Clinical Learning Guide                       Pediatric general examination                             STEP/TASK         ...
STEP/TASK                                     CASES    •    Head circumference, rate of growth.    •    Head asymmetry, mi...
STEP/TASK                                  CASESDiaper, genitalia, anus (permission is asked verbally)   •   Only perform ...
Appendex1                                  Clinical Learning Guide                                  Measuring Radial Pulse...
   Special character:     Comment if there is a special character .   Compare to the other radial pulse .              ...
Appendex2                                 Clinical Learning Guide                                 Measuring Apical Pulse  ...
Clinical Learning Guide                                          Appendex 3                                  Clinical Lear...
Ask the patient to lie supine            Using the tips of your fingers            Feel the pulse in the groove midway b...
Appendix 4                                    Clinical Learning Guide                                  Measuring the Respi...
Appendex5                                 Clinical Learning Guide                                Measuring Blood Pressure ...
STEP/TASK                                       CASES    artery, just below but not touching the cuff or tubing.10. Close ...
Appendix 6                        Clinical Learning Guide             Measuring Pediatric Axillary Temperature Using      ...
Clinical Learning Guide                                          Appendix 7                               Clinical Learnin...
   Place the patient’s elbow in a semiflexed position   For examining the right side, put your right palm    over the po...
Appendix 8                                    Clinical Learning Guide:                                    Examination of t...
16
Palpation :        Advise the patient to sit on a stool        Stand behind the patient        Instruct the patient to ...
Appendix 9                                Clinical Learning Guide                               Examination of the Mouth  ...
STEP/TASK                                   CASES 8. Examination of the teeth:        Inspect the teeth for their shape, ...
STEP/TASK                                   CASES12. Examination of the fauces (throat) and palate        Ask the patient...
Appendix 10                 Clinical Learning Guide           Measurement of the Height of a Child                      Ab...
Appendix 11                      Clinical Learning Guide                  Measurement of the Weight of an                 ...
near that box exactly as you wrote the year of      birth near the box for the month of birth.   3. Carefully calculate th...
2. The importance of the direction of the growth   curve is illustrated in Fig. below. Arrows A, B,   C, and D have been d...
curve that is more important than the position      of the dots on the curve, The dots parallel to      arrow B (in Fig. a...
Appendix 12                      Clinical Learning Guide                     Measurement of the Head                      ...
Appendix 13                      Clinical Learning Guide                     Measurement of Mid-Arm                       ...
Appendix 13                      Clinical Learning Guide                     Measurement of Mid-Arm                       ...
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  1. 1. Clinical Learning Guide Pediatric general examination STEP/TASK CASESGETTING READY1. Pre-exam checklist: WIPE: a. Wash your hands [thus warming them]. b. Introduce yourself to pt, explain what going to do. c. Position pt [+/- on parents knee]. d. Expose area as needed [parent should undress].2. Examine from the Right side of the patient. PEDIATRICS: EXAMINATIONGeneral appearance • Posture, body positions, body shape. • Hydration. • Dress, hygiene. • Alertness, happiness. • Crying: high-pitched vs. normal. • Any unusual behavior. • Parent-child interaction, reaction to someone new walking entering the room (child abuse). • Ask if tenderness anywhere, before start touching them. • If asleep, do the heart, lungs and abdomen first.Vital signs (see specific learning guide) • Radial pulse. (Appendix 1) • Apical Pulse (Appendix 2) • Femoral pulse and other peripheral pulses. (Appendix 3) • Respiratory rate (Appendix 4) • Blood Pressure. (Appendix 5) • Temperature. (Appendix 6)Taking Pediatric Vital Signs Reference.Lymph nodes (appendix 7) • Palpate lymph nodes in the neck, inguinal, epitrochlear, supraclavicular, axillary, and posterior occipital regions. Comment on size in its largest diameter, consistency, adherent or freely mobile, tender or not, skin overlying. (check foundation skills)Head and neck Appendix 8
