Physical_growth Of Pediatric Child

Pediatric Nursing Skill

MEASURING PHYSICAL GROWTH Assessing physical growth is one of the most frequently used skills in pediatric nursing. Physical growth parameters include weight, height, head and chest circumferences, and body mass index. By accurate completion and correct plotting on growth charts, a visual representation of growth emerges. Trends revealed through serial measurements are sensitive indicators of health and nutritional status in children. Related Text Chapter 33, Physical Assessment of Children Anthropometric measurement, p. 818 Nursing Diagnoses Health-seeking behaviors (growth assessment) related to promotion of infant/child physical growth Altered growth and development related to illness, stress, nutritional intake, and/or parental knowledge deficit. STEPS

RATIONALE

Assessment 1. Determine presence of any physical anomalies.

Certain physical anomalies may interfere with accurate growth measurements. For example, deformities that prevent full extension preclude accurate measurement of height, or presence of a cast does not allow accurate weight measurement. Special Considerations: If accurate measurement is not possible, that growth parameter can be deferred or omitted, or special techniques maybe necessary, such as sitting height or crown-to-rump length.

2. Calculate child's age. Age is rounded to nearest month on birth to 36-month charts, or to nearest 3 months on 2- to 18-year charts.

Age determines which growth measurements are to be completed and assists in selection of proper measuring devices. Correct age is also essential for accurate plotting on growth charts. Special Considerations: For premature infants,weeks of prematurity are subtracted from actual age before plotting on growth charts. Adjustments are made until 18 months of age for head circumference, 21 months of age for weight, and 36 months of age for length or stature.

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3. Determine which growth measurements are to be obtained. a. Weight is measured at all ages. b. Recumbent length is measured for children under 24 months of age. Stature, or standing height, is measured for children over 36 months of age. Either measurement may be used from 24 to 36 months; recumbent length must be plotted on birth to 36-month charts, and stature must be plotted on 2to 18-year charts.

3. Determine which growth measurements are to be obtained, a. Weight is measured at all ages. b. Recumbent length is measured for children under 24 months of age. Stature, or standing height, is measured for children over 36 months of age. Either measurement may be used from 24 to 36 months; recumbent length must be plotted on birth to 36- month charts, and stature must be plotted on 2- to 18-year charts. c. Head circumference is commonly measured up to 2 years of age. d. Chest circumference may be measured for comparison with head circumference.

The growth parameters to be measured will guide selection of equipment and growth charts needed for accurate determinations.

The growth parameters to be measured will guide selection of equipment and growth charts needed for accurate determinations.

Marked disproportion between head and chest circumference is generally the result of abnormal head growth.

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4. Obtain family history relating to growth parameters, including heights, weights, and head circumferences of parents and siblings, if known. Information regarding general growth patterns of siblings may also be beneficial. Planning and Goal Setting 1. Assemble and prepare equipment.

a. Calibrate digital scale or balance beam scale, either pediatric or adult model, depending on child's age. Before using a balance beam scale, balance scale by placing weights at zero position and adjusting screws as necessary until beam is in zero balance. Pediatric scales should be covered with clean paper that is changed aftereach use; if paper is to be used, scales should be balanced with paper in place. Scales should be cleaned with disinfectant daily or more often if contaminated.

b. Infant measuring board if recumbent length is to be measured or wall-mounted measuring board if stature is to be measured. Check to see that sliding headboards and footboards move easily, are not worn, loose, jagged, or broken, and are perpendicular to measurement surface. If device is not available, a nonstretchable measuring tape or yardstick may be used. It should be attached to a rigid surface (door, wall without baseboard, table top) with “0” mark either at floor if child is to be measured standing, or at fixed headboard if recumbent length is to be measured; a right angle board is required to complete the measurement. c. Flexible, nonstretchable tape measure (paper or plastic) for measuring head and chest circumferences.

Growth is significantly influenced by genetic make-up. Thus tall parents tend to have tall children; small parents have small children.

Properly selected and maintained equipment is essential in achieving accurate growth measurements.

If measurements are to be compared with standardized norms, length or stature measurements must be accurate to ensure valid interpretation of findings. Special Considerations: Measuring devicesshould be in same unit of measure, such as inches or centimeters, used within agency to avoid calculation errors. Movable measuring rods attached to platform scales are unstableand do not ensure accurate measurement of length or stature. Marking at child's head and feet as closely as possible, then measuring distance between marks, provides only an estimate of length or stature in absence of proper equipment. Caution must be used in interpreting such measurements by comparisonwith standardized norms. Cloth tape measures stretch, giving a falsely small measurement Some metal tape measures may not be adequately flexible and may injure the child.

