 8 details the specifics of the pediatric physical
ric health care providers. examination, including assessment techniques;
The second edition of Advanced Pediatric developmental approaches to examining infants,
Assessment is divided into four units. Unit I, children, and adolescents; and sequencing of the
The Foundations of Child Health Assessment, physical examination according to age and devel-
comprises five chapters that provide readers with opmental level. Chapter 9 focuses on the well-
the foundational approach to health assessment child examination and Chapter 10 on assessment
of the pediatric patient. Chapter 1 begins with of nutritional status in the pediatric patient.
a general overview of the anatomic and physi- Chapter 11 is devoted to an in-depth discussion
ologic differences among infants, children, and of assessment of the neonate.

x Preface
The remaining 11 chapters in the unit focus on the knowledge gained from all previous chapters in
physical assessment by body system. Each chapter the text, and using this knowledge in an organized
is organized as follows: manner to conduct a full, age-appropriate, head-
QQ Anatomy and Physiology to-toe pediatric health examination.
QQ Developmental Considerations Other noteworthy features of the second e dition
QQ Cultural, Ethnic, and Racial Considerations include all-new illustrations and photos; summary
QQ Health History boxes listing notable clinical findings, which con-
QQ Physical Examination clude chapters in Units II and III; and updated clin-
QQ Common Diagnostic Studies ical practice guidelines reflecting the most recent
QQ Documentation of Findings recommendations. An added feature with this

It is hoped that this uniform presentation of edition is a separate Study Guide to Accompany
content will help the reader to think in a systematic Advanced Pediatric Assessment, Second Edition: A
and organized manner. Case Study and Critical Thinking Review, which
Unit III, Assessment of Child Mental Health can be purchased separately or with this textbook
and Welfare, includes two chapters focusing on as a two-book set.
psychosocial issues. Chapter 23 surveys mental Child health care is both complicated and chal-
disorders in children, including screening for addic- lenging, but every child deserves the safest, most
tion, depression, and suicidal ideation. Chapter 24 comprehensive, culturally sensitive health care pos-
specifically addresses various types of child abuse sible. It is my sincere hope that Advanced Pediatric
and neglect, and peer victimization. Assessment, Second Edition, will assist both stu-
Unit IV, Synthesizing the Components of dents and practicing pediatric health care providers
the Pediatric Health Assessment, is a new addi- to achieve this goal.
tion to the second edition of Advanced Pediatric
Assessment. Its sole chapter is devoted to integrating Ellen M. Chiocca

Acknowledgments
It was both an honor and privilege to write the I sincerely appreciate the work of my chapter
second edition of my book for Springer Publishing contributors for the first edition, and I thank them
Company. I am especially grateful to the wonder- for sharing their knowledge and expertise. Thank
ful Elizabeth Nieginski, Executive Editor, who never you Diane Boyer, Patricia Sullivan, Shirley Butler,
ceases to amaze me with her kindness, patience, sup- Pat Hummel, Gloria Jacobson, Lisa Kohr, and
portiveness, and diplomacy. I am especially thankful Joanne Kouba.
for her never-ending encouragement, and for work- Thank you so much to my intensely adored,
ing so hard to keep me moving across the finish line. beloved, and precious daughter Isabella, whom I love
An enormous thanks goes to my brilliant more each day. Thank you, Bella, for being so under-
photographer, Aris Michaels, who is endlessly standing, yet again, while I worked on this project.
calm and tolerant, kind, talented, and creative. A And last, but not least, I want to thank my won-
very special thank you is due to Christine Michaels, derful husband Ralph Zarumba, whom I love so
Paul Chiocca, Elizabeth Gariti, and Claudia Brown dearly, resolutely, and infinitely. Thank you from
for their hard work and patience during the photo the bottom of my heart for providing me with con-
shoot. And a special thank you to Lucas Michaels, tinuous encouragement, support, and love through-
who was especially patient, accommodating, and out this process, as well as doing far beyond your
such a good sport. fair share around the house while I wrote into the
Thank you to Claire Sorenson for her help with wee hours. I am eternally grateful to you not just
Chapter 7. for this, but for all that you are.


U N I T
I
THE FOUNDATIONS OF CHILD
HEALTH ASSESSMENT


C H A P T E R
1
Child Health Assessment:
An Overview
Children experience dramatic changes in their bodies and mechanisms. This helps to explain both the varied physi-
minds, beginning at birth and continuing through adoles- ologic responses seen in infants and children, and why
cence. Because of these anatomic, physiologic, and devel- infants and young children absorb, distribute, metabolize,
opmental changes, it is crucial for the pediatric health and excrete drugs very differently than adults. These fac-
care provider to possess specialized knowledge and skills tors affect the frequency, timing, and length of pediatric
to accurately assess infants, children, and adolescents health care visits. Table1.1 presents an overview of the
during health and illness. Concepts related to health major anatomic, physiologic, metabolic, and immuno-
assessment and physical examination of the adult patient logic differences among infants, children, and adults,
cannot be applied to children; they are not simply little and the corresponding clinical implications of these
adults. In order for the health care of children to be safe, differences.
thorough, and developmentally appropriate, the pedi-
atric health care provider must ensure that child health
assessment is based on a thorough knowledge of pediatric GROWTH AND DEVELOPMENT
anatomy and physiology, pathophysiology, pharmacol-
ogy, and child development. The childs social situation, The physical, psychosocial, and cognitive aspects of
the community in which he or she lives, and the familys child development are interrelated key indicators of
culture are other important components that should be the childs overall health and must be assessed at every
included. In addition, when working with children of dif- health care visit. The assessment of a childs growth
ferent ages and developmental levels, effective, develop- and development helps to evaluate the childs physi-
mentally appropriate communication skills are essential. cal growth and progress toward maturity, can pro-
These skills are used to build rapport with children, their vide clues to health conditions that impeded physical
families, or caregivers, as well as to provide clear and growth, shows cognitive delays, and may point to abuse
objective documentation of assessment findings. or neglect. Normal growth and development occurs in
a predictable sequence but at a variable rate and pace.
Deviations from this pattern may signify an abnormal-
ANATOMIC AND PHYSIOLOGIC DIFFERENCES IN ity, making it essential for the provider to be familiar
INFANTS AND CHILDREN with normal developmental milestones and childrens
growth patterns, and to monitor these trends over time.
In order to recognize abnormalities found during the In this text, infants, children, and adolescents are
physical examination, the pediatric health care provider arranged into six age groups: neonates, infants, tod-
must have strong knowledge of the anatomic and physi- dlers, preschoolers, school-aged children, and adoles-
ologic differences between infants, children, and adults. cents. The corresponding ages are:
Because each body system is immature until at least age 2 QQ Neonates: birth to 28 days
years, the provider must adjust his or her expectations for QQ Infants: 1 month to 1 year
physical findings according to the childs age. In addition, QQ Toddlers: 1 to 3 years
an infant or young childs physical condition can go from QQ Preschoolers: 3 to 6 years
stable to life-threatening very quickly because of imma- QQ School-aged children: 6 to 12 years
ture body systems that lack fully developed feedback QQ Adolescents: 12 to 21 years