  2. 2. STEP/TASK CASES • Head circumference, rate of growth. • Head asymmetry, microcephaly, macrocephaly, other visible abnormalities. • Fontanelle, if <18 months: o Full or flat or depressed. • Thyroid enlargement, other lumps. • Neck stiffness. • Neck lymph nodes: location, size in cm, tenderness, consistency.Eyes • Exam position: mother holds child on lap facing forward, one arm encircling childs arms, the other hand on childs forehead. • Pupils: reaction to light, accommodation. • Strabismus o Strabismus is normal before 4-6 months. • Photophobia, proptosis, sclerae, conjunctivae, ptosis, congenital cataracts.Ears • Exam position: same as eye, but child faces the side. • Discharge, canals, external ear tenderness. • Test hearing.Nose• Nares patency, septum, nasal flaring.• Discharge, mucous membranes, sinus tenderness.Mouth (Appendix 9)Throat • Breath odor. • Lips: color, fissures and dryness. • Tongue. • Teeth: number, arrangement, dental caries. • Gums: color, hypertrophy (phenytoin) • Throat: epiglottis • Tonsils: size, signs of inflammation.Height, weight, skull circumference and midarm circumference (Appendices 10-13) • Measure and plot on appropriate centile chart. 2
  3. 3. STEP/TASK CASESDiaper, genitalia, anus (permission is asked verbally) • Only perform when indicated. • Diaper: o Inspect contents. o Inspect napkin area • Male: o Testes decent, hernias. o Circumcision, testes, hydrocele. • Female: o Vulva, clitoris. • Both sexes: o Discharge. o Abnormalities. o Tanner stage. • Anus inspection: o Hemorrhoids, fissures, prolapse. o Sphincter tone, tenderness, mass. o Peri-anal inflammation.Extremities and Back • Infants: hip abduction in infants with knees flexed. • Feet abnormalities, such as rocker-bottom feet. • Similar signs as seen in hands, nail. • Spine: deformity, masses, tenderness, limitation of movement, spina bifida and pilonidal dimple.Skin • Rashes, using proper terminology. • skin color, consistency, and hydration. • Cyanosis, jaundice, edema, bruises, petechiae, and pallor. • Note café-au-lait spots, hemangiomas and nevi, their size and location. 3
  4. 4. Appendex1 Clinical Learning Guide Measuring Radial Pulse STEP/TASK CASESGetting Ready: 1. Prepare equipment: Watch or clock with a counter for seconds. 2. Explain the procedure to the patient. 3. Assist the patient to pronate and slightly fix the forearm. 4. Wash the hands.Procedure: 1. Locate the radial artery just medial to the distal radius and proximal to the patient’s wrist on the thumb side. Frequently, transmitted pulsations can be seen on careful inspection. 2. Place the tips of the index, middle & ring fingers just proximal to the patient’s wrist on the thumb side, orienting them over the vessel. 3. Push lightly at first, gradually adding pressure till you feel the pulse.Pushing too hard might occlude the vessel and lead to faultily perceiving theexaminers pulse as that of the patient.Post Procedure: 1. Wash the hands. 2. Discuss the findings with the patient. 3. Record the results as beats / minute and comment on regularity and volume.During palpation, note the following:  Rate: Measure the rate of the pulse (recorded in beats per minute). Count for 30 seconds and multiply by 2. If the rate is particularly slow or fast, it is probably best to measure for a full 60 seconds in order to minimize the impact of any error in recording over shorter periods of time.  Compare to apical pulsations  Rhythm: Is the time between beats constant? so it may be : • Regular. • Regular irregularity (if there are extra beats). • Irregular irregularity (if there is no discernable pattern as cases of atrial fibrillation).N.B. if the pulse is irregular; verify the rate by listening over the heart (apical pulse).  Volume: (i.e. the subjective sense of fullness). • Normal. • Big. • Small • Variable volume.  State of the vessel wall: • Place the tip of the three fingers ( ring , middle , index ) over the radial artery • Press proximally using the index finger to close the radial artery. • Press by the ring finger distally to prevent the back flow. • Palpate the vessel wall by the middle finger. 4
  5. 5.  Special character:  Comment if there is a special character . Compare to the other radial pulse . 5