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2. Select appropriate National Center for HealthStatistics (NCHS) growth chart. Sixteen charts and an easy-to-use BMI calculator are available online: http://www.cdc.gov/growthcharts/. Choose the charts appropriate to the sex of the child. a. From birth to 36 months: • Chart showing norms for recumbent length by weight and age. • Chart showing norms for head circumference by age and we1ght by recumbent length. b. From 2 to 18 years: • Chart showing norms for stature, weight, and body mass index (BMI) by age.

The correct standardized norms are essential for accurate interpretation. Growth norms may vary based on sex, age, measurement by recumbent length, or stature. The weightby-age, recumbent length-by-age, statureby-age, and head circumference-by-age charts compares the child's measurements with those of the same-age children in the general population. The weight-byrecumbent length or weight-by-stature charts allows comparison of the proportions of the child's body measurements. BMI-forage permits identification of children and adolescents who are at risk or overweight.

3. Develop individualized goals of nursing care: • Accurate, age-appropriate growthmeasurements will be obtained. • Growth measurements will be correctly plotted on appropriate NCHS growth charts. • Growth measurements falling outside normal parameters and child's own growth curve will be identified. Implementation 1. Prepare child.

By allaying anxiety and fear of unknown, child is better able to cooperate.

a. For infants and some toddlers, distraction may be necessary to keep them still during measurement. For cooperative toddlers and older children, ageappropriate explanations of procedures, equipment, and results are given. b. Remove child's clothing. • Infants are completely undressed. • For children, all but minimal indoor clothing is removed: coats, shoes, caps, etc.

Special Considerations: If child is uncooperative and resistant, making accurate measurementimpossible, postpone or omit measurement. Document reason. Removal of clothing is required for accurate weight determination. Removal of shoes and headwear is necessary to measure length or stature. Removal of headwear is also essential for accurate measurement of head circumference. Special Considerations: Serial measurements will provide a more accurate picture if same approach is used each time child is measured, such as if the infant is always nude.

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2. Obtain height measurement. a. To obtain recumbent length, place child supine on measuring board; have parent or attendant hold head firmly against headboard with child's line of vision straight up. Completely extend legs by gently pushing down on both knees while positioning footboard firmly against heels with toes straight up. Read measurement to nearest 1/8 inch (0.3 cm).

Along with weight, height is a good indicator of overall growth. Serial measurements provide good representation of growth rate. Shortness may be caused by chronic malnutrition, chronic disease affecting absorption or utilization of nutrients, or inadequate growth hormone; it may also be related to genetic factors and be a normal growth pattern. Tallness is generally related to genetic factors and a normal growth pattern, although excessively rapid growth may result from hormonal imbalance or accelerated maturation.

b. To obtain stature, have child stand with heels slightly apart, feet flat on floor, back straight, chin level, and eyes looking straight ahead; heels, buttocks, and shoulder blades should touch measuring surface. Lower headboard to rest firmly on child's head. Read measurement to nearest 1/4 inch (0.6 cm).

Special Considerations: A child normally grows approximately 10 inches (25 cm) in first year of life, 5 inches (13 cm) in the second year, 3 to 4 inches (8 to 10 cm) in the third year, and then 2 to 3 inches (5 to 8 cm) per year until pubertalgrowth spurt. Birth length is normally doubled by 4 years and tripled by 13 years. Greatest height gain usually occurs in spring, and least gain, in fall. Serial weight measurements provide a good indicator of growth rate. Rapid or sudden weight loss suggests serious, acute disease or dehydration. Gradual weight loss suggests chronic disease or malnutrition. Underweight with normal growth rate may be caused by inadequate nutrition or may be related to genetic factors and normal for a specific child. Rapidweight gain usually indicates overfeeding, but may be a sign of fluid retention. Generalized overweight or obesity is generally due to overeating and/or underactivity but may be caused by endocrine disorders.

3. Obtain weight measurement. Place undressed child in middle of weighing surface. Infants and young children are weighed while lying or sitting on pediatric scales; keep hand close to but not touching child to prevent accidental falls. Children over 2 to 3 years of age may be weighed standing on adult scales. Read digital display or adjust beam weights on scale until horizontal beam is balanced at zero. Read weight to nearest ½ ounce (15 g) on pediatric scales or ¼ pound (0.1 kg) on adult scales.

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4. Measure head and chest circumferences. a. Place tape measure around largest part of head, the frontal-occipital circumference (FOC), passing it over forehead just above eyebrows, above ears, and around occipital prominence. Place tape 3 times to ensure accuracy; record greatest circumference. b. Measure chest circumference at nipple line midway between inspiration and expiration.