4 UNIT I THE FOUNDATIONS OF CHILD HEALTH ASSESSMENT
TABLE 1.1 Anatomic and Physiologic Differences in Infants, Children, and Adolescents
BODY STRUCTURE/ ANATOMIC/PHYSIOLOGIC AGE GROUP

CLINICAL IMPLICATIONS
FUNCTION DIFFERENCES AFFECTED
Skin Thin stratum corneum Infants; Blood vessels are visible through newborns skin,
toddlers until causing ruddy appearance; increased absorption
approximately age of topical drugs; skin burns easily; prone to
23 years, when hypothermia and dehydration
skin becomes
thicker because of
daily friction and
pressure
Thin layer of subcutaneous fat Neonates Affects temperature control
Epidermis is more loosely bound Infants; children Skin layers separate readily, causing easy
to dermis (Ball, Bindler, & Cowen, through early blistering (e.g., adhesive tape removal);
2012) school age susceptible to superficial bacterial skin infections
and more likely to have associated systemic
symptoms with some skin infections; skin is a
poor barrier, contributing to fluid loss
Sebaceous glands are active in Neonates; Milia develop in neonates; acne develops in
neonate because of maternal adolescents adolescents
androgen levels (Hockenberry &
Wilson, 2011) and again at puberty
because of hormonal changes (Ball
et al., 2012)
Eccrine glands are functional at Infants; toddlers Palmar sweating occurs; helps to assess pain in
birth; full function does not occur until preschool neonate
until age 23 years (Vernon, Brady, age
Barber Starr, & Petersen-Smith,
2013)
Apocrine glands are nonfunctional Adolescents Function of apocrine glands at puberty causes
until puberty (Vernon et al., 2013) body odor
Production of melanin reaches adult Infants; children Affects assessment of skin color as child ages
levels by adolescence (Ball et al., until adolescence
2012)
Greater body surface area Infants; toddlers Increases exposure to topically applied drugs;
until age 2 years may result in toxicity in some instances
Head and neck Head is proportionately larger than Infants; toddlers Larger, heavier head increases potential for
other body structures because until age 2 years injury during falls or collisions when body is
of cephalocaudal development. thrown forward, resulting in a high incidence
Head circumference exceeds chest of head trauma in this age group
circumference from birth to age
2 years
Cranial sutures are not fully fused at Infants: Posterior Full anterior fontanelle can indicate increased
birth to accommodate brain growth fontanelle should intracranial pressure; sunken anterior fontanelle
be closed by can indicate dehydration
2 months; anterior
fontanelle should
be closed by
1218 months

CHAPTER 1 CHILD HEALTH ASSESSMENT: AN OVERVIEW 5
TABLE 1.1 Anatomic and Physiologic Differences in Infants, Children, and Adolescents (continued)

Short neck and prominent occiput Infants; children Increased potential for injury in infants and
(Bissonnette et al., 2011). Neck until age toddlers; airway structures are closer together;
lengthens at age 34 years 34 years affects intubation technique in children younger
(Hockenberry & Wilson,2011) than preschool age
Eyes Eye structure and function are Neonates; infants Affects expected findings in physical
immature at birth; pupils are small examination
with poor reflexes until about 5
months of age; transient nystagmus
and esotropia are common in
neonates younger than 6 months of
age (Ball et al., 2012); irises have
little pigment until 612 months of
age (Hockenberry & Wilson,2011)
Vision is undeveloped at birth; Infants; children Affects expected findings in and approach to
by age 4 months, infants can until school age physical examination and vision screening
fixate on an image with both eyes
simultaneously; ability to distinguish
color begins by age 8 months;
children are farsighted until about
age 67 years (Ball
et al.,2012)
Ears Newborns can hear loud sounds at Neonates Newborns react to loud sounds with startle
90 decibels (Hockenberry & Wilson, reflex; they react to low-frequency sounds
2011) by quieting; differences affect techniques for
hearing assessment
Short, wide eustachian tube, lying in Infants; Fluid in middle ear cannot easily drain into
horizontal plane toddlers until pharynx; prone to middle ear infections and
approximately age effusions
2 years
External auditory canal is short and Infants; toddlers Pinna should be pulled down and back to
straight with upward curve until age 3 years perform otoscopic examination
External auditory canal shortens and Preschoolers aged Pinna should be pulled up and back to perform
straightens as child grows 3 years and older otoscopic examination
Mouth, nose, throat, Saliva is minimal at birth; increases Infants Increased aspiration risk; presence of drooling
and sinuses by age 3 months; salivary secretions does not signify teething
increase after age 3 months
(Hockenberry & Wilson, 2011)
Deciduous teeth should erupt Infants; toddlers Delay may signify hypothyroidism or poor
between ages 6 and 24 months nutrition
Obligate nose breathers Neonates; infants Nasal passages are easily obstructed by
until age secretions; affects airway patency and ability
45 months to feed
(continued)