  6. 6. Appendex2 Clinical Learning Guide Measuring Apical Pulse STEP/TASK CASESGetting Ready: 1. Prepare equipment: Watch or clock with a counter for seconds. 2. Explain the procedure to the patient. 3. Assist the patient to a comfortable position: supine or semi- sitting position. 4. Stand to the right of the patient. 5. Expose chest well. 6. Wash the handsProcedure: 1. By inspection: look tangentially, from the side of the patient for apical pulsation. 2. Palpate the apex by palmer surface of the hand. 3. Localize the apex (the lowermost outermost powerful pulsation) with the tip of your index finger. 4. Auscultate the apex with the bell of the stethoscope.Post Procedure: 1. Discuss the findings with the patient. 2. Wash your hands. 3. Record the results as beats / minute 6
  7. 7. Clinical Learning Guide Appendex 3 Clinical Learning Guide Measuring Apical Pulse Measuring Peripheral pulses STEP/TASK CASESGetting Ready 1. Greet the patient respectfully and with Kindness. 2. Tell the patient you are going to examine the neck. 3. Ask the patient to sit on the examining table with arms at sides. 4. Wash hands thoroughly and dry them 5. Put on new examination or high-level disinfected surgical gloves on both hands. 6. Exposure: Instruct the patient to remove all clothing covering the examination areasMeasuring Peripheral Arterial pulses:1. Femoral artery:Ask the patient to:  Lay supine  Partially flex the knee  Abduct and externally rotate the hip  Using the tips of your fingers  Feel the pulse below the mid-inguinal point  Compare both sides. 2. Popliteal artery:Ask the patient to lie supine and partially flex the knees  Feel the pulse with the fingers encircling and supporting the knee from both sides.Alternate method:  Ask the patient to lie prone  Using the tips of your fingers with the tips of the thumbs of both hands pressing against the femur  Feel along the line of the artery  Compare both sides. 3. Posterior tibial artery: 7
  8. 8. Ask the patient to lie supine  Using the tips of your fingers  Feel the pulse in the groove midway between the medial malleolus and the heel( tendo-achilles)  Compare both sides. 4. Dorsalis pedis artery:  Using the tips of your fingers  Feel the pulse lateral to the extensor hallucis longus tendon and proximal to the first metatarsal space.  Compare both sides. 5. Brachial artery:  Partially flex the elbow  Using the thumb  Feel the pulse over the elbow just medial to the biceps tendon. 6. Radial artery: See specific learning guide 8
  9. 9. Appendix 4 Clinical Learning Guide Measuring the Respiratory Rate STEP/TASK CASESGetting Ready: 1. Prepare equipment: Watch or clock with a counter for seconds. 2. Assist the patient to a comfortable semi-sitting position 3. Wash the hands.Procedure: 1. Do not explain the procedure to the patient,* pretend you are measuring the radial pulse, while inspecting and counting the elevations of the chest wall in 30 seconds. 2. If you could not count the respiratory rate easily because of clothes or any other reason, let the patient lie flat and pretend that you are measuring the apical pulse or performing cardiac examination while counting the respiratory rate in 30 seconds.Post Procedure: 1. Wash your hands. 2. Record the results as breathes/ minute and comment on regularity and difficulty.* If the patient becomes aware that the respiratory rate is being counted, s/he may voluntarily alter the rate of breathing. 9
  10. 10. Appendex5 Clinical Learning Guide Measuring Blood Pressure STEP/TASK CASESGetting ready: 1. Greet the child and parents. 2. Explain the procedure and attempt to gain the child’s and parent’s confidence before approaching the child. 3. Explain that the procedure will not hurt. 4. Put the patient in a supine or sitting position with back supported for 5 minutes and legs uncrossed, feet flat on the floor and patient relaxed. The patient must not eat. 5. Prepare equipment (stethoscope and mercury or aneroid sphygmomanometer) 6. Determine if the pulses are equal, use right arm; if unequal, use arm with the strongest pulse). 7. Take off the sleeve of the identified arm. 8. Arm should be abducted, supinated and at the level of the heart (if sitting, use arm support). 1. Choose the correct size of the width of the cuff. The bladder should be at least40% of the circumference of the midpoint of the upper arm and the length should be 80% of the upper arm.TAKING THE BLOOD PRESSURE 1. Place the cuff around the upper arm with the lower edge of the cuff, with its tubing connections, placed one inch above the antecubital space across the inner aspect of the elbow. 2. Wrap the cuff snuggly1 around the inflatable inner bladder centered over the area of the brachial artery. 3. Close the valve of the pump. 4. Inflate the cuff while palpating the radial pulse.Inflate the cuff rapidly to 70 mmHg then 10 mmHg at time till the pulse will no longer be felt (the pulse obliteration pressure). This is the approximate systolic blood pressure. 5. Deflate the cuff 6. Add 20-30 mm Hg to previously measured number to know the maximum inflation level (MIL). 7. Place the earpieces of the stethoscope into ears,with the earpiece angles turned forward toward thenose. 8. Palpate the brachial artery. 9. Apply the diaphragm in of the stethoscope over the brachial 1 Snuggle: properly fitting not tight nor loose. 10