Special Considerations: Birth weight is normally doubled by 5 to 6 months, tripled by 12 months, and quadrupled by 2 to 2½ years. During first 3 months, infants gain about 1 ounce (30 g) perday or 2 pounds (1 kg) per month; between ages 3 to 12 months, weight gain is about 1 pound (0.5 kg) per month. During second year of life, weight gain is approximately ½ pound (0.25 kg) per month. After 2 years of age, weight gain averages 5 pounds (2.25 kg) per year until puberty, when growth spurt occurs. Greatest weight gain usually occurs in fall,and least gain, in spring. Head circumference is an indicator of head and brain growth. Chest circumference is measured primarily for comparison with head circumference; marked disproportion between head and chest circumference is generally due to abnormal head growth rather than abnormal chest growth. A large head circumference suggests hydrocephalus. Small head suggests microcephaly, craniostenosis, or genetic disorders. . Special Considerations: To prevent paper cuts,use caution not to slide or pull paper tape against the skin of the child. Special Considerations: FOC normally increasesabout 12 cm (5 inches) during first year of life, and another 10 cm (4 inches) from 1 to 16 years. Average chest circumference at birth is 1 cm (0.75 inch) less than FOC. Chest remains about same circumference as head until approximately 1 to 2 years of age. At 2 years, chest circumference exceeds head circumference. During childhood chest circumference exceeds FOC by 5 to 7 cm (2 to 3 inches), although it may be greater in children with

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chronic respiratory problems, such as asthma or cystic fibrosis. 4. Calculate body mass index (see text, Appendix E).

5. Plot growth measurements on appropriate NCHS growth chart. Find child's age on horizontal scale and growth measurement on vertical scale; make dot or cross where two lines intersect. Repeat for each measurement obtained. On weight-by-length or weight-by-stature graphs, find length or stature on horizontal scale and weight on vertical scale. Age is plotted to nearest month on birth to 36-month chart and to nearest quarter year on 2- to 18-year chart.

6. Interpret measurements by comparison with percentiles on charts. In general, normal measurements for height, weight, and head circumference should fall between the 5th and 95th percentiles after making any indicated adjustment for prematurity. Serial measurements should follow the normal growth curve.

Evaluation Outcomes 1. Accurate, appropriate growth measurements are obtained.

Accurate plotting on appropriate charts is required for comparison with norms and interpretation. Special Considerations: For premature infants,weeks of prematurity are recorded on growth chart and then subtracted from actual age before plotting on growth charts. Adjustments are made until 18 months of age for FOC, 21 months for weight, and 36 months for length or stature. If accurate measurements have been obtained, measurements falling about 95th percentile or below 5th percentile or serial measurements showing marked change in percentile levels are suggestive of health or nutrition problems. A change from one edge of percentile zone to other edge of that zone or shift across percentile zones away from 50th percentile is significant. The greater the change in growth percentile since previous measurements, the quicker the change has occurred, and the younger the age of child, the greater the reason for concern. Special Considerations: Additional techniquesfor assessment of growth are available, such as skin fold thickness measurements, water-resistance measure for percent of body fat, ultrasound methods, and incremental growth measurements. These tools may be used for more accurate assessment of children falling outside of normal range on general growth parameters. Observational Guidelines Accuracy may be confirmed by repeating all measurements 3 times. Weight is obtained on all children. Recumbent length is measured if child is under 24 months and stature is measured if over 36 months; between 24 and 36 months, either measurement is acceptable. FOC is measured if child is under 12 to 24 months of age. BMI is calculated. Other

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measurements are completed on an individual basis.

2. Growth measurements are correctly plotted on appropriate NCHS growth chart.

Confirm accuracy by rechecking plot points on chart. Recumbent length is graphed on birth to 36-month chart; stature is plotted on 2- to 18year chart. Adjustments are made for prematurity, if indicated.

3. Growth measurements falling outside range of normal are identified.

Measurements above 95th percentile or below 5th percentile, or serial measurements showing significant change in percentile are documentedand referrals are made as appropriate.

Documentation

Child and Family Teaching Date and actual numerical values of all measurements completed are recorded and plotted on appropriate NCHS growth charts.

Results of physical growth assessment should always be reviewed with the family and child. Growth charts are shared and the meaning

Any factors that may affect accuracy or interpretation of measurements, such as clothing, prosthesis, casts, prematurity, physical anomalies, or an uncooperative child, are documented.

of plotted points is explained. For example, if child falls at 25th percentile on weight for age, explain that if 100 children of the same age were compared, approximately 75

Nursing diagnoses and plan of care, including referrals, are documented.

would weigh more and 25 would weigh less than this child. Normalcy is important to family and child and can be reassuring. This is particularly important to adolescents for whom body image is a primary concern. For those falling outside norms, sharing growth charts can provide an opening for developing intervention plans with family and child, such as discussing nutrition in more detail or referring family to nutritionist.

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