Airway and nasal passages are small Infants; children Increased potential for airway obstruction and
and narrow; larynx is narrowest at through age infection; endotracheal intubation difficult,
level of cricoid cartilage (subglottis) 5 years and accidental extubation more likely with
(Bissonnette et al., 2011); 1 mm of (Bissonnette movement (Bissonnette et al., 2011)
edema can narrow an infants airway et al.,2011)
by 60% (Bissonnette et al., 2011)
Large tongue in proportion to mouth Infants; children Potential for airway obstruction is greater
size (Bissonnette et al., 2011) until age
812 years when
mandible has a
growth peak
Proportionately large soft palate and Infants; Any soft tissue swelling increases the risk for
large amount of soft tissue in the children until airway obstruction
airway approximately
age 1112 years
(Bissonnette
et al.,2011)
Ability to coordinate swallowing and Neonates; infants Increased risk of aspiration and
breathing is immature (Bissonnette until age gastroesophageal reflux (GER) (Bissonnette
et al., 2011) 45 months et al., 2011)
Proportionately large, floppy, and Infants; children Increased potential for airway obstruction with
long epiglottis (Bissonnette through school swelling; endotracheal intubation difficult
et al., 2011) age
Maxillary and ethmoid sinuses are Infants; toddlers Often early sites of infection; can be visualized
small and undeveloped (Hockenberry until age 3 years on radiograph by age 12 years (John & Brady,
& Wilson, 2011) 2013)
Sphenoid and frontal sinuses become School-aged Sphenoid sinuses become sites of infection by
visible on radiograph at children; age 34 years; frontal sinuses by age 610 years
56 years of age (John & Brady, 2013) adolescents (John & Brady, 2013)
Thorax and lungs Hypoxic and hypercapnic drives are Neonates; infants Periodic breathing (i.e., apnea 10 seconds)
not fully developed (Bissonnette until age without cyanosis or bradycardia is within normal
et al., 2011) 3 months limits because of neurologic immaturity of
respiratory drive. Central apnea lasts longer than
20 seconds and is outside normal limits
Chest circumference should closely Infants; toddlers Assists provider in assessing normal growth
match head circumference from
age 6 months to 2 years; chest
circumference should exceed
head circumference at age 2 years
Easily compressible cartilage of Infants; toddlers Limits tidal volume; lowers functional residual
chest wall (Bissonnette et al., 2011) until age 2 years capacity; rib cage is flexible and provides
with very little musculature little support for lungs; negative intrathoracic
pressure is poorly maintained, causing increased
work of breathing (Bissonnette et al., 2011);
soft thoracic cage collapses more easily during
labored breathing

(continued)

Rounded thorax in infancy; ribs lie in Infants; toddlers Limits tidal volume (Bissonnette et al., 2011);
horizontal plane; xiphoid process is until age 3 years ribs are flexible and provide very little support
moveable (Bissonnette et al., 2011) for lungs; negative intrathoracic pressure is
poorly maintained, causing increased work of
breathing
Alveoli are thick walled at birth; Infants; children Affects gas exchange; oxygen consumption
infants have only 10% of the total through age in neonates is almost twice that in adults
number of alveoli found in the adult 8 years (Bissonnette et al., 2011); accounts for increased
lung; over the childs first 8 years of respiratory rate; children with pulmonary
life, alveoli increase in number and damage or disease at birth can regenerate
size (Bissonnette new pulmonary tissue and may have normal
et al., 2011) pulmonary function; contributes to high number
of respiratory diagnoses when infant or child
is acutely ill; respiratory failure is common
in premature infants because of surfactant
deficiency, causing alveolar collapse (Bissonnette
et al.,2011)
Smaller lung volume; tidal volume is Infants; children High respiratory rate, which decreases to adult
proportional to childs weight (710 until age 10 years value by adolescence
mL/kg) (Ball
et al.,2012)
Newborns produce little respiratory Neonates Increased susceptibility to respiratory infections

mucus (Bissonnette
et al., 2011)
Mucous membranes lining the Infants; toddlers Potential for airway edema is greater, causing
respiratory tract are loosely attached potential airway obstruction; more respiratory
and very vascular secretions are produced, increasing the potential
for obstruction or aspiration
Larynx is located 23 cervical Infants; Child is vulnerable to aspiration

vertebrae higher than in adults at children until
level of C3C4 (Bissonnette approximately age
et al., 2011) 810 years
Proportionately small and Infants; children Great potential for airway obstruction, mucus,
narrow oropharynx; trachea is until adolescence and foreign body; resistance to airflow; air is
proportionately shorter and has a warmed and humidified much less effectively
small diameter (Ball
et al., 2012); tracheal cartilage
is elastic and collapses easily;
the trachea continues to grow in
diameter until age 5 years (Ball
etal., 2012) and triples in size
between birth and puberty
Right bronchus is significantly Children Breath sounds are loud and high in pitch; easily
shorter, wider, and more vertical beginning at age heard through thin chest wall; inhaled foreign
than left (John & Brady, 2013); 2 years bodies are easily aspirated into right bronchus
childs trachea bifurcates at higher
level than adults (Ball
et al., 2012)
(continued)