  11. 11. STEP/TASK CASES artery, just below but not touching the cuff or tubing.10. Close the valve of the pump.11. Inflate the cuff rapidly to the MIL previously determined.12. Open the valve slightly and maintain a constant rate of deflation at approximately 2mm per second.13. Allow the cuff to deflate14. Listen throughout the entire range of deflation until 10mm Hg below the level of the diastolic reading. The first loud beat will be the systolic recording (Korotkopf I) ,the sudden reduction of sound (Korotkopf IV) will denote the diastolic reading1.15. Fully deflate the cuff by opening the valve.16. Remove the stethoscope earpieces from the ears.17. Write down the systolic and diastolic readings to the nearest 2mmHg.18. Deflate cuff completely, if the sound were not heard clearly or the blood pressure recording is high raise arm above head level for one minute then lower arm and repeat steps 3 to 15. 1 In case the sound continues to zero, record the diastolic blood pressure as a range of the kortokopf IV sound to zero. 11
  12. 12. Appendix 6 Clinical Learning Guide Measuring Pediatric Axillary Temperature Using a Mercury Thermometer STEP/TASK CASESGetting Ready:1. Prepare equipment (thermometer tray, tissue paper and thermometer)2. Tell the mother what is going to be done and encourage her to ask questions.Procedure:1. Place the baby on her/his back or side on a clean, warm surface.2. Shake the thermometer until it is below 35°C.3. Place the tip of the thermometer high in the apex of the axilla and hold the arm continuously against the body for at least two minutes. • Remove the thermometer and read the temperature by holding it at eye-level and rotating the stem until the mercury is clearly seenPost Procedure:1. Wipe the thermometer with a disinfectant solution after each use.2. Record results on a notepad 12
  13. 13. Clinical Learning Guide Appendix 7 Clinical Learning Guide Measuring Apical Pulse Examination of Lymph Nodes STEP/TASK CASESGetting Ready 7. Greet the patient respectfully and with Kindness. 8. Tell the patient you are going to examine the neck. 9. Ask the patient to sit on the examining table with arms at sides. 10. Wash hands thoroughly and dry them 11. Exposure: Instruct the patient to remove all clothing covering the examination areasExamination of Peripheral Lymph NodesLymph Nodes in the Inguinal RegionAsk the patient to:  Fully expose the inguinal region  Lay supine  Flex the contra-lateral knee  Palpate above and below the inguinal ligament  Examine both sidesLymph Nodes in the AxillaExamine the patient from the front:  With the patient’s arm adducted, rest his/her left forearm on your right forearm  Insert your right hand into the patients left axilla  Slide the fingers against the chest wall  Palpate the anterior axillary fold  Palpate the lateral axillary wall  Using the tips of your fingers  Use the left hand for the patient’s left side  With the palm directed laterally against the upper end of the humerus, palpate for the lymph nodes  Palpate the posterior axillary fold from behindEpitrochlear Lymph Nodes 13
  14. 14.  Place the patient’s elbow in a semiflexed position For examining the right side, put your right palm over the posterior aspect of the patients right elbow. Do the opposite when examining the left side. Using the thumb for palpation, roll the epitrochlear lymph node against the bone in an antro-posterior direction 14
  15. 15. Appendix 8 Clinical Learning Guide: Examination of the Neck STEP/TASK CASESGetting Ready 1. Greet the patient respectfully and with kindness. 2. Tell the patient you are going to examine the neck. 3. Ask the patient to sit on the examining table with arms at sides. 4.Wash hands thoroughly and dry them 5. Put on new examination or high-level disinfected surgical gloves on both hands. 6. Exposure: Instruct the patient to remove all clothing down to the nipple line.PROCEDUREInspection:  Observe the contour of the neck and notice any abnormalities  Ask the patient to swallow and notice any masses moving with deglutition Define the anatomical site of any observed swelling Notice any neck pulsations, dilated veins, scars Allow patient to recline at 45 degrees, this makes normal neck veins visible just above clavicles with their characteristic pulsationsComment on: o Arterial pulsations(suprasternal and or prominent carotid pulsations) o Venous pulsations; congestion, pulsations (a & v waves and x & y descent) and their relation to inspiration o Thyroid swelling o Other swellings 15
