techniques for young patients.ppt handoutdepts.washington.edu/hcsats/training/core_sane... ·...

Techniques for Young Patients

Joanne Mettler, ARNPjoanneu@u.washington.edu

206-744-1600

Why are children different?

• Often no verbal report, or only vague report

• Interpretation of statements may be biased• Time of contact uncertain

Why are children different?

• Bathed before exam• Long time before exam• Exam may be distressing to child• Orifice swabs may be painful

Purpose of the acute exam

• TO:• Identify Acute

injury• Diagnose other

conditions(If in your scope of practice)

• Collect forensic evidence

• NOT:– Identification of

healed injury– Determine if

abused has ever occurred

– Make the child uncomfortable

Do

• Talk to the parent alone – listen to their concerns• Introduce your self to the child they should know

who you are and what you do• Help the child relax before the exam• Provide simple explanation of exam (i.e. we are

going to check your whole body from your head to you toes) to both parent and child

Do’s Continued

• Explain the parent’s role in the exam, one of support to the child, distraction for the child and that you will tell them all about the exam after it is done.

• Allow the child to check out the equipment • Assure the child that we check all children this

way • Allow questions both for the child and parent• Proceed at the child’s pace

Do’s Continued

• Provide distractions for the child-view master, bubbles, singing

• Reassure the child and the parent that there is no serious or permanent injury

• Inform the parent that you cannot come to a conclusion about abuse or not from the exam alone.

• BE FLEXIBLE

Don’t

• Don’t force an exam with an unwilling child• Don’t hurt the child – the exam should

never be worse than the abuse• Don’t insert swabs into a pre or early

pubertal child’s vagina- it can really be painful

• Don’t rush to exam conclusions- most findings can have different diagnoses

GENITAL EXAMINATION TECHNIQUES

• Labial separation• Labial traction• Downward traction• Prone knee-chest• Options for frog-leg or stirrups

Prone knee chest position

BleedingDifferential Diagnosis

• Trauma– Straddle– Impalement– Abuse

• Vaginitis• Vaginal foreign body• Dermatitis• Lichen sclerosis

• Urethral prolapse• Hematuria• Genital warts• Tumor

– Vaginal sarcoma• Anal blood

– Fissure– Colitis

• Shigella, salmonella

MALE GENITAL STRUCTURES TO OBSERVE AND DESCRIBE

• Pubic area and inguinal nodes• Penis• Urethral meatus• Scrotum

MALE NORMAL ANATOMIC VARIANTS

Examples:–Prominent frenulum–Pearly pink penile papules–Hemangiomas

EVALUATION OF THE ANUS

• External inspection sufficient• Use of magnification helpful• Digital examination or insertion of

instrument or scope RARELY needed• Positions: KCP, legs raised, decubitus

Anal and Perianal Findings to Note

• Pigmentation• Tags, hemorrhoids• Venous engorgement• Diastasis Ani• Sphincter tone• Rugal pattern

Anal traumaDifferential diagnosis

• Venous congestion• Normal anal dilitation• Visible mucosa• Anal fissures• Perianal strep• Inflicted trauma• Failure of Midline Fusion• Perineum and median raphe