Tracheobronchial tree has large Infants; children Fast respiratory rate is needed to meet oxygen
amount of anatomic dead space through school requirements; child is at risk for respiratory
where gas exchange does not take age acidosis if lungs cannot remove carbon dioxide
place (Bissonnette et al., 2011) (CO2) quickly enough
Infants and children breathe using Infants; children Respirations may be inefficient when crying or
diaphragm and abdominal muscles until age 6 years with anything that restricts breathing, such as
(Ball et al., 2012) abdominal distention; child may retain CO2 as
a result, causing acidosis
Breathing becomes thoracic as in Children aged Respiratory rate decreases to near adult levels
the adult 810 years
Intercostal, scalene, Infants; Immature respiratory muscles must work hard

sternocleidomastoid, and toddlers until to assist in respiratory effort; nasal flaring may
diaphragmatic muscles have few approximately occur; poorly developed respiratory muscles
type I muscle fibers, which are used age 2 years hinder expulsion of thick respiratory secretions;
in sustained respiratory activity (Bissonnette muscles are easily fatigued, which can lead to
(Bissonnette et al., 2011) et al., 2011) CO2 retention, apnea, and respiratory failure
Heart and With first breath at birth, pulmonary Neonates Increased pulmonary blood flow; low systemic
vasculature vascular resistance falls blood pressure (BP)
Left atrial pressure is greater than Neonates Foramen ovale closes within first hour of life
right atrial pressure
Increased arterial oxygen tension Neonates Ductus arteriosus closes about 1015 hours
after birth; fibroses develop within 24 weeks of
age; systolic murmurs may be audible in the first
2448 hours of life because of transition from
fetal circulation
Relatively horizontal position of Infants; children Heart sounds are easily audible because of
heart at birth becomes more vertical until age 7 years thin chest wall; apical pulse is heard at fourth
as child grows intercostal space to left of the midclavicular
line; apex reaches fifth intercostal space at the
midclavicular line by age 7 years; heart may
seem enlarged when percussed; displacement
of the apical pulse may indicate pneumothorax,
dextrocardia, or diaphragmatic hernia
Stroke volume is somewhat fixed Neonates; infants Poor compliance and reduced contractility
because of less muscular and poorly (Bissonnette et al., 2011)
developed left ventricle (Bissonnette
et al.,2011)
Resting cardiac output is high: Neonates; Cardiac output must be high in neonate and
300400 mL/kg/min at birth and infants through infant to meet tissue oxygen demands; this is
200 mL/kg/min within a few months adolescents attained by increasing heart rate
(Bissonnette et al., 2011), decreasing
to 100 mL/kg/min by adolescence
(Bissonnette et al.,2011)


Cardiac output is heart-rate Neonates; children Heart rate is rapid in children; the younger the
dependent, not stroke-volume until late school child, the more rapid the heart rate because of
dependent (Bissonnette age; adolescents increased oxygen and energy needs for growth
et al.,2011) (Ball et al., 2012) and higher metabolism. The provider should
be familiar with age-specific norms for heart
rate; the pulse rises with fever and hypoxia;
tachycardia during sleep is abnormal
Vagal parasympathetic tone dominant Neonates; young Prone to episodes of bradycardia

(Bissonnette et al., 2011) infants
EKG readings differ from adults; Infants; young EKG changes reflect ongoing development of
heart rhythm varies more in children children myocardium (Bissonnette et al., 2011); sinus
than adults (Bissonnette et al., 2011) arrhythmia is within normal limits in children
and common in adolescence
Left ventricular muscle is Infants; children Radial pulse may not be palpable until age
undeveloped until age 6 years until school age 6 years; apical pulse should be taken until then;
the younger the child, the lower the BP; BP rises
as child matures in correlation with increased
blood volume and body weight, reaching adult
levels by adolescence
Reduced catecholamine stores; Neonates; infants Poor response to hypotension via

poor response to exogenously vasoconstriction; hypotension without
administered catecholamine tachycardia is seen with hypovolemia in
(Bissonnette et al., 2011); neonates and infants (Bissonnette et al., 2011)
baroreceptor reflexes are immature
Innocent murmurs are common in Infants; Innocent murmurs are heard during systole;
children; may be present in up to preschool-aged they do not cause cyanosis, fatigue, shortness of
80% of children (Bissonnette children through breath, or failure to thrive
et al., 2011) adolescents
Abdomen Weak abdominal musculature; Infants; toddlers Liver and spleen are not well protected;
abdomen is protuberant in neonates contributes to pot-bellied appearance in
and is prominent in toddlers while infants and toddlers
standing but flat when supine
Abdomen is larger than chest in Infants; children Distended or scaphoid abdomen is indicative a
young children until age 4 years pathologic finding
Abdomen is cylindrical in shape Infants Peristalsis may be visible and may indicate a
pathologic finding such as pyloric stenosis
Abdominal contour changes to adult Preschool-aged Affects provider expectations during physical
shape by adolescence children to examination
adolescents
Stomach lies in a transverse plane Infants; toddlers Affects normal area for auscultation and
until age 2 years palpation during physical examination
Gastric pH is alkalotic at birth; Infants; toddlers Affects oral medication absorption; increases
gastric acid production slowly until age 2 years incidence of GER
increases to adult levels by age
2 years (Bissonnette et al.,2011)
(continued)


Neonate has small stomach capacity Neonates; infants; Need for small feeding amounts at birth;
(approximately 60 mL); stomach toddlers increases incidence of GER
capacity reaches approximately 500
mL by toddler age (Ball et al.,2012)
Stomach capacity reaches 1,000 Adolescents Correlates with increased appetite

1,500 mL by adolescence
Lower esophageal sphincter tone Neonates Increases incidence of GER