  16. 16. 16
  17. 17. Palpation :  Advise the patient to sit on a stool  Stand behind the patient  Instruct the patient to relax the neck muscles so as to allow you to move the head in any direction  Hold the head with one hand and flex it gently to one side while palpating the front of the neck with the other hand  Flex the patient’s head towards the side that is being palpated  Ask the patient to resist your movement in order to contract the muscles; continue to palpate the neck while the muscles are being contracted.  Examine the relationship of any masses detected to: o The trachea: Notice the movement of the mass with swallowing o The hyoid bone: Notice the movement of the mass with protrusion of the tongue  Palpate the cervical lymph nodes o Can be done either while facing or while standing behind the patient o Examine all the groups systematically (superficial and deep, upper and lower) o Palpate beneath the mandible, over the tonsillar L Ns, over the anterior triangles. Above the clavicles and deep to sternoclavicular attachments of the sternomastoid muscles  Palpate both carotid arteries for equality and presence of a thrillComment on: o Thyroid gland: o size o shape o tenderness o mobility o consistency o Lymph node enlargements o Pulsations and thrillPercussion :  Tap with the index finger over the manubrium sterni in order to rule out any retrosternal extension of the thyroid gland, which will elicit a dull note on percussionAuscultation:  Listen over the thyroid gland (mainly over the superior thyroid artery) for any bruit or murmur.  Listen over both carotid arteries for any bruit or murmur. 17
  18. 18. Appendix 9 Clinical Learning Guide Examination of the Mouth STEP/TASK CASESGetting Ready 1. Greet the patient respectfully and with kindness. 2. Tell the patient you are going to examine the mouth. 3. Ask the patient to sit on the examining table with arms at sides. 4. Wash hands thoroughly and dry them 5. Put on new examination or high-level disinfected surgical gloves on both hands. 6. Prepare a good light (torch) and spatulaPROCEDUREEXAMINATION OF THE MOUTH 1. Retract the lip to inspect the buccal mucosa 2. Push the cheek outwards to see the buccal side of the gum (for abnormalities) 3. Push the tongue away from the inside of the gum and the floor of mouth; then push it aside to inspect the lateral aspect of its posterior third 4. Depress the tongue to look at fauces (throat), tonsils and pharynx 5. Always remember to palpate the structures in the mouth bimanually; one finger inside the mouth and one outside. 6. Examination of the lips:  Inspect the lips and evert the lip fully to examine the mucous surface of its inner aspect and the gingivo-labial fold  Palpate the lips using two fingers 7. Examination of the cheeks:  Retract the angle of the mouth and illuminate the interior of the mouth using a torch  Inspect the interior of the cheek for pigmentations, ulcers, swellings  Inspect the orifice of the parotid duct. 18
  19. 19. STEP/TASK CASES 8. Examination of the teeth:  Inspect the teeth for their shape, color, dental cares and presence of rough or broken edges.  Inspect for pulpless, impacted, non-erupted or missing teeth by counting their number  If the patient wears dentures, ask for its removal before proceeding with the examination, notice if it is smooth and well fitting. 9. Examination of the gum:  Evert the lips fully to inspect the gums  Look at the color, the crenated edges, the relation to the necks of the teeth, pigmentation, ulcers, swellings10. Examination of the tongue:  Inspect the tongue for size, shape, color, surface, mobility o Determine the general condition of the mucous membrane; dry or moist, clean or furred o Note if there is any swellings, ulcers or fissures  Palpate the tongue o Ask the patient to relax the tongue and not to move it. o Palpate with the index finger of the right hand while pressing the fingers of the left hand firmly into the cheek, in such a way that the cheek intervenes between the teeth. In order to prevent the patient from biting the examiner finger. o To palpate the posterior quarter of the tongue, ask the patient to open the mouth widely.11. Examination of the floor of the mouth :  Ask the patient to open the mouth and to put the tip of the tongue on the roof of the mouth and to bend the head slightly backwards.  Inspect the floor of the mouth and the undersurface of the tongue  Bimanually palpate any visible swelling 19