(Ball et al., 2012)
Prolonged gastric emptying time Neonates; Affects absorption of nutrients and medications,
(68 hours) and transit time through infant: reaches increasing the chance of adverse side effects and
the small intestine (Guthrie, 2005) adult levels by toxicities
approximately
age 68 months
(Guthrie, 2005)
Length of small intestine is Infants; toddlers Child loses proportionately more water and
proportionately greater, with electrolytes in stool with diarrhea
greater surface area for absorption
relative to body size (Hockenberry &
Wilson,2011)
Large intestine proportionately Infants Less water absorbed, explaining soft stools of
shorter with less epithelial lining infancy
(Ma & Dowell, 2012)
Pancreatic enzyme (e.g., amylase, Neonates; infants Varied bioavailability of drugs that may depend
lipase, trypsin) activity decreased at until age 46 on specific enzymes to aid in drug absorption;
birth (Ball et al., 2012) months (Ball enzymes not present in sufficient quantities to
et al., 2012) digest food fully
Liver and biliary Liver functionally immature at birth Neonates; infants Bilirubin is excreted in low concentrations in
glands (Bissonnette et al., 2011) (Ball et al., 2012) newborns; prothrombin levels in neonate are
only 20%40% of adult levels, which affects
clotting; vitamin storage is inadequate, which
contributes to young childrens frequent
infectious illnesses; process of gluconeogenesis
is immature
Liver occupies more of abdominal Infants; children Affects normal area for palpation and
cavity than in adults; palpable at until adolescence percussion; organs are typically nonpalpable by
0.52.5 cm below the right costal school age; enlarged liver can indicate right-
margin in infants, 12 cm below sided heart failure
the right costal margin in toddlers
(Hockenberry & Wilson, 2011). Liver
reaches adult size and function by
adolescence
Decreased hepatic enzyme function Infants; children Enzyme systems for biotransformation of drugs
in young children (Bissonnette et al., until age are not fully developed, which affects drug
2011); drug enzyme systems mature 34 years dosing; infants and children metabolize drugs
at different rates more slowly than adults; can easily build up
toxic levels of drugs
Liver conjugation reactions are Neonates Jaundice; long drug half-lives (infants and children
impaired (Bissonnette et al., 2011) have short drug half-life) (Bissonnette et al., 2011)


Liver synthesizes and stores Neonates; infants May become hypoglycemic easily; hypoglycemia in
glycogen less effectively (Bissonnette until 1 year neonate can cause permanent neurologic damage;
et al., 2011) young children need to eat more frequently during
childhood (e.g., a.m. and p.m. snacks)
Maternal iron stores in liver are Neonates; infants Infant requires outside source of iron (e.g., iron
depleted by age 6 months until age drops, fortified cereal) beginning at age
6 months 6 months
Lower level of plasma albumin and Neonates; infants Protein binding of drugs is decreased in
globulin (Bissonnette et al., 2011); until age 1 year newborns; high levels of free drug remain in
endogenous compounds such as bloodstream, which can lead to toxic level of
bilirubin and free fatty acids are drug or neonatal coagulopathy; endogenous
already bound to albumin compounds (e.g., bilirubin) can also displace
a weakly bound drug; high loading doses of
protein-bound drugs may be needed in neonate.
Certain drugs (e.g., sulfonamides) can displace
bilirubin from albumin-binding sites, causing
kernicterus in the neonate
Lymphatics Lymph tissue is well-developed at Infants; children Potential for airway obstruction with upper
birth and reaches adult size by age through respiratory infections, chronic tonsillar or
6 years; it continues to grow until adolescence adenoidal swelling, or both; large tonsils and
age 1012 years, when a maximum adenoids can make intubation difficult
size of approximately twice the
normal adult size is reached;
lymph tissue then rapidly declines
to normal adult size by end of
adolescence (Ball et al., 2012)
Spleen may be palpable 12cm Infants; toddlers Affects approach to physical examination; spleen
below the left costal margin should be nonpalpable by preschool age
Blood Vitamin Kdependent clotting Neonates through Vitamin K is administered at birth to prevent
factors and platelet function are early infancy bleeding disorders in newborns
inefficient
Blood volume is weight dependent. Neonates Overhydration and dehydration occur more
Total circulating blood volume (mL quickly than in an adult; blood loss can cause
of blood per kg of body weight) is hypovolemic shock and anemia in infant or
greater than adult by 25%. Blood young child more quickly than in an adult
volume is highest in neonate
(8090 mL/kg); in premature infants
approximately 105 mL/kg; normal
adult values are 7080 mL/kg
(Bissonnette et al., 2011)
At birth, 70%90% of hemoglobin is Neonates; infants HbF has higher affinity for oxygen than adult
fetal hemoglobin (HbF) (Bissonnette until age hemoglobin (HbA); protects red blood cells from
et al., 2011,2005) 4 months sickling in those with sickle cell disease; oxygen
saturation curve is left-shifted for HbF; oxygen
is not delivered as readily to tissues; HbF is
replaced by HbA by age 4 months
(continued)


Immunity Infants fight infection primarily Neonates; infants After age 6 months, infants are prone to
by passive immunity acquired until age infection and build immunity to common
transplacentally (Ball et al., 2012) 68 months (Ball illnesses as they are exposed to them
and by breastfeeding (Hockenberry et al., 2012)
& Wilson, 2011) or until
breastfeeding is
discontinued
Humoral and cell-mediated Neonates; children Frequent infectious illnesses occur in children
immunity is not fully developed until age 6 years younger than approximately 6 years
(Ball et al., 2012)
Reticuloendothelial system is active Infants; Lymphatic tissue, tonsils, and adenoids swell
in childhood children until rapidly in response to mild infections; swollen
approximately age tissues can cause airway obstruction
10 years
Kidneys and urinary Kidneys are proportionately larger Infants; toddlers; Tip of right kidney may be palpated because of
tract than in adults, and are surrounded by preschoolers thin abdominal wall, especially during inspiration;
less fat (Ball et al., 2012) childs kidneys are susceptible to trauma
Ureters are relatively short; urinary Infants; toddlers Bladder descends into pelvis by age 3 years;
bladder lies between symphysis and until then location affects providers approach to
umbilicus (Hockenberry & Wilson, physical examination
2011)
Kidneys are immature at birth; Neonates; Kidneys cannot concentrate and dilute urine
increased renal vascular resistance; toddlers until effectively (most pronounced in first year
incomplete glomerular and tubular age 2 years of life); young infants cannot handle large
development causes decreased renal (Bissonnette et al., amounts of solute-free water or concentrated
blood flow, glomerular filtration rate, 2011) infant formulas; prone to dehydration with fluid
and tubular function (Bissonnette losses (e.g., diarrhea, vomiting) or decreased
et al., 2011) oral intake; prone to fluid overload; electrolyte
secretion and absorption are suboptimal: infants
kidneys cannot conserve or excrete sodium;
kidneys play a role in excreting metabolized
drugs, determining half-life of drugs excreted
through glomerular filtration; prolonged dosage
adjustments may be needed; minimum urine
output is 12 mL/kg/hr
Renal system is not mature at birth Premature Decreased creatinine clearance; poor sodium
neonates retention, glucose excretion, and bicarbonate
reabsorption; ineffective ability to concentrate
and dilute urine; great potential for fluid
overload, insensible losses, and dehydration;
consequent potential cardiac complications, and
electrolyte imbalances
Testicles enlarge between 9.5 and School-aged Early puberty is present if testicles enlarge
13.5 years children; before 9.5 years
adolescents


Fluid balance Proportion of fluid to body weight Infants; toddlers Poor adjustment to fluid deficit or overload;
is larger than in adults; total body until age 2 years increased potential for dehydration or
water is 80%85% of body weight hypovolemia in children younger than 2 years;
in infants (90% in premature response to fluid loss is tachycardia and
infants); total body water reaches vasoconstriction, causing increased capillary
adult values (65%) by approximately refill time and mottling; greater fluid volume
age 3 years (Bissonnette et al., for distribution or dilution of a drug in young
2011); this change is caused by children may require dose adjustment
decrease in extracellular fluid,
which is approximately 45% in a
term infant and reaches adult levels
(25%) by age 3 years (Bissonnette
et al., 2011)
Large body surface area Infants; toddlers Increased potential for insensible water loss
until age 2 years (e.g., perspiration, tachypnea, fever); increased
risk for dehydration; metabolism and heat
production influence fluid loss; allows large
amounts of fluid to be lost via insensible water
loss through perspiration
Bones and muscles Spine is C-shaped at birth Infants until age Affects infants head control
(Hockenberry & Wilson, 2011) 34 months
Bones are not fully ossified until Infants; children Types and locations of fractures in very young
adulthood; bones are soft and easily through children must be fully evaluated to distinguish
bent (Ball et al., 2012) adolescence between intentional and unintentional injuries
Percentage of cartilage in ribs is Infants; children Rib fractures are uncommon in young children;
high; ribs are flexible and compliant through ribs provide minimal protection to underlying
(Ball et al., 2012) adolescence organs and blood vessels
Lordosis is a normal variation in Infants; toddlers Causes appearance of abdominal distention in

infants and toddlers (Hockenberry & this age group
Wilson, 2011)
Skeleton grows continuously (at Infants; children Normal growth pattern

varying rate and pace among through
children) over a period of adolescence
1920years (Ball et al., 2012)
Skeleton grows faster than muscles Adolescents Hands and feet grow faster than body
Body growth spurts occur during Adolescents: Provider should expect considerable growth
puberty peaks at age during this time
12years for
females and
14years for males
Bow-leggedness because of leg Infants; toddlers Normal growth pattern

muscles bearing weight of relatively
large trunk
(continued)


Lower muscle mass (Bissonnette Neonates Use of intramuscular route for medication
et al., 2011) administration limited
Muscles have less tone and Neonates; infants Increased risk for injury; muscle growth
coordination during infancy; muscles contributes greatly to weight gain during
comprise 25% of weight in infants childhood; walking and weight bearing stimulate
compared with 40% in adults (Ball growth of bone and muscle
et al.,2012)
Brain and nerves The neurologic system is Infants; children Nerve impulses do not travel as quickly
anatomically complete at birth; through school down unmyelinated nerves; these impulses
however, since it is not fully age are slower and less predictable. Myelination
myelinated, it is functionally occurs cephalocaudally and proximodistally
immature; myelination is rapid in the and corresponding advances in gross and fine
first 2 years of life and is completed motor function are seen, as evidenced by more
by approximately age 7 years localized stimulus response, increasing sphincter
(Bissonnette et al.,2011) control, and better balance, memory, and
comprehension; most actions in newborns are
primitive reflexes
Bloodbrain barrier (BBB) Neonates More permeable BBB allows passage of large,
underdeveloped at birth but lipid-soluble molecules (e.g., bilirubin) and
develops quickly postnatally some drugs (e.g., some antibiotics, barbiturates,
(Bissonnette et al., 2011) opioids) (Bissonnette et al., 2011), causing some
drugs to have an increased and variable central
nervous system effect or unpredictable duration
ofaction
Brain growth is very rapid; half of Infants; toddlers Head circumference should increase as a
postnatal brain growth is completed until age 2 years reflection of brain growth
by age 1 year; brain reaches
75% of adult size by age 3 years
(Hockenberry & Wilson,2011)
Brain reaches 90% of adult size by School-aged Reflection of brain growth

age 6 years (Hockenberry & Wilson, children;
2011); brain reaches adult size by adolescents
age 12 years
Spinal cord ends at intervertebral Infants; children Necessitates altered approach for lumbar
level L3, reaching adult level of until age 8 years puncture and epidural anesthesia in children
L1L2 by age 8 years (Bissonnette younger than 8 years
et al.,2011)
Cerebral vessels are thin-walled and Premature infants Increased risk for intraventricular hemorrhage
fragile (Bissonnette
et al.,2011)
Immature parasympathetic and Neonates; infants Neonates have less ability to control BP;
sympathetic function (Bissonnette they may respond to pain with tachycardia,
et al., 2011) increased BP