  20. 20. STEP/TASK CASES12. Examination of the fauces (throat) and palate  Ask the patient to tilt the head slightly backwards and to open the mouth to its fullest extent  Inspect the movement of the palate while instructing the patient to say (AAH)  Depress the tongue with a spatula and illuminate the throat; inspect the tonsils, pillars of the fauces (throat) and the posterior pharyngeal wall  To palpate the pharynx,(if needed): o Seat the patient on a stool, and stand on the right side. o Hold the head firmly with the left hand, the index finger of which is pushed in between the jaws to prevent the patient from biting the examiners finger. o The right index finger is then passed behind the soft palate to palpate the posterior nares, nasopharynx and back of tongue. 20
  21. 21. Appendix 10 Clinical Learning Guide Measurement of the Height of a Child Above Two Years STEP/TASK CASESGetting ready: • Use a measuring device e.g. studiometer or wall- mounted measuring ruler. 1. Introduce yourself to the mother 2. Ask her the permission to examine the child 3. Ask the mother/child to remove shoes and socks. 4. Ensure the correct positioning by beginning at the feet and working upwards. • Place the feet together flat on the ground with the heels touching the zero point. • Ask the child to stand as straight as possible with the heels, buttocks and shoulders touching the measuring device/wall • Be sure the knees are fully extended • Put the head carefully in the neutral position with the lower margins of the orbit in the same horizontal plane as the external auditory meatus (Frankfurter plane) 5. Record the reading and plot it on an Egyptian growth chart. 21
  22. 22. Appendix 11 Clinical Learning Guide Measurement of the Weight of an Infant Below 2 Years STEP/TASK CASESGetting Ready:1. Prepare a clean scale and a disposable piece of Paper.2. Put a cloth on the scale pan to avoid chilling of the Infant.3. Adjust the scale to the zero point.4. Introduce yourself to the mother and explain The steps you are going to do to her.5. Instruct the mother to remove the childs cloth leaving as least as possible of itProcedure:1. Place the child gently on the center of the weighing Scale2. Wait till the scale display stops flashing (digital scale), or the pointer settles (mechanical scale). In case you use a beam scale, move the weight on the main scale beam away from the zero point until the indicator settles at the center1.3. Take the child off the scale and repeat the previous Step4. Record the average of both readingsPost procedure:1. Return the child to his mother and instruct her to dress it2. Record the weight and plot it on a growth chart.Recording weight on the growth chart (plotting measurements) 1. Write the month of birth in the box below the first vertical column) the first box which has thick lines around it). Near the box, write the year of birth. 2. Beginning with the month of birth, write out the following months of the year in the following boxes. When you reach January, write the year 1 The child must not touch the table and the mother must not support his body. 22
  23. 23. near that box exactly as you wrote the year of birth near the box for the month of birth. 3. Carefully calculate the childs age to the nearest month. 4. Record the weight by putting a big dot on the line corresponding to that weight in kilograms. For example, if the weight of a child is 6 kg in a given month, find the horizontal line representing 6 kg and put a dot at the point on that line where it meets the column for the month in which the weight is being taken. Use a straight edge (as shown in the figure below) to draw a horizontal line across from that point until it intersects the vertical line. 5. Adjust the position of the dot within a column. If the child is being weighed early in the month, put the dot towards the left side of the column. Put the dot in the middle of the column if the weight is being taken in the middle of the month. If the weight is being taken late in the month, put the dot towards the right side of the column. 6. Follow the above instructions each time you record the weight on a chart. Join subsequent dots by a line. This is the line of growth.Interpreting the growth line 1. Look carefully at the growth line. Remember that when the line is going up, parallel to the reference curves (3rd and 97th percentiles, as shown in this figure), the child is growing well; this is good. If the child is not following his percentile i.e. the lines becomes horizontal or going down, then the child is not growing well. 23