Thermoregulation Body surface area is three times that Neonates; infants Heat loss is greater in children than in adults;
of an adult; head is proportionately susceptible to hypothermia and hyperthermia;
larger until age2 years, creating a thermoregulation is difficult because of thin
greater surface area for heat loss in epidermis, little subcutaneous fat, and poorly
infants, especially when the head is developed sweating and vasoconstriction
exposed mechanisms (Bissonnette et al., 2011); the
premature infant is even more prone to
hypothermia because of thin skin and minimal
fat stores; low body temperature can cause
respiratory depression, acidosis, and decreased
cardiac output (Bissonnette et al., 2011)
Body heat is lost by radiation, Neonates Lower body temperature increases risk for
conduction, convection, and respiratory depression, acidosis, and infection;
evaporation when neonate loses body heat, body attempts to
conserve heat through acrocyanosis (i.e., hands
and feet turn blue); if infants hands or feet do
not become pink when warmed, provider should
consider congenital heart disease
Thermogenesis by shivering is Infants; children Requires body heat to be produced in other ways
undeveloped (Bissonnette et al., until age 6 years (e.g., brown fat thermogenesis), which causes
2011) metabolic acidosis; oxygen consumption also
increases in cold-stressed neonates because it is
needed to metabolize brownfat
Sweating and vasodilation Infants; toddlers Infants do not flush to release body heat with
mechanisms not fully developed; until age 2 years increased body temperature or fever; body does
peripheral vasodilation is inefficient not cool as fast, making child prone to febrile
because of incomplete myelination seizures
Metabolism Metabolic rate is higher than in Infants; children Need more oxygen than adult to support rapid
adults through body growth, work of breathing; metabolic
adolescence rate increases during fever or illness; children
have difficulty maintaining homeostasis during
illness; young children are prone to hypoxia
and dehydration, have high heart rates, and
have high caloric and fluid requirements to
support active metabolism; certain drugs are
metabolized faster in children than adults
Proportion of fat to lean body mass Infants; children Distribution of fat-soluble drugs is limited in
increases with age (Bissonnette et until age 12 years children; a drugs lipid or water solubility affects
al., 2011) the dose for the infant or child
Endocrine glands Not fully mature until adolescence Infants; children Affects bone growth, thyroid function, adrenal
with hormonal and physical changes until adolescence cortex, and secretion of sex hormones
that occur in puberty
Thelarche normally takes place School-aged Affects physical examination; provider should
between 8 and 13 years; pubarche children; be aware of precocious or delayed puberty;
between 8 and 14 years; menarche adolescents gynecomastia in adolescent boys may be caused
about 2 years after thelarche by pubertal changes, obesity, or use of marijuana
or anabolic steroids; pubic hair heralds the onset of
puberty in boys; thelarche signifies puberty in girls
BP, blood pressure, GER, gastroesophageal reflux.

For each age group, the pediatric provider must be assessment of television, computer, and video time;
knowledgeable about age-appropriate developmental family structure, including an assessment of all persons
abilities: living in the home and their relationship to the child;
QQ Gross and fine motor abilities, particularly until parenting style and disciplinary methods; as well as
age 6 years. assessment of depression, eating disorders, and sexual
QQ Language and communication abilities. Assessment activity. (See Chapter 6 for a detailed discussion of the
of language milestones is very important; delays pediatric health history.)
can signal hearing loss, learning problems, even
neglect. Depending on the childs age, tempera-
ment, and developmental level, the child may not THE PEDIATRIC PHYSICAL EXAMINATION
be able to verbalize anxiety, fear, or pain, making
it necessary for the provider to make these assess- A childs age and developmental level determine the
ments independently or to rely on the parent. providers approach to the physical examination.
QQ Cognitive abilities depend on interplay of genetics The approach also depends on the severity of illness
as well as family, educational, and social environ- or injury and whether the childs primary caregiver
ment. These abilities change and develop as the is present. It is usually recommended that a com-
child grows. plete physical examination be done in an organized,
QQ Psychosocial and behavioral stages. Knowledge head-to-toe fashion to minimize any omissions of
of normal psychosocial developmental stages body system assessments. However, this sequence
can be used to make an accurate developmental should be adjusted to the childs age, temperament,
assessment of a child and to engage the child in and developmental level. For example, infants and tod-
the health care encounter in an age-appropriate dlers dislike intrusive procedures such as inspection of
manner. (See Chapter 2 for a discussion of devel- the throat and ears, and these examinations often elicit
opmental assessment.) crying. For this reason, it is wise to first auscultate the
young childs heart, lungs, and abdomen when the child
is quiet, and inspect the ears and mouth last. Children
COMMUNICATION SKILLS REQUIRED TO WORK who are preschool age and older are typically able to
WITH CHILDREN cooperate with a physical examination that proceeds in
The pediatric health care provider must be able to a head-to-toe direction. (See Chapter 8 for an in-depth
communicate with children of all ages and at all
discussion of physical assessment.)
developmental levels. This is quite challenging because
each developmental stage requires vastly different UNDERSTANDING THE CAREGIVERCHILD
approaches specific to the age, developmental stage, RELATIONSHIP
and temperament of the child. The provider must also
know when the child is developmentally, cognitively, In all pediatric health encounters, whether the child
and temperamentally able to provide his or her own is well or ill, the provider should appraise the childs
answers during the medical history. In addition, each social situation and home environment, paying par-
child must be viewed within the context of his or her ticular attention to the parentchild interaction during
family, culture, and social situation. (See Chapter 3 for a the health care encounter. The caregivers responses to
discussion of the communication skills needed to work and interactions with the child can provide a wealth of
with children and families.) information regarding the childs emotional health and
the parentchild relationship. Children are also highly
influenced by the emotional state of their caregiver.
OBTAINING THE PEDIATRIC HEALTH HISTORY This can be reflected in the childs overall behavior,
The reason for the childs visit dictates the type of history sleep patterns, appetite, school performance, and peer
that the health care provider obtains (see Chapter 6). For relationships. The provider must also be sure to assess
example, interval histories involve a specific complaint these relationships within the context of the familys
and require only injury- or illness-specific data. During culture. (See Chapter 4 for further discussion of family
health maintenance visits, the provider obtains a very assessment and Chapter 5 for a discussion of cultural
complete history. Data that provide information about assessment.)
the childs growth and development, nutrition, daily
life, health and safety, environment, parental knowl- ROLE OF THE PEDIATRIC HEALTH CARE PROVIDER
edge base, and teaching needs are especially impor-
tant. The complexity of life in the 21st century presents The role of the pediatric health care provider is to
new risks to children that also require assessment such collaborate and cooperate with the childs parent or

as obesity; exposure to violent and sexually explicit primary caregiver and to advocate for and protect the
media; exposure to community and domestic violence; childs best interests. Children are dependent on the

adults in their lives for many years, and the health confidence, competence, and health behaviors through
care provider can greatly influence the quality of care teaching, role modeling, positive reinforcement, and
that they receive from their family. If parents feel sup- reassurance. Fostering a trusting, caring, provider
ported and validated by the health care provider, they family relationship leads to healthful behaviors
are more likely to feel comfortable asking questions that and healthy psychosocial development of the child.
will enhance their childs emotional and physical health. Having well-developed pediatric assessment skills is
This can be achieved by creating a partnership with the the first step in delivering excellent care to the child
child and family in promoting health and preventing ill- and family.
ness. Bright Futures, a developmentally based approach
to child health assessment, health promotion and ill- References
ness prevention, has delineated six steps for building
Ball, J. W., Bindler, R. C., & Cowen, K. J. (2012). Principles of
the providerchildfamily partnership (Hagan, Shaw, & pediatric nursing: Caring for children (5th ed.). Upper Saddle
Duncan, 2008): River, NJ: Pearson Education.
1. Model and encourage open, respectful, non- Bissonnette, B., Anderson, B. J., Bosenberg, A., Engelhardt, T.,
judgmental communication, building trust and Mason, L. J., & Tobias, J. D. (2011). Pediatric anesthesia: Basic
principlesstate-of-the-art future. Shelton, CT: Peoples Medical
empathy.
Publishing House.
2. Identify health issues through effective listening Guthrie, E. W. (2005). Pediatric dosing considerations. U.S. Pharmacist,
and by asking open-ended questions. 30(12), 510.
3. Affirm strengths of the child and family, praising Hagan, J. F., Shaw, J. S., & Duncan, P. M. (Eds.). (2008). Bright
the achievements of the child and family. futures: Guidelines for health supervision of infants, children and
adolescents (3rd ed.). Elk Grove Village, IL: American Academy
4. Identify mutual and shared goals, reinforcing the
of Pediatrics.
notion of a partnership between provider, child, Hockenberry, M. J., & Wilson, D. (2011). Wongs nursing care of
and family. Refer the child and family to appro- infants and children (9th ed.). St. Louis, MO: Mosby.
priate community resources as needed. John, R. M., & Brady, M. A. (2013). Respiratory disorders. In C. E.
5. Develop a plan of action based on shared goals. Burns, A. M. Dunn, M. A. Brady, N. B. Starr, & C. G. Blosser
(Eds.), Pediatric primary care (5th ed., pp. 708738). St. Louis,
Goals should be simple, achievable, measurable,
MO: W. B. Saunders.
and time-specific. Ma, A., & Dowell, M. (2012). Gastrointestinal alterations. In N. L.
6. Evaluate the effectiveness of the partnership on Potts & B. L. Mandelco (Eds.), Pediatric nursing: Caring for chil-
an ongoing basis. dren and their families. New York, NY: Delmar.
The pediatric health care provider cares for the Vernon, P., Brady, M. A., Barber Starr, N., & Petersen-Smith,
A. (2013). Dermatologic disorders. In C. Burns, A. M. Dunn,
entire family when assessing and treating a child.
M.A. Brady, N. B. Starr, & C. Blosser (Eds.), Pediatric primary
During the health care encounter, the provider can care (5th ed., pp. 877927). St. Louis, MO: W. B. Saunders.
have a significant impact on the parents and childs

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| C h i o cca |

Advanced Pediatric Assessment

| E l l e n M . C h i o cca | MSN, CPNP, APN, RNC-NIC

Advanced Pediatric Assessment

New t o t he S eco n d E ditio n :

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Ellen M. Chiocca, MSN, CPNP, APN, RNC-NIC

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Copyright 2015 Springer Publishing Company, LLC

Printed in the United States of America by McNaughton & Gunn.

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To the two great loves of my life

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Prefaceix 14. Assessment of the Ears291

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BODY STRUCTURE/ ANATOMIC/PHYSIOLOGIC AGE GROUP

Thin layer of subcutaneous fat Neonates Affects temperature control

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BODY STRUCTURE/ ANATOMIC/PHYSIOLOGIC AGE GROUP

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BODY STRUCTURE/ ANATOMIC/PHYSIOLOGIC AGE GROUP

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BODY STRUCTURE/ ANATOMIC/PHYSIOLOGIC AGE GROUP

Newborns produce little respiratory Neonates Increased susceptibility to respiratory infections

Larynx is located 23 cervical Infants; Child is vulnerable to aspiration

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BODY STRUCTURE/ ANATOMIC/PHYSIOLOGIC AGE GROUP

Intercostal, scalene, Infants; Immature respiratory muscles must work hard

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BODY STRUCTURE/ ANATOMIC/PHYSIOLOGIC AGE GROUP

Vagal parasympathetic tone dominant Neonates; young Prone to episodes of bradycardia

Reduced catecholamine stores; Neonates; infants Poor response to hypotension via

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BODY STRUCTURE/ ANATOMIC/PHYSIOLOGIC AGE GROUP

Stomach capacity reaches 1,000 Adolescents Correlates with increased appetite

Lower esophageal sphincter tone Neonates Increases incidence of GER

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BODY STRUCTURE/ ANATOMIC/PHYSIOLOGIC AGE GROUP

Springer Publishing Company

BODY STRUCTURE/ ANATOMIC/PHYSIOLOGIC AGE GROUP

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BODY STRUCTURE/ ANATOMIC/PHYSIOLOGIC AGE GROUP

Lordosis is a normal variation in Infants; toddlers Causes appearance of abdominal distention in

Skeleton grows continuously (at Infants; children Normal growth pattern

Bow-leggedness because of leg Infants; toddlers Normal growth pattern

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BODY STRUCTURE/ ANATOMIC/PHYSIOLOGIC AGE GROUP

Brain reaches 90% of adult size by School-aged Reflection of brain growth

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BODY STRUCTURE/ ANATOMIC/PHYSIOLOGIC AGE GROUP

BP, blood pressure, GER, gastroesophageal reflux.

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