  24. 24. 2. The importance of the direction of the growth curve is illustrated in Fig. below. Arrows A, B, C, and D have been drawn on the growth chart parallel to the growth curve for different periods. The growth curve parallel to arrow A is good. The growth curve parallel to arrow B is not satisfactory and action should have been taken. When the growth curve fell, parallel to Arrow C, the child has a problem, and an urgent action is needed. When the growth curve returns to the direction of arrow D, the childs growth is becoming normal again.3. Remember that it is the direction of the growth 24
  25. 25. curve that is more important than the position of the dots on the curve, The dots parallel to arrow B (in Fig. above) are above the lower reference line, but the growth curve is leveling off and this is a matter for concern. The dots parallel to arrow D are below the reference lines, but the direction of the growth line is once again upwards and therefore the mother is congratulated for her good care.Counseling the mother about her childs growth 1. Tell the mother the difference in her childs weight compared to the previous month. Use the growth chart to do this. 2. Explain whether her child is gaining weight or not. Use the growth chart to do this. 3. Tell the mother if her child is malnourished or not. 4. Ask the mother open-ended questions (related to her childs feeding practices). 5. Write down proper notes about the childs feeding practices. 6. Compliment the mother for what she is doing correctly. 7. Urge the mother to continue the things she is doing correctly. 8. Counsel the mother on any problems identified during the diagnosis. 9. Urge the mother to change any faulty behavior that needs to be changed. 10. Ask the mother what things that would make it difficult for her to follow the advice that she is given. 11. If so, help the mother to work through any obstacles. 12. If the child has been ill, talk about ways to prevent or manage the illness. 13. Verify that the mother understands the advice by using questions. 14. Ask the mother to mention the key things that she should stop doing. 15. Ask the mother to repeat back the key things that she should continue to do in the upcoming month(s). 16. Ask the mother to commit to the suggested behaviors. 25
  26. 26. Appendix 12 Clinical Learning Guide Measurement of the Head Circumference STEP/TASK CASESGetting Ready:1. Prepare a non-stretchable measuring tape2. Introduce yourself to the mother3. Ask her permission to examine the childProcedure:1. Pass the tape on the forehead along the plane midway between the eyebrow and the hairline, to the occipital prominence at the back of the head2. Measure to the nearest millimeterPost procedure:Record measurement on head circumference chart 26
  27. 27. Appendix 13 Clinical Learning Guide Measurement of Mid-Arm Circumference STEP/TASK CASESGetting Ready:1. Prepare the following tools: • A non-stretchable measuring tape • A skin marker2. Introduce yourself to the mother3. Ask her permission to examine the child4. Ask the mother to undress the child exposing the Left shoulder and arm.5. Help the child put the arm in an extended relaxed PositionProcedure:1. Identify the mid-point between the acromion andthe olecranon on the lateral side of the arm.2. Pass the tape around the arm at the identified plane, perpendicular to the long axis of the arm3. Measure to the nearest millimeterPost procedure:Record the reading 27
  28. 28. Appendix 13 Clinical Learning Guide Measurement of Mid-Arm Circumference STEP/TASK CASESGetting Ready:1. Prepare the following tools: • A non-stretchable measuring tape • A skin marker2. Introduce yourself to the mother3. Ask her permission to examine the child4. Ask the mother to undress the child exposing the Left shoulder and arm.5. Help the child put the arm in an extended relaxed PositionProcedure:1. Identify the mid-point between the acromion andthe olecranon on the lateral side of the arm.2. Pass the tape around the arm at the identified plane, perpendicular to the long axis of the arm3. Measure to the nearest millimeterPost procedure:Record the reading 